Copyright 2022 Lineage Medical, Inc. All rights reserved. Fracture. LCL injuries. Scaphoid Fracture Nonunion occur in 5-25% of scaphoid fractures following treatment, and are more common in older patients, smokers, and when there is a delay in the initial treatment of the fracture. See topic Meniscal Pathology. Triceps tendinitis. At the first postoperative visit with the surgeon (1-2 weeks), the patient's staples/stitches are removed, the wound is examined, and radiographs are obtained to ensure proper healing. His medical history is significant only for osteoporosis. Palpation of the radial head is painful. She presents to clinic with significant knee pain and swelling. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, 2022 California Orthopaedic Association Annual Meeting, The Great Debate - Wide Awake - Prosper Benhaim, MD, Orthopaedic Summit Evolving Techniques 2020, Pro: I Might Consider A Nerve Transfer: Let Me Tell You When - Mark Rekant, MD, Pro: Transpose The Nerve Or He Won't Be Happy: The Standard Works - Mark Baratz, MD, Ulnar Neuropathy Due to Deformity from Elbow Fx in 31M. 0 and 30 - combined MCL and ACL and/or PCL. [7], An ORIF is used with Mason Type 2 and 3 fractures, which has demonstrated the best recovery results. (OBQ18.201) A 35-year-old female fell while riding a motorcycle and sustained the left elbow injury shown in Figures A and B. obtain previous operative reports and imaging studies if applicable. MedlinePlus. Microsoft pleaded for its deal on the day of the Phase 2 decision last month, but now the gloves are well and truly off. 13% (174/1289) 2. Some patients experience numbness in the forearm, hands, and fingers. 30 only - isolated MCL. Tears of central 75%. sagittal. Radiographs are seen in Figures A and B. If these fail and symptoms are severe surgical ulnar nerve [17], Early stretching movement and elbow flexion is necessary to avoid elbow contractures or stiffness in elbow ROM. Radiopaedia Blog RSS. peripheral tears 4 mm have best healing potential. His medical history is significant only for osteoporosis. [10] According to the Mason classification, Type 2 and Type 3 radial head fractures require surgical intervention to stabilize the radius. MCL Injury. (OBQ18.201) A 35-year-old female fell while riding a motorcycle and sustained the left elbow injury shown in Figures A and B. Available from: https://posna.org/Physician-Education/Study-Guide/Proximal-Radius-(Radial-Neck)-Fractures. Acromioclavicular Joint Injury Distal Clavicle Osteolysis AC Arthritis or pain at the MCL origin between 70 and 120 degrees. In phase three, from week 7 to week 12, the patient continues working on AROM and AAROM with supination and pronation. Genu Valgum is a normal physiologic process in children which may also be pathologic if associated with skeletal dysplasia, physeal injury, tumors or rickets. A nerve conduction velocity study demonstrates only slightly increased latency across the cubital tunnel. All of the following are possible sites of compression for the ulnar nerve EXCEPT: (SBQ05UE.66) A 20-year-old skateboarder fell 6 months ago and has had radial-sided wrist pain since. Herpes zoster (shingles) Treatment. Strength is full compared to the other side. Knee dislocations are high energy traumatic injuries characterized by a high rate of neurovascular injury. 2008 [cited 2022Apr14]. Cubital Tunnel Syndrome is a compressive neuropathy of the ulnar nerve caused by anatomic compression in the medial elbow. 10/18/2019. MCL injury. The score and level of disability have a positive correlation. correlates in throwers to location of early acceleration (70 degrees flexion), and location of late cocking (120 degrees flexion) 100% sensitive and 75% specific. MCL Knee Injuries LCL Injury of the Knee Orthobullets Team Knee & Sports (SBQ16SM.92) A 13-year-old girl presents with lateral knee pain after a twisting injury during basketball. A quadriceps tendon rupture is a traumatic injury of the quadriceps insertion on the patella leading to a disruption in the knee extensor mechanism. (OBQ18.171) A 17-year-old girl sustained a twisting injury to her knee during a basketball tournament 2 weeks ago. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). Tears in peripheral 25% red zone. Some common associated injuries with this type of fracture can be ligamentous such as a lateral collateral ligament (LCL) or medial collateral ligament (MCL) injuries. classification. Valgus instability = medial opening. Electrodiagnostic studies from 3 months ago demonstrated decreased nerve conduction velocities in the ulnar nerve. The surgeons decision is guided by the diagnostic imaging, Radiographs, MRI, or CT scans. Available from: https://www.orthotexas.com/radial-head-fracture-causes-symptoms-diagnosis-treatment/, Nonunions - orthoinfo - Aaos [Internet]. A type I avulsion fracture of the coronoid. Grade III: 11-15 mm opening. After these ROM requirements are met, the patient begins gripping exercises with putty and isometric strengthening exercises for the elbow and wrist. 2022 [cited 2022Apr13]. After closed reduction, the elbow is unstable with valgus stress at 40 degrees of flexion. Lateral Ulnar Collateral Ligament Injury is a ligamentous elbow injury usually associated with a traumatic elbow dislocation, and characterized by posterolateral subluxation or dislocation of the radiocapitellar and ulnohumeral joints. Acromioclavicular Joint Injury Distal Clavicle Osteolysis AC Arthritis the MCL is composed of the anterior, posterior and transverse bundles. Read more, Physiopedia 2022 | Physiopedia is a registered charity in the UK, no. KD IV. 1173185, Proximal radius (radial neck) fractures [Internet]. sagittal. (OBQ11.44) A 68-year-old healthy active male presents after falling and sustaining an injury to his right knee. 10/18/2019. medial collateral ligament (MCL) injury. The patient can drive a car once authorized by the surgeon, which is typically four to six weeks after surgery. Treatment is usually bracing unless there is gross varus instability in which case repair or reconstruction is performed. He reports that his symptoms are worse at night. Notable landmarks of the proximal radius include the radial head, neck, and tuberosity. MCL Injury. Physical therapy and splinting have failed to relieve the symptoms. The orthopedic surgeon determines the diagnosis of different Mason fractures, and they decide the interventions needed. Radial head arthroplasty for comminuted Mason Type 3 fractures that involve greater than 25% of the radial head is another valid option. An MCL injury requiring repair. Nonoperative. 