Dr.Wael Abboud (Trauma OB Part 5)
‫بسم اهلل الرحمن الرحيم‬
Trauma OB (421)
401-Which of the following radiographs (Figures A-E) are most
characteristic of an anterior coronal shear fracture of the
distal humerus?
FIGURES: A
B
C
D
E
Dr.Wael Abboud (Trauma OB Part 5)
Dr.Wael Abboud (Trauma OB Part 5)
1.
2.
3.
4.
5.
Figure A
Figure B
Figure C
Figure D
Figure E
PREFERRED RESPONSE ▼ 3
McKee et al described a unique "shear fracture of the distal
articular surface of the humerus" which involved coronal fractures
of the capitellum and a portion of the trochlea. He described the
characteristic radiographic finding as the "double-arc sign" which
represents the subchondral bone of the displaced capitellum and
lateral trochlea ridge. Figure C and Illustration A (below)
demonstrate the radiographic "double-arc" finding. Figure A shows
a radial head fracture. Figure B shows an elbow dislocation. Figure
D shows a pediatric lateral condyle fracture. Figure E shows a
pediatric medial epicondyle apophyseal avulsion fracture.
Dr.Wael Abboud (Trauma OB Part 5)
402-What is the most common complication of the fracture
seen in figure A, if operatively treated as seen in figure B?
FIGURES: A
B
Dr.Wael Abboud (Trauma OB Part 5)
1.
Decreased elbow range of motion
2.
Wound healing complications
3.
Iatrogenic ulnar nerve injury
4.
Inadvertent intra-articular hardware penetration
5.
Nonunion of either distal humerus fracture or olecranon
osteotomy
PREFERRED RESPONSE ▼ 1
Decreased elbow range of motion is the most common
complication after open reduction internal fixation of distal humerus
fractures. Per Galano et al, this loss of motion can arise from "a
variety of causes, including articular incongruity or adhesions,
capsular contractures, loose bodies, heterotopic ossification, and
prominent hardware."
Other complications include nonunion of the distal humerus (210%) and ulnar neuropathy (0-12%).
Dr.Wael Abboud (Trauma OB Part 5)
403-A patient sustains a transection of the posterior cord of
the brachial plexus from a knife injury. This injury would
affect all of the following muscles EXCEPT?
QID: 658
1.
2.
3.
4.
5.
Subscapularis
Latissimus dorsi
Supraspinatus
Teres minor
Brachioradialis
PREFERRED RESPONSE ▼ 3
The posterior cord of the brachial plexus gives rise to the 1) upper
subscapular nerve 2) lower subscapular nerve 3) thoracodorsal
nerve 4) axillary nerves 5) radial nerve. The upper subscapular
nerve innervates the subscapularis. The lower subscapular nerve
innervates teres major and also subscapularis. The thoracodorsal
nerve innervates latissimus dorsi. The axillary nerves innervates
deltoid and teres minor. The radial nerve innervates the triceps,
brachioradialis, wrist extensors, and finger extensors. The
supraspinatus is innervated by the suprascapular nerve off the
upper trunk and therefore would not be affected by an injury to the
posterior cord. The anatomy of the brachial plexus is shown in
Illustration A.
Dr.Wael Abboud (Trauma OB Part 5)
404-Which of the following is true regarding anterior
sternoclavicular joint dislocations?
QID: 387
1.
Reduction may result in tracheal injury
2.
They are usually stable following closed reduction
3.
They require fusion to hold the reduction
4.
They are rarely symptomatic when left unreduced
5.
They should be treated acutely with medial clavicle
excision
PREFERRED RESPONSE ▼ 4
From the Bicos article, “Anterior SC joint instability should primarily
be treated conservatively. The patients should be informed that
there is a high risk of persistent instability with nonoperative or
operative care, but that the persistent instability will be well
tolerated and have little functional impact in the vast majority.
Therefore, operative intervention for anterior SC joint instability is
mainly cosmetic in nature."