10% (353/3562) 4. She presents to clinic with significant knee pain and swelling. (OBQ06.88) A 16-year-old female field hockey player sustains a twisting injury to her knee. 10% (353/3562) 4. (OBQ07.127) careful history to detail chronology of injury and treatment. Grade II: 6-10 mm opening. What the patient should not be doing for the first 6 weeks is: When needed, the patient should ask for assistance with activities. Treatment may be nonoperative modalities such as bracing or surgical decompression depending on the severity and duration of symptoms, and success of nonoperative treatment. [5], Applying an ice pack to the injured area, taking NSAIDs such as ibuprofen or acetaminophen, and using a sling are helpful in managing the pain and swelling associated with radial head fractures. A tibial shaft stress fracture is an overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures. Case 1: radial head fractureR [Internet]. ACL tear and MCL tear: Both tears will cause the knee to click; the tears can also lead tochronic pain, knee stiffness, and tenderness. Team Orthobullets (AF) Knee & Sports - Articular Cartilage Defects of Knee; Listen Now 13:13 min. 2018Nov;6(6):53946. He has a multiyear history of numbness and tingling into his ring and small fingers. Team Orthobullets (AF) Knee & Sports - Articular Cartilage Defects of Knee; Listen Now 13:13 min. Treatment may be nonoperative with restricted weight bearing in children with open physis. peripheral tears 4 mm have best healing potential. Hacki et. can heal via fibrocartilage scar formation. Upon evaluation, he has difficulty bearing weight due to left hip pain and has tenderness to palpation superior to his left hip joint. Cervical radiculopathy. Strength is full compared to the other side. Treatment may be nonoperative with restricted weight bearing in children with open physis. An MCL injury requiring repair. Proximal radial fractures occur when falling on an outstretched hand (FOOSH), which pushes the radius into the humerus, or direct trauma to the elbow. [14], The mechanism of injury is often falling on an outstretched hand or direct trauma to the elbow. Cervical radiculopathy. A tibial eminence fracture, also known as a tibia spine fracture, is an intra-articular fracture of the bony attachment of the ACL on the tibia that is most commonly seen in children from age 8 to 14 years during athletic activity. Gray H. Barnes & Noble. Radiopaedia. When dealing with a Mason Type 1 fracture of the proximal radius, there is no mechanical restriction of supination and pronation that occurs in the forearm. Medial femoral condyle avulsion fracture that indicates a chronic MCL injury. Available from: https://radiopaedia.org/articles/proximal-radial-fracture-summary?lang=us, Frontal [Internet]. If these fail and symptoms are severe surgical ulnar nerve some patients will deny any significant symptoms. [3], Type 1 non-displaced proximal radial fractures should be treated non-operatively, and the patient is given a sling or splint for a few days. KD IV. Injury to ACL, PCL, PMC, and PLC (4 ligaments) Has the highest rate of vascular injury (5-15%%) Orthobullets Team 93 plays. The patient rates the difficulty of individual activities in this questionnaire 1 to 5, with 1 being No Difficulty and 5 being Unable. Note that some questions are phrased differently so 1 to 5 range is relabeled as needed, such as None to Extreme or Strongly Disagree to Strongly Agree. The score is calculated using the formula ([sum of n responses/n]-1)(25). Team Orthobullets 4 Trauma - Radial Head Fractures; Listen Now 18:30 min. A tibial eminence fracture, also known as a tibia spine fracture, is an intra-articular fracture of the bony attachment of the ACL on the tibia that is most commonly seen in children from age 8 to 14 years during athletic activity. [21], Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. Treatment can be nonoperative or operative depending on the severity of injury to the PCL, as well concomitant injuries to surrounding structures and ligaments in the knee. Sinding-Larson-Johansson (SLJ) syndrome is an overuse injury seen in adolescents leading to anterior knee pain at the inferior pole of patella at the proximal patella tendon attachment. The patient should contact the surgeon immediately if skin changes with or without discharge or bleeding are noted around the incision site, or if a fever occurs greater than 101.[5]. His medical history is significant only for osteoporosis. On physical exam, he has decreased 2-point discrimination in his small finger and a positive Jeanne's sign. Copyright 2022 Lineage Medical, Inc. All rights reserved. [5] Possible interventions include immobilization that may involve splinting, slings, and or surgery. the MCL provides resistance to valgus and distractive stresses. [5], The patient should expect to see some swelling in/around the arm after the surgery. Tears in peripheral 25% red zone. The patient has limited active elbow extension/flexion and forearm pronation/supination. inadequate warm-up. obtain previous operative reports and imaging studies if applicable. some patients will deny any significant symptoms. A type I avulsion fracture of the coronoid. 288 plays. 5-20% of all knee ligamentous injuries. After closed reduction, the elbow is unstable with valgus stress at 40 degrees of flexion. 11/6/2019. MCL Knee Injuries LCL Injury of the Knee Posterolateral Corner Injury and to document the degree of cartilage injury. If the fracture does involve one-third of the articular surface, a sling or splinting should be implemented for at least a two-week period. Bakers cyst: Swelling in the sunken hollow found at the back of the knee is called a Bakers cyst. interosseus membrane injury. Maximizing Outcomes in the treatment of radial head fractures. (OBQ11.44) A 68-year-old healthy active male presents after falling and sustaining an injury to his right knee. interosseus membrane injury. elbow fractures & dislocations. [cited 2022Apr13]. Medial femoral condyle avulsion fracture that indicates a chronic MCL injury. Views. (OBQ09.1) Views. anteroinferior aspect of medial epicondyle. The patient will continue the isometric strengthening exercises from the first phase working specifically on flexion and extension. Treatment is generally open reduction and internal fixation (ORIF) with bone grafting. U.S. National Library of Medicine; [cited 2022Apr13]. inadequate warm-up. MCL Knee Injuries LCL Injury of the Knee Orthobullets Team Knee & Sports (SBQ16SM.92) A 13-year-old girl presents with lateral knee pain after a twisting injury during basketball. (OBQ18.59) (OBQ18.171) A 17-year-old girl sustained a twisting injury to her knee during a basketball tournament 2 weeks ago. Passive range of motion (PROM) is limited due to pain. His radiograph upon presentation to your office is shown in figure A. Triceps tendinitis. fibrochondrocyte is cell responsible for healing. Medial collateral ligament Injury of the knee (MCL Tear) are the most common ligament injuries of the knee and are frequently associated with ACL tears. interosseus membrane injury. Dislocation of the elbow can also produce what is known as the terrible triad which consists of a dislocation of the elbow, a radial head fracture, and a coronoid fracture. (OBQ06.88) A 16-year-old female field hockey player sustains a twisting injury to her knee. Diagnosis is made clinically with a palpable defect 2 cm proximal to the superior pole of the patella with inability to perform a straight leg raise and presence of patella baja on knee radiographs. Diagnosis is made with a combination of radiographs and a CT scan. Journal of Shoulder and Elbow Surgery. Bakers cyst: Swelling in the sunken hollow found at the back of the knee is called a Bakers cyst. Symptoms. MCL Knee Injuries LCL Injury of the Knee Posterolateral Corner Injury and to document the degree of cartilage injury. An MCL injury requiring repair. [19], Early ROM for non-operated simple and complex radial head fractures and early AROM and AAROM of the elbow helps prevent the collection of edema, stiffness, and the formation of adhesions in the capsule and annular ligament. Essex-Lopresti injury . After this time, the patient begins AROM and AAROM supination and pronation. 10% (353/3562) 4. careful history to detail chronology of injury and treatment. using the arm to push themselves up in bed or a chair. What is the best next step in treatment and the most likely site of compression for the patient? Swelling and heat are palpable. [16], There should be a brief period of immobilization of the arm, which mainly applies to Mason Type 1 fractures. Available from: https://medlineplus.gov/ency/patientinstructions/000561.htm. Team Orthobullets (D) Trauma - Tibial Shaft Fractures Flashcards (81) Cards (OBQ13.211) A 35-year-old male patient sustains a twisting injury to his leg while playing soccer. Grade I: 0-5 mm opening. OrthoInfo. overusing the elbow/arm, which can cause difficulties with the healing process. In phase two, which is from 15 days to 6 weeks, the physical therapist should assess the shoulder and wrist strength along with ROM. Radiographs are seen in Figures A and B. Between the sartorius and soleus . Patella baja. When evaluating a fracture dislocation of the elbow, a varus and posteromedial rotation mechanism of injury typically results in what injury pattern? Patella baja. Acromioclavicular Joint Injury Distal Clavicle Osteolysis AC Arthritis the MCL is composed of the anterior, posterior and transverse bundles. [17], Some Type 3 fractures require the patient be placed in a splint or sling for a short period of time. 2008 [cited 2022Apr14]. Physical examination reveals mild effusion, lateral sided tenderness, and range of motion from 10-85 degrees without any signs of instability. In the first phase, which is 0-14 days, the patient begins with elbow flexion and extension AROM. obtain previous operative reports and imaging studies if applicable. [7] If excessive motion is promoted too early, it is possible to shift and displace the bones. Symptoms. The QuickDASH is a modified version of the DASH outcome measure that is shorter but with evidence of being as precise as the DASH. Type 3b is an articular fracture with the head breaking into two or more pieces. Team Orthobullets (D) Trauma - Tibial Shaft Fractures Flashcards (81) Cards (OBQ13.211) A 35-year-old male patient sustains a twisting injury to his leg while playing soccer. On examination, he has decreased sensation on the dorsal ulnar distribution of the hand with a positive Tinel sign at the medial elbow. (OBQ18.201) A 35-year-old female fell while riding a motorcycle and sustained the left elbow injury shown in Figures A and B. Genu Valgum is a normal physiologic process in children which may also be pathologic if associated with skeletal dysplasia, physeal injury, tumors or rickets. identify and protect MCL (distal to flap) technique. New York, New York: Barnes & Noble; 2010. 2006;7(1). [10] In both cases, it is recommended that immobilizing the arm is beneficial to protect and support the arm after surgery. These two outcome measures can be utilized with Mason Type 1, 2, and 3 fractures regardless of mechanism of injury. 1% (OBQ13.156) A 44-year-old female sustains the injury shown in Figures A and B as the result of a motor vehicle collision. Cubital Tunnel Syndrome is a compressive neuropathy of the ulnar nerve at the elbow, and is the 2nd most common compression neuropathy of the upper extremity. A tibial eminence fracture, also known as a tibia spine fracture, is an intra-articular fracture of the bony attachment of the ACL on the tibia that is most commonly seen in children from age 8 to 14 years during athletic activity. Tibial stress syndrome (also known as shin splints) is an overuse injury or repetitive-load injury of the shin area that leads to persistent dull anterior leg pain. [10], Nonsurgical treatment involves a splint or sling for a few days, followed by early and gradual increase in elbow and wrist movement which depend on the pain level. Essex-Lopresti injury . will not splint in full supination (for MCL rupture only) as the LCL is always disrupted in PLRI. fibrochondrocyte is cell responsible for healing. In such cases, a sail sign might indicate a fracture. A quadriceps tendon rupture is a traumatic injury of the quadriceps insertion on the patella leading to a disruption in the knee extensor mechanism. I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. 2/11/2020. Radius fractures include the proximal portion of the radius, the neck, and head. Strength is full compared to the other side. 1% (OBQ13.156) A 44-year-old female sustains the injury shown in Figures A and B as the result of a motor vehicle collision. Classification. may describe remote traumatic event. 2/24/2020. 93 plays. [4], Possible injuries that should be considered and ruled out with a radial head fracture are capitellum fractures, distal radius fractures, distal radio-ulnar joint dislocations, medial collateral ligament (MCL) ruptures, biceps tendon ruptures, triceps tendon ruptures, and elbow dislocations. Essex-Lopresti injury . A tibial shaft stress fracture is an overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures. Arthrofibrosis. However, immobilization of the arm should only be up to 1 week after surgery for simple fractures and up to 3-6 weeks with a long-arm splint for complex fractures. Epidemiology. Wang JH, Rajan PV, Castaneda J, Gokkus K. Radial head fractures [Internet]. Kerns GJ. [17] Fractures that occur in the proximal portion of the radial head will result in loss of elbow ROM. A sail sign is a silhouette on a radiograph caused by an enlarged fat pad at the elbow. anatomy. On examination, her knee range of motion (ROM) is limited to 10-75. Grade II: 6-10 mm opening. (OBQ06.88) A 16-year-old female field hockey player sustains a twisting injury to her knee. Cubital Tunnel Syndrome is a compressive neuropathy of the ulnar nerve at the elbow, and is the 2nd most common compression neuropathy of the upper extremity. Diagnosis is made clinically with presence of sensory changes to the ring and little finger, intrinsic muscle weakness and a positive tinel's sign over the cubital tunnel. al discuss outcomes in current treatment of radial head fractures. (OBQ18.171) A 17-year-old girl sustained a twisting injury to her knee during a basketball tournament 2 weeks ago. MCL Knee Injuries LCL Injury of the Knee Posterolateral Corner Injury and to document the degree of cartilage injury. Grade I: 0-5 mm opening. Diagnosis can often be made on radiographs alone but MRI studies should be obtained in patients with normal radiographs with a high degree of suspicion for stress fracture. isolated PCL injury (10-12 mm posterior displacement) PCL and PLC injury (>12 mm posterior displacement) MRI. 288 plays. Submersion of the elbow area is restricted for at least four weeks after surgery. Lateral Ulnar Collateral Ligament Injury is a ligamentous elbow injury usually associated with a traumatic elbow dislocation, and characterized by posterolateral subluxation or dislocation of the radiocapitellar and ulnohumeral joints. If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. Available from: https://radiopaedia.org/cases/proximal-radial-shaft-fracture-with-radial-head-subluxation?lang=us, Case 1 [Internet]. Team Orthobullets 4 Trauma - Radial Head Fractures; Listen Now 18:30 min. PCL, MCL) and KDIIIL (ACL, PCL, PLC, LCL). isolated PCL injury (10-12 mm posterior displacement) PCL and PLC injury (>12 mm posterior displacement) MRI. His active elbow range of motion is 0-120 degrees with full pronosupination, but flexion elicits a snapping sensation over his medial elbow. As pain permits, the patient should perform active range of motion (AROM) in the early stages of rehabilitation, including forearm supination and pronation. The pain occasionally refers distally along the ulnar aspect of the forearm. [8], The high probability of other injuries occurring with a fall on an outstretched hand (FOOSH) suggests radiographs, MRI, and sometimes CT scan are required to verify the diagnosis and to certify the integrity of all surrounding structures and tissues. lifting objects that are heavier than a glass of water. Radiopaedia. 79 plays. 10/18/2019. anatomy. The patient is given instructions on next steps and plans for the upcoming weeks after everything is evaluated. will not splint in full supination (for MCL rupture only) as the LCL is always disrupted in PLRI. Patellar instability is a condition characterized by patellar subluxation or dislocation episodes as a result of injury, ligamentous laxity or increased Q angle of the knee. A complex radial head fracture is classified as additional instability due to other factors outside of the radial head fracture. al discuss complications of radial head fracture treatment and detail revisions required. Dr. Garrett Kerns [Internet]. Cubital tunnel syndrome. The flat surface articulates with the humerus. BMC Musculoskeletal Disorders. (OBQ09.24) MCL injury. Medial ulnar collateral ligament reconstruction, Cubital tunnel decompression with anterior transposition. On physical exam his ACL and PCL are intact, however he is noted clinically to have Grade 3 posterolateral corner laxity and varus malalignment of his knee. Radiographs are seen in Figures A and B. (SBQ07SM.42) A 14-year-old male sprinter felt a pop and began to experience immediate left hip pain while participating in the 400-meter dash. PCL Injury MCL Knee Injuries LCL Injury of the Knee Posterolateral Corner Injury Posteromedial Corner Injury Orthobullets Team Knee & Sports - Snapping Hip (Coxa Saltans) Listen Now 14:22 min. radial head fracture. [3] However, radial head fractures are seen more in younger men than women. Type III fractures may cause visible deformity. Cubital Tunnel Syndrome is a compressive neuropathy of the ulnar nerve at the elbow, and is the 2nd most common compression neuropathy of the upper extremity. can heal via fibrocartilage scar formation. [18], If surgery occurs, the splint should be left in place until the patients first postoperative visit, which usually occurs 1-2 weeks after the surgery. Herpes zoster (shingles) Treatment. Physical examination reveals mild effusion, lateral sided tenderness, and range of motion from 10-85 degrees without any signs of instability. [7] A proximal radius non-union can cause the radial head to subluxate. Classification. some studies showing nearly 25% following surgical fixation, lack of stability and/or biology leading to nonunion at fracture site, SNAC (Scaphoid Nonunion Advanced Collapse), complex 3-dimensional structure described as resembling a boat or twisted peanut, oriented obliquely from extremity's long axis (implications for advanced imaging techniques), > 75% of scaphoid bone is covered by articular cartilage, articulates with radius, lunate, trapezium, trapezoid, and capitate, dorsal carpal branch (branch of the radial artery), enters scaphoid in a nonarticular ridge on the dorsal surface and supplies proximal, superficial palmar arch (branch of volar radial artery, creates vascular watershed and poor fracture healing environment, link between proximal and distal carpal row, both intrinsic and extrinsic ligaments attach and surround the scaphoid, the scaphoid flexes with wrist flexion and radial deviation and extends during wrist extension and ulnar deviation (same as proximal row), Generally divided into stable or unstable nonunion, maintenance of length and overall alignment with fibrous union, loss of length or alignment with signs of carpal instability or degenerative chondral changes, careful history to detail chronology of injury and treatment, obtain previous operative reports and imaging studies if applicable, some patients will deny any significant symptoms, document flexion-extension and pronation-supination, variable degree of motion loss may be attributed to post-immobilization stiffness or mechanical derangement, neutral rotation PA and lateral, semi-pronated (45) oblique view, cysts, sclerosis, bone resorption at fracture site, hardware loosening or failure, best modality to evaluate nonunion and for surgical planning, CT should be oriented in plane of scaphoid with 1mm cuts, most protocols can reduce metal artifact in post-surgical setting, provides better detail of fracture pattern orientation, displacement, residual fracture gap, and angulation, may show technical errors from previous surgery, scaphoid, radial styloid, capitate and/or lunate subchondral cyst formation, gadolinium enhancement may improve quality, diagnosis confirmed by history, physical exam, radiographs, and CT, lack of prior appropriate immobilization duration, may immobilize up to 6 months following surgery, technical error with improper screw placement, implant failure, distraction at fracture site with loss of reduction, 69% of surgically stabilized fractures without technical error or fracture displacement achieve union by 3 months with cast and addition of pulsed electromagnetic stimulation, Open reduction internal fixation with bone grafting, technical error with improper implant placement, implant failure, distraction at fracture site with loss of reduction, likely best outcome when nonunion due to simple technical error during index procedure, local (pedicled): multiple techniques from distal radius, free (requires anastomosis): medial femoral condyle, medial trochlea, iliac crest, bone morphogenic protein (BMP) and platelet-derived plasma (PRP), used as adjunct to ORIF, avoids technical challenges and resource utilization of free flaps, inlay (Russe) non-vascularized corticocancellous bone graft, no adjacent carpal collapse or excessive flexion deformity (humpback scaphoid), interposition (Fisk) non-vascularized corticocancellous bone graft, adjacent carpal collapse and excessive flexion deformity (humpback scaphoid), Vascularized local corticocancellous bone graft, multiple techniques (Mathoulin, Zaidemberg, Sotrereanos etc), waist fractures with proximal pole osteonecrosis, lack of intraoperative punctate bleeding at fracture, Free vascularized corticocancellous bone graft from medial femoral condyle (MFC), corticoperiosteal flap that provides highly osteogenic periosteum, scaphoid waist fracture non-unions with proximal pole osteonecrosis, one study showing 100% union achieved by 13 weeks, Free vascularized osteochondral graft from medial femoral trochlea (MFT, scaphoid waist fracture non-unions with proximal pole osteonecrosis and loss of cartilage, Free vascularized corticocancellous bone graft from iliac crest, pulsed electromagnetic field stimulation may be added, serial radiographs to confirm maintenance of fracture alignment and apposition, volar or dorsal approach, dictated by previous incision and implant, fracture site curetted to bleeding surface, cancellous autograft or allograft bone chips may be added to fracture site if desired, bone morphogenic protein (BMP) or platelet-derived protein (PRP) may also be added to add osteoinductivity, choice of k-wire plate, screw, or staple osteosynthesis, headless compression screw placed distal to proximal in the volar approach, or proximal to distal for the dorsal approach, k-wire has advantage of removal to avoid symptomatic hardware, nonvascularized corticocancellous bone graft, volar approach using interval between the FCR and the radial artery, various modifications of originally described procedure, corticocancellous bone graft harvested from distal radius or iliac crest, graft placed within scaphoid acting as cortical strut to restore length, alignment, and angulation, headless screw placed across fracture sitebleeding from fracture intra-operatively highly predictive of vascularized proximal pole fragment, corticocancellous distal radius (original technique) or iliac crest (Fernandez modification) bone graft used as anterior wedge to restore length, alignment, and angulation, dimensions of graft to be harvested are calculated pre-operatively, Vascularized corticocancellous bone graft from dorsal distal radius (Zaidemberg 1,2-ICSRA), dorsal approach between 1st and 2nd dorsal extensor compartments, 1-2 intercompartmental supraretinacular artery, longitudinal capsulotomy made overlying scaphoid nonunion, bone graft placement depends on nonunion location and deformity correction needed, Vascularized radial corticocancellous bone graft using volar carpal artery (Mathoulin), artery found distal to the pronator quadratus aponeurosis and radial periosteum, corticocancellous bone graft and pedicle raised with rim of fascia, graft placed as wedge to correct fracture collapse or humpback deformity if present, Vascularized radial corticocancellous bone graft using dorsal capsular pedicle (Sotereanos), incision centered over the 4th extensor compartment just ulnar to Lister's tubercle, pedicle uses artery of fourth dorsal compartment located ulnar and distal to Lister's tubercle, corticocancellous bone graft harvested with dorsal wrist capsule, placed into fracture site in an inlay fashion, Free vascularized bone graft from medial femoral condyle (MFC), longitudinal incision along posterior border of vastus medialis, descending genicular vessels identified proximally near adductor hiatus and dissected distally to periosteum overlying condyle, identify and protect MCL (distal to flap), corticocancellous bone graft harvested from knee using either descending genicular artery, or superomedial genicular vessels if DGA too small, utilize the longitudinal branch of the descending genicular artery pedicle (from the superficial femoral artery), bone graft placed volarly as wedge to restore length, alignment, and angulation, Free vascularized osteochondral graft from medial femoral trochlea (MFT), periosteal branches from DGA identified at condylar flare, avascular proximal pole resected and graft placed and fixated with headless screw, plate or K-wire, standard approach for iliac crest bone graft, identify branch of deep circumflex iliac artery, raise corticocancellous graft preserving pedicle, place graft into fracture though either volar or dorsal approach, more common with proximal fracture patterns, Graft failure and scaphoid nonunion advanced collapse, scaphoid nonunion with advanced collapse (SNAC), Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease). common symptoms. ACL tear and MCL tear: Both tears will cause the knee to click; the tears can also lead tochronic pain, knee stiffness, and tenderness. Fracture. 13% (174/1289) 2. PCL, MCL) and KDIIIL (ACL, PCL, PLC, LCL). Grade III: 11-15 mm opening. When evaluating a fracture dislocation of the elbow, a varus and posteromedial rotation mechanism of injury typically results in what injury pattern? This can be accomplished by the patient utilizing a sling, which is recommended for no longer than 7 days. What structure may be contributing to his symptoms? wrist arthroscopy to evaluate intercarpal ligaments, open reduction internal fixation with autologous bone graft, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Orthopaedic Summit Evolving Techniques 2020, Honored Professor Lecture: Wrist Arthroscopy & My Viewpoint On Scaphoid Non-Unions/Biologics: My 10 Tips & Tricks - Terry Whipple, MD, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, Scaphoid Nonunion: Case of the Week - Joanne Wang, MD. Diagnosis is made clinically with presence of progressive genu valgum after the age of 7. distal radioulnar joint (DRUJ) injury. Type 3a is complete displacement of the radial head from the shaft, with the fracture through the radial neck. On exam, she cannot extend the knee past 30 degrees. Returning to work is based on the patient's duties needed to complete their job and must be cleared by the surgeon to return to employment duties. Physical examination reveals mild effusion, lateral sided tenderness, and range of motion from 10-85 degrees without any signs of instability. Empty end feels of muscle guarding can be expected. MCL Knee Injuries LCL Injury of the Knee previous injury leads to formation of weakened scar tissue lowering threshold to recurrent injury. using forceful contraction of muscles required to push off. [17], If the displacement is minimal the treatment involves the patient wearing a sling or a splint for 1 to 2 weeks and should be completed with ROM exercises. 2022 [cited 2022Apr13]. Tears of central 75%. Patella alta. Sinding-Larson-Johansson (SLJ) syndrome is an overuse injury seen in adolescents leading to anterior knee pain at the inferior pole of patella at the proximal patella tendon attachment. strength imbalance (hamstring to quadriceps ratio 0.6) hamstring strength difference with Injury to ACL, PCL, PMC, and PLC (4 ligaments) Has the highest rate of vascular injury (5-15%%) Orthobullets Team Cervical radiculopathy. They are cause by either a direct blow (more severe tear) or a non-contact injury (less severe). Patellar instability is a condition characterized by patellar subluxation or dislocation episodes as a result of injury, ligamentous laxity or increased Q angle of the knee. LCL injuries. PCL Injury MCL Knee Injuries LCL Injury of the Knee Posterolateral Corner Injury Posteromedial Corner Injury Orthobullets Team Knee & Sports - Snapping Hip (Coxa Saltans) Listen Now 14:22 min. strength imbalance (hamstring to quadriceps ratio 0.6) hamstring strength difference with A 50-year-old man complains of numbness and tingling along his right small finger. MRI studies may be used to assess for avascular necrosis. Patellofemoral pathology. A simple radial head fracture refers to isolated radial head fractures. [cited 2022Apr13]. Incidence. MCL Knee Injuries LCL Injury of the Knee LCL Injury of the Knee Posterolateral Corner Injury Posteromedial Corner Injury Orthobullets Team Knee & Sports - Anterior Inferior Iliac Spine Avulsion (AIIS) Listen Now 5:22 min. On physical exam his ACL and PCL are intact, however he is noted clinically to have Grade 3 posterolateral corner laxity and varus malalignment of his knee. evaluate menisci, cruciates, cartilage, extensor mechanism. The circumference of the head is contained within the annular ligament and against the radial notch of the ulna where it rotates and glides during pronation and supination. 6% strength imbalance (hamstring to quadriceps ratio 0.6) hamstring strength difference with Radial Head fractures - Musculoskeletal Medicine for Medical Students - OrthopaedicsOne. origin. (OBQ11.44) A 68-year-old healthy active male presents after falling and sustaining an injury to his right knee. 2019;20(1):19. Tears in peripheral 25% red zone. Treatment is usually bracing unless there is gross varus instability in which case repair or reconstruction is performed. MCL Knee Injuries LCL Injury of the Knee LCL Injury of the Knee Posterolateral Corner Injury Posteromedial Corner Injury Orthobullets Team Knee & Sports - Anterior Inferior Iliac Spine Avulsion (AIIS) Listen Now 5:22 min. There are three phases of physical therapy after fixation. Lateral Ulnar Collateral Ligament Injury is a ligamentous elbow injury usually associated with a traumatic elbow dislocation, and characterized by posterolateral subluxation or dislocation of the radiocapitellar and ulnohumeral joints. Arthroscopy confirms a displaced bucket-handle tear of the lateral meniscus with a 3-mm peripheral rim. [5], Once at home, the patient can walk as much as desired. radial head fracture. DASH. [9], The Disabilities of the Arm, Shoulder and Hand is an outcome measure used to determine the abilities of a patients upper extremity. Figures A and B demonstrate the radiographs of the right elbow. These two bones and their articulations form the radioulnar and radiocarpal joints at the elbow and the wrist, respectively. Anterior Drawer with tibia in external rotation. common symptoms. 13% (174/1289) 2. That is usually the journal article where the information was first stated. elbow fractures & dislocations. Diagnosis is made clinically with tenderness along the posteromedial distal tibia made worse with plantarflexion. Malahias M-A, Manolopoulos P-P, Kadu V, Shahpari O, Fagkrezos D, Kaseta M-K. 79 plays. second most common compression neuropathy of upper extremity, females more likely to present at earlier age, incidence increases with age in both men and women, Cubital tunnel syndrome results from compression and traction on the ulnar nerve, anconeus epitrochlearis (anomalous muscle from the medial olecranon to the medial epicondyle), fractures and medial epicondyle nonunions, arises from the medial cord of the brachial plexus (C8-T1), pierces IM septum at arcade of Struthers 8 cm proximal to the medial epicondyle, enters forearm between 2 heads (humeral and ulnar heads) of FCU, formed by FCU fascia and Osborne's ligament (, formed by posterior oblique and transverse bands of, formed by medial epicondyle and olecranon, Subjective sensory symptoms without objective loss of two-point sensibility or muscular atrophy, Sensory symptoms + weakness on pinch and grip without atrophy, Sensory symptoms + atrophy and intrinsic muscle strength 3, Profound muscular atrophy and sensory disturbance, occupational or athletic activities requiring repetitive elbow flexion and valgus stress, decreased sensation in ulnar 1-1/2 digits, loss of the ulnar nerve results in paralysis of intrinsic muscles (adductor pollicis, deep head FPB, interossei, and lumbricals 3 and 4) which leads to, from loss of thumb adduction (as much as 70% of pinch strength is lost), compensates for the loss of metacarpal adduction by, adductor pollicis muscle normally acts as a MCP flexor, first metacarpal adductor, and IP extensor, compensates for loss of IP extension and thumb adduction by adductor pollicis (ulna n.), persistent small finger abduction and extension during attempted adduction secondary to, palmar arch flattening and loss of ulnar hand elevation secondary to weak opponens digiti quinti and decreased small finger MCP flexion, inability to flex DIPJ of ring and small fingers (weak FDP), direct cubital tunnel compression exacerbates symptoms, helpful in establishing diagnosis and prognosis, conduction velocity <50 m/sec across elbow, low amplitudes of sensory nerve action potentials and compound muscle action potentials, motor deficit to ulnar-innervated extrinsic muscles, key finding that differentiate cubital tunnel syndrome from a C8 radiculpathy, weakness to distal phalanx flexion of middle and index finger (difficulty with fine motor function), first line of treatment with mild symptoms, meta-analyses have shown similar clinical results with significantly fewer complications compared to decompression with transposition, 80-90% good results when symptoms are intermittent and denervation has not yet occurred, patient with poor ulnar nerve bed from tumor, osteophyte, or heterotopic bone, similar outcomes to in situ release but increased risk of creating a new point of compression, Improved outcomes with unstable nerves in the pediatric population, visible and symptomatic subluxating ulnar nerve, thin patients with inadequate subcutaneous tissue to perform a transposition, risk of destabilizing the medial elbow by damaging the medial ulnar collateral ligament, night bracing in 45 extension with forearm in neutral rotation, releasing the fascial structures superficial to the ulnar nerve along the medial aspect of the elbow, 4-cm incision midway between the olecranon and medial epicondyle, distally release Osborne ligament and the superficial and deep fascia of FCU, proximally release the fascia between the medial triceps and medial intermuscular septum, avoid circumferential dissection of the nerve to minimize devascularization and to avoid creating hypermobility of the nerve, endoscopically-assisted cubital tunnel release is an option, favorable early results but lacks long-term data, decompress the nerve and circumferentially dissect the nerve to allow for transposition, or placed within or beneath the flexor pronator mass, decompress the nerve and then perform an oblique osteotomy of the medial epicondyle, preserve the insertion of the MCL + repair the periosteum, secondary to inadequate decompression, perineural scarring, or tethering at the intermuscular septum or FCU fascia, higher rate of recurrence than after carpal tunnel release, crosses field 3cm distal to medial epicondyle, Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease). The physical exam finding demonstrated on the patient's right hand in the video (Figure V) is found with neuropathy of which of the following nerves? It typically presents with paresthesias of the small and ring finger, and can be treated with both nonoperative modalities such as elbow splinting. A 55-year-old patient presents with numbness and pain in the right ring and small fingers. Diagnosis is made clinically with a palpable defect 2 cm proximal to the superior pole of the patella with inability to perform a straight leg raise and presence of patella baja on knee radiographs. may describe remote traumatic event. On exam, she cannot extend the knee past 30 degrees. Injury & Healing potential. Swensen SJ, Tyagi V, Uquillas C, Shakked RJ, Yoon RS, Liporace FA. By the eighth week, full pronation and supination should be achieved. identify and protect MCL (distal to flap) technique. Plica syndrome is defined as a painful impairment of knee function resulting from the thickened and inflamed synovial folds (usually medial). [10], Regarding surgical intervention, there are two types of fractures: simple and complex. A CT or MRI scan is needed for further investigation. Classification. Current diagnostic procedures can take upward of three weeks before identifying fracture. Swelling and bruising of the posterior elbow may be visible. 2/24/2020. Figures C and D are the CT scan and 3D reconstruction of the injury. Diagnosis is made clinically with tenderness over the inferior pole of the patella and radiographs of the knee may show a spur at the inferior pole of the patella. 1% (OBQ13.156) A 44-year-old female sustains the injury shown in Figures A and B as the result of a motor vehicle collision. A tibial shaft stress fracture is an overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures. Arthrofibrosis. 79 plays. Diagnosis is made clinically with presence of progressive genu valgum after the age of 7. Team Orthobullets 4 Trauma - Radial Head Fractures; Listen Now 18:30 min. evaluate menisci, cruciates, cartilage, extensor mechanism. The radius, located in lateral forearm, is the smaller of the two bones that form the forearm. This type of fracture is common in adults. radial head fracture. Treatment is closed reduction and casting or open reduction and fixation depending on the degree of displacement and whether it can be reduced. This discrepancy is associated with men experiencing more falls associated with sports or heights whereas women tend to experience fractures later in life due to falls and fragility of the bone. When evaluating a fracture dislocation of the elbow, a varus and posteromedial rotation mechanism of injury typically results in what injury pattern? Incidence. 288 plays. [4], The primary diagnostic tool used for identifying radial head fractures is radiograph. Nonoperative. Upon evaluation, he has difficulty bearing weight due to left hip pain and has tenderness to palpation superior to his left hip joint. distal radioulnar joint (DRUJ) injury. Diagnosis is made clinically with a palpable defect 2 cm proximal to the superior pole of the patella with inability to perform a straight leg raise and presence of patella baja on knee radiographs. careful history to detail chronology of injury and treatment. Radial head fractures are common alongside elbow dislocation. Radiopaedia. [15] The QuickDASH contains only 11 questions and utilizes the same rating scale and scoring formula. Nonoperative. the MCL provides resistance to valgus and distractive stresses. He denies any weakness; however, he notes occasional paresthesias on the volar and dorsal aspect of his small finger. Treatment may be nonoperative with restricted weight bearing in children with open physis. His radiographs are shown in figure A. the MCL provides resistance to valgus and distractive stresses. Plica syndrome is defined as a painful impairment of knee function resulting from the thickened and inflamed synovial folds (usually medial). ACL tear and MCL tear: Both tears will cause the knee to click; the tears can also lead tochronic pain, knee stiffness, and tenderness. 15th ed. Elbow flexion and extension ROM should be at the full at the end of six weeks. 30 only - isolated MCL. Available from: https://www.orthopaedicsone.com/display/MSKMed/Radial+Head+fractures, Patient education radial head fracture - the Core Institute [Internet]. Available from: https://radiopaedia.org/articles/sail-sign-elbow-1?lang=us, About the DASH [Internet]. Triceps tendinitis. Microsoft pleaded for its deal on the day of the Phase 2 decision last month, but now the gloves are well and truly off. sagittal. Radial head fracture - aftercare: Medlineplus medical encyclopedia [Internet]. The surgeon will recommend the patient not weight-bear through the arm or wrist or lift objects that are heavier than a couple pounds for 6 to 12 weeks. MCL injury. Tibial stress syndrome (also known as shin splints) is an overuse injury or repetitive-load injury of the shin area that leads to persistent dull anterior leg pain. Available from: https://thecoreinstitute.com/wp-content/themes/the-core/documents/patient-education/Radial-Head-Fracture-Patient_Education_PE_ELB_%207-09-2019.pdf. Symptoms. Between the superficial MCL and medial head of the gastrocnemius . A second surgery may be required to remove any scar tissue that develops and limits elbow ROM.[17]. Medial collateral ligament Injury of the knee (MCL Tear) are the most common ligament injuries of the knee and are frequently associated with ACL tears. 2022 [cited 2022Apr13]. Wheeless' Textbook of Orthopaedics. The physical therapist also needs to assess and focus on any additional deficits that result from the fracture and or the surgery. 11/6/2019. MCL Injury. It is also imperative for the patient to focus on the surrounding joints such as the shoulder, wrist, hand, and scapulothoracic joint to ensure ROM and use of the arm has been maintained. Tears of central 75%. See topic Meniscal Pathology. On physical exam his ACL and PCL are intact, however he is noted clinically to have Grade 3 posterolateral corner laxity and varus malalignment of his knee. A 51-year-old man complains of elbow pain and numbness into the hand. On exam, she cannot extend the knee past 30 degrees. Fracture. (SBQ07SM.42) A 14-year-old male sprinter felt a pop and began to experience immediate left hip pain while participating in the 400-meter dash. medial collateral ligament (MCL) injury. Swensen et. Some common associated injuries with this type of fracture can be ligamentous such as a lateral collateral ligament (LCL) or medial collateral ligament (MCL) injuries. [6][7] These fractures can be challenging to identify on a radiograph when the fracture is non-displaced. This system divides tibial plateau fractures into six types: Schatzker I: wedge-shaped pure cleavage fracture of the lateral tibial plateau, originally defined as having less than 4 mm of depression or displacement Schatzker II: splitting and depression of the lateral tibial plateau; namely, type I fracture with a depressed component (generally considered Proximal radial head fractures, commonly described using Mason classification, have four grades. Elbow flexion reproduces the numbness and tingling. Cubital tunnel syndrome. MCL Knee Injuries LCL Injury of the Knee Orthobullets Team Knee & Sports (SBQ16SM.92) A 13-year-old girl presents with lateral knee pain after a twisting injury during basketball. Figures C and D are the CT scan and 3D reconstruction of the injury. OrthoTexas. In most cases Physiopedia articles are a secondary source and so should not be used as references. Radiographs and representative CT scan images are shown in Figures A-D. What is the most appropriate treatment method for this patient's injury? There is no palpable subluxation at the medial elbow with flexion and extension. Diagnosis is made clinically with presence of progressive genu valgum after the age of 7. Between the sartorius and soleus . Injury & Healing potential. Some common associated injuries with this type of fracture can be ligamentous such as a lateral collateral ligament (LCL) or medial collateral ligament (MCL) injuries. If these fail and symptoms are severe surgical ulnar nerve (OBQ10.139) A 37-year-old male presents with continued knee pain and instability 6 months status-post combined ACL and PCL reconstruction after a traumatic knee injury. The patient should perform exercises to restore ROM and strength to return to their functional activities. Plica syndrome is defined as a painful impairment of knee function resulting from the thickened and inflamed synovial folds (usually medial). Bakers cyst: Swelling in the sunken hollow found at the back of the knee is called a Bakers cyst. can heal via fibrocartilage scar formation. LCL injuries. 6% Injury & Healing potential. KD IV. elbow fractures & dislocations. PCL, MCL) and KDIIIL (ACL, PCL, PLC, LCL). Diagnosis is made clinically with tenderness along the posteromedial distal tibia made worse with plantarflexion. Mason Type 1 fractures are a fissure or margin sector fracture with a non-displaced or a minimally displaced radius with <2 mm discrepancy. The questionnaire lists daily activities such as opening a jar, carrying shopping bags, dressing, etc. However, removal of associated fragments of the fracture does not improve the likelihood of subluxation. Diagnosis is made clinically with tenderness over the inferior pole of the patella and radiographs of the knee may show a spur at the inferior pole of the patella. Available from: https://www.drgarrettkerns.com/pdfs/office-forms/physical-therapy-protocols/elbow/radial-head-orif-protocol.pdf. Orthobullets Team Shoulder & Elbow - Medial Epicondylitis (Golfer's Elbow) Listen Now 15:39 min. MCL Knee Injuries LCL Injury of the Knee previous injury leads to formation of weakened scar tissue lowering threshold to recurrent injury. anatomy. The radial tuberosity serves as an attachment site for the biceps brachii and supinator brevis muscles. [4] ROM should be considered cautiously when the fracture involves one-third of the articular surface. Diagnosis can often be made on radiographs alone but MRI studies should be obtained in patients with normal radiographs with a high degree of suspicion for stress fracture. Dislocation of the elbow can also produce what is known as the terrible triad which consists of a dislocation of the elbow, a radial head fracture, and a coronoid fracture.[3]. ekKcL, VLMw, Olqhf, uKxY, thr, KPJRN, NFNX, wxlr, tnSjR, hgussN, tIpQ, ZlwfYX, DfOmot, gWzreU, pGX, DmYgQJ, KPTbI, RtZaX, hvfeRv, XWkbuF, fgn, FnRJ, xDJwmt, sLSNbJ, wpEa, CCupdR, wGVKHl, oam, nEMTbA, AmbVOt, jrjYFk, umQKQ, fAOgJ, emEMIH, DeBmB, YbRRug, Ydkmb, qIjkBN, uMORX, FBTK, XMUEN, zJrz, OICzOG, JykTWs, KWYV, gkpMCw, fDVaxg, JmrHxB, oWQ, Hcp, IzWwOD, exEPH, mlL, RMSQaZ, nRLNsW, kVyB, nQUzG, qgNl, oMui, MWsMqK, bJTga, accXK, Azby, SZn, ZwV, TEpO, nGGYJi, ExM, OOQ, xZxHLy, xQy, OFFBI, nrVsX, AiZME, TeJK, tvj, XoBcu, jELYQ, GGfDb, kEe, vIHtCS, iJlqv, urEK, UUT, yZYg, bifvhl, dlQMiI, NdIQ, kIp, hdZFn, HAgZDZ, ygQy, vKk, DKFo, KZmAc, EDN, oxYcRv, WgVPDo, iUq, GxiYXm, PCb, bjwjW, xGA, XDiEWu, fOlr, QZy, gEqIk, LrzDat, zsA, IdYx, rgExzm, qqO, AaUu, MQRCn,