Dr.Wael Abboud (Trauma OB Part 5)
405-A 16-year-old male fell from a roof onto his right shoulder
and presents with decreased pulses in his right upper
extremity. Imaging reveals a posterior sternoclavicular
dislocation. What is the best treatment at this time?
QID: 15
1.
Nonoperative treatment with a sling and swathe for six
weeks
2.
Nonoperative treatment with immediate active range of
motion of the shoulder
3.
Closed reduction in the emergency room
4.
Open reduction and percutaneous pinning with thoracic
surgery back-up
5.
Open reduction and ligament reconstruction with
thoracic surgery back-up
PREFERRED RESPONSE ▼ 5
Symptomatic acute posterior sternoclavicular dislocations in
adolescents should undergo open reduction and ligament
(costoclavicular) reconstruction with thoracic surgery back-up. In
patients younger than age 20-25, this is usually a physeal injury,
as the medial clavicular physis does not close until this age range.
Chronic anterior or posterior dislocations are recommended to be
treated conservatively, especially if not symptomatic.
The review article by Wirth and Rockwood notes the following
complications with posterior dislocation: respiratory distress,
venous congestion or arterial insufficiency, brachial plexus
compression, and myocardial conduction abnormalities. They
recommend reconstruction of the costoclavicular ligaments with
resection of the medial clavicular head as needed for unstable
injuries.
The referenced article by Waters et al noted 100% excellent shortterm outcomes in adolescents with open reduction and
Dr.Wael Abboud (Trauma OB Part 5)
reconstruction of the costoclavicular ligament in pure dislocations
or with suture fixation of the medial physis in physeal injuries.
406-A 33-year-old female with generalized ligamentous laxity
is diagnosed with spontaneous atraumatic subluxation of the
sternoclavicular joint. She notes mild, intermittent pain and a
small amount of prominence to that area. What is the most
appropriate treatment at this time?
QID: 16
1.
No treatment is indicated at this time
2.
Figure of eight brace
3.
Resection arthroplasty of the sternoclavicular joint
4.
Sternoclavicular and costoclavicular ligament
reconstruction
5.
Sternoclavicular arthrodesis
PREFERRED RESPONSE ▼ 1
Spontaneous atraumatic subluxaton of the sternoclavicular joint is
a rare condition and is generally associated with ligamentous
laxity. Higginbotham et al reported that spontaneous atraumatic
anterior subluxation of the sternoclavicular joint may occur during
overhead elevation of the arm. The majority of cases are not
painful, and the subluxation usually reduces with lowering the arm.
Surgery is rarely indicated. Nonsurgical management, including
patient education of the benign nature of the condition, is
recommended. Rockwood et al reviewed a series of 37 patients
with this condition and noted that at an average follow-up of eight
years, the twenty-nine patients who were treated non-operatively
had excellent results, with no limitations of activity or changes in
lifestyle. The eight patients who were treated operatively (group II)
had numerous problems, including noticeable scars, persistent
instability, pain, or limitation of activity that resulted in an alteration
in lifestyle. The referenced article by Higginbotham is a review of
atraumatic disorders of the sternoclavicular joint.
Dr.Wael Abboud (Trauma OB Part 5)
407-A 33-year-old secretary presents three months after a
motor vehicle collision with a mild asymmetry to her sternal
area. She denies any complaints of respiratory distress,
dysphagia, or upper extremity paresthesias. Her upper
extremity neurovascular exam shows no deficits. A 3-D
computed tomography image is shown in Figure A. What is
the most appropriate treatment for this patient?
FIGURES: A
1.
Nonoperative treatment with a sling and unrestricted
activity in 3 months
2.
Nonoperative treatment with immediate unrestricted
active range of motion of the shoulder
3.
Closed reduction in the office with local anesthetic
4.
Closed reduction in the operating room with thoracic
surgery back-up
5.
Open reduction in the operating room with thoracic
surgery back-up
PREFERRED RESPONSE ▼ 2
The clinical presentation is consistent with a chronic
sternoclavicular dislocation, which is defined as being greater than
3 weeks old. The 3D CT image shows posterior displacement of
Dr.Wael Abboud (Trauma OB Part 5)
the medial clavicle relative to the sternum. Chronic anterior or
posterior dislocations are recommended to be treated
conservatively, especially if not symptomatic. Nonoperative
treatment with immediate range of motion of the shoulder is
indicated in this patient.
The review article by Wirth and Rockwood notes the following
complications with posterior dislocation: respiratory distress,
venous congestion or arterial insufficiency, brachial plexus
compression, and myocardial conduction abnormalities. They
recommend reconstruction of the costoclavicular ligaments with
resection of the medial claviclar head as needed for unstable or
symptomatic injuries.
408-A 35-year-old right hand dominant man falls from a ladder
and sustains the injury seen in Figure A. When discussing the
risks and benefits of operative versus nonoperative treatment
for his fracture, which of the following is true?
FIGURES: A
1.
2.
No difference in shoulder function
Higher risk of nonunion with operative management
Dr.Wael Abboud (Trauma OB Part 5)
3.
Higher risk of symptomatic malunion with nonoperative
management
4.
Earlier return to sport with nonoperative management
5.
No difference in union rates
PREFERRED RESPONSE ▼ 3
Historically, displaced midshaft clavicle fractures, as seen in Figure
A, were managed nonoperatively. Recent literature has
demonsrated improved outcomes with operative management of
these fractures.
Khan et al review current concepts in the management of clavicle
fractures. For displaced midshaft clavice fractures, operative
treatment seems to result in improved patient and surgeon-based
outcomes, decreased rates of malunion and nonunion, and shorter
time to union.
Kim and McKee review recent evidence regarding the
management of clavicle fractures. For midshaft clavicle fractures,
the incidence of nonunion and symptomatic malunion with
nonoperative management is higher than previously believed.
They state that risk factors include 100% displacement,
comminution, increasing age and female gender.
Incorrect Answers
Answer 1. Recent randomized prospective trials have shown
improved short term shoulder function with operative management
of displaced midshaft clavicle fractures.
Answer 2. Nonunion rates of 7-15% have been shown with
nonoperative management versus 2% with operative fixation
Answer 4. Earlier return to activities has been reported with
operative management
Answer 5. As with answer 2, there is a significantly higher rate of
nonunion with nonoperative management
409-What is the preferred treatment of displaced distal clavicle
fractures in children less than eight years old?
QID: 3182
Dr.Wael Abboud (Trauma OB Part 5)
1.
2.
3.
4.
5.
Closed reduction and pinning of the fracture
Open reduction and plating
Sling immobilization
Coracoclavicular ligament reconstruction
Open reduction and suture fixation
PREFERRED RESPONSE ▼ 3
Pediatric distal clavicle fractures are typically treated nonoperatively because of the great osteogenic capacity of the intact
inferior periosteum. The coracoclavicular ligaments remain
attached to the periosteum and new bone fills any remaining bony
gaps within the periosteal sleeve. Recent articles by Nenopoulos
et al recommend sling immobilization for the majority of fractures
(84%) and only attempt surgical fixation for children >8 years old
with severely displaced fractures (>2 cortical diameters). They
found excellent function with conservative treatment and union in
all fractures. Surgical care resulted in improved cosmetic
appearance.
410-A 32-year-old female sustains an isolated midshaft
clavicle fracture, as shown in Figure A. Her clinical exam does
not reveal skin tenting or neurovascular injury, but shortening
is measured at 2.6 cm. Which of the following treatment
methods has been shown to have the lowest rate of nonunion
and symptomatic malunion?
FIGURES: A
Dr.Wael Abboud (Trauma OB Part 5)
1.
Open reduction and internal fixation with plating
2.
Open reduction and percutaneous pinning
3.
Closed reduction and percutaneous pinning
4.
Closed reduction and external fixation
5.
Nonoperative treatment with a sling and early range of
motion
PREFERRED RESPONSE ▼ 1
Figure A shows a left clavicle fracture with significant shortening.
Open reduction and internal fixation with plate and screw
constructs of displaced, shortened clavicle fractures has been
shown to lead to the best patient reported functional outcomes as
well as have the least incidence of nonunion and symptomatic
malunion. Factors associated with poor functional outcome as well
as nonunion in these injuries include fracture displacement >2cm,
fracture comminution, fracture displacement > 100%, female
gender, and advancing age. The referenced article by Khan et al is
an excellent review of the indications, treatment methods and
outcomes of clavicle fractures.
Dr.Wael Abboud (Trauma OB Part 5)
411-Which of the following factors increase the risk of
nonunion in midshaft clavicle fractures when treated
nonoperatively?
QID: 440
1.
2.
3.
4.
5.
Sling immobilization
Displacement and comminution
Age less than 40 years old
Immediate motion exercises
Male
PREFERRED RESPONSE ▼ 2
Robinson et al have shown that lack of cortical apposition,
comminution, female gender, and advancing age are the 4 factors
that contribute to nonunion.
The Canadian Orthopaedic Trauma Society in a randomized,
prospective study showed that for midshaft fracture in adults with
100% displacement, ORIF results in improved DASH and Constant
scores (p = 0.001 and p < 0.01, respectively), lower nonunion (2
vs. 7, p=0.042) & lower malunion (0 vs. 9, p=0.001). Surgery
resulted in quicker radiographic union (16.4 weeks vs. 28.4 weeks,
p=0.001). However, 15% had hardware and wound complications.
At one year, the operative group was more likely to be satisfied
with the shoulder in general (p=0.002) and the appearance of the
shoulder in particular (p=0.001) in comparison to the nonoperative
group.
Prior studies have shown that greater than 2cm of shortening
treated non-operatively results in increased fatigueability and poor
outcome, but not necessarily nonunion. The Lazarides article
concluded that “Final clavicular shortening of more than 18 mm in
male patients and of more than 14 mm in female patients was
significantly associated with an unsatisfactory result.”
Studies have shown no difference in outcome when treated with a
Figure-of-8 harness compared to a simple sling.
Dr.Wael Abboud (Trauma OB Part 5)
412-A 20-year-old woman is involved in a high-speed motor
vehicle collision and sustains bilateral tibial plateau fractures
as well as the clavicle fracture shown in Figure A. What is the
most appropriate management of the clavicular injury?
FIGURES: A
1.
2.
3.
4.
5.
Closed reduction and figure of 8 splinting
Open reduction and plate fixation
Open reduction and percutaneous pinning
Simple sling to involved side
Sling with abduction pillow to involved side
PREFERRED RESPONSE ▼ 2
The radiograph shows a comminuted clavicle fracture with
significant displacement. Indications for surgical fixation of clavicle
fractures include: open fractures, underlying neurovascular injury,
or impending open fracture from internal bony pressure causing
skin compromise. Relative indications for fixation include: greater
than 15 mm of shortening, greater than 100% displacement (no
bony contact), highly comminuted fractures, and polytrauma
patients.
Dr.Wael Abboud (Trauma OB Part 5)
Jeray et al review the evaluation and treatment of midshaft clavicle
fractures. They state "when midshaft clavicular fractures are
completely displaced or comminuted, and when they occur in
elderly patients or females, the risk of nonunion, cosmetic
deformity, and poor outcome may be markedly higher. Thus, some
surgeons propose surgical stabilization of a complex midshaft
clavicular fracture with either plate-and-screw fixation or
intramedullary devices. Further randomized, prospective trials are
needed to provide better data on which to base treatment
decisions."
413-A 22-year-old male sustains a right shoulder injury after
being thrown from his motorcycle. After six months of
conservative treatment, he continues to complain of pain. A
current radiograph is shown in Figure A. What is the most
appropriate treatment?
FIGURES: A
1.
2.
3.
Addition of a bone stimulator
Figure of eight brace
Closed reduction and percutaneous pinning
Dr.Wael Abboud (Trauma OB Part 5)
4.
5.
Open reduction and internal fixation
Open reduction and internal fixation with bone grafting
PREFERRED RESPONSE ▼ 5
Figure A shows an atrophic clavicular nonunion. Observation is the
wrong answer because the patient is symptomatic (if the patient is
asymptomatic an atrophic nonunion of the clavicle can be
observed unless neurovascular symptoms are present).
Intramedullary fixation is difficult because the pin has to pass
through thin atrophic ends of bone close to neurovascular
structures. Percutaneous pinning may cause distraction and
migration of K-wires is common.
In the two referenced studies, the authors note success in treating
these nonunions, when compression and lag-screw fixation
(absolute stability) is used in conjunction with cancellous autograft.
414-A 45-year-old male falls onto his left shoulder while
biking. An injury radiograph is shown in Figure A. He elects
for nonoperative treatment. What is the most likely clinical
outcome?
FIGURES: A
1.
2.
3.
Symmetric cosmesis of shoulders
Reduced shoulder motion
Symptomatic nonunion
Dr.Wael Abboud (Trauma OB Part 5)
4.
5.
Shoulder instability
Decreased shoulder strength and endurance
PREFERRED RESPONSE ▼ 5
Patients who have nonoperative treatment of displaced midshaft
clavicle fractures have significant decreases in both strength and
endurance to approximately 80% of the contralateral side as
described by the McKee article. There was a trend correlating
shortening >2cm with poor outcome (p=0.06). Motion was found to
be preserved. In the Canadian Orthopaedic Trauma Society's
landmark randomized control trial of operative versus nonoperative
treatment for displaced clavicle fractures, patients treated nonoperatively had lower subjective outcomes scores, slower rates to
union, more nonunions, more symptomatic malunions, and were
less satisfied with the appearance of their shoulder. There were
more hardware related complications in the operatively treated
group. The second McKee article describes improvements in
subjective outcome scores after midshaft clavicle malunion
corrective osteotomy.
415-A 31-year-old male sustains the injury shown in Figure A.
As compared to treatment with a simple sling, what is the
primary advantage of treatment with a figure-of-eight brace?
FIGURES: A
Dr.Wael Abboud (Trauma OB Part 5)
1.
Decreased sleep disturbance
2.
Decreased personal care and hygiene impairment
3.
Decreased rates of malunion
4.
Improved long-term clinical outcomes
5.
No advantage, equivalent result between a simple sling
and figure-of-eight brace
PREFERRED RESPONSE ▼ 5
Figure of eight braces have been shown to have no differences as
compared to simple slings in regard to healing times, healing rates,
and alignment at final follow-up. The referenced study by
Andersen et al is a randomized controlled study showing
equivalent cosmetic and clinical outcomes with sling versus figure
of eight bracing despite increased sleep disturbances and
increased rate of personal care impairment. The second
referenced study by Nordqvist et al is a case series designed to
analyze the long-term outcome of mid-clavicle fractures in adults
and to evaluate the clinical importance of displacement and
fracture comminution. They found a 39/225 rate of moderate
shoulder pain with figure of eight bracing. Overall they concluded
that few patients with fractures of the mid-part of the clavicle
require operative treatment.
Dr.Wael Abboud (Trauma OB Part 5)
416-The modified Judet approach to the posterior scapula
exploits the internervous interval between what two muscles?
QID: 520
1.
2.
3.
4.
5.
Supraspinatus and infraspinatus
Supraspinatus and subscapularis
Infraspinatus and teres minor
Terers minor and teres major
Teres major and lattisimus
PREFERRED RESPONSE ▼ 3
The posterior or modified Judet approach to the scapula is typically
used for internal fixation of scapular fractures. This approach
utilizes a transverse incision over the scapular spine with
detachment of the posterior deltoid. The interval between the
infraspinatus (suprascapular n.) and teres minor (axillary n.) is
identified and used to gain access to the posterior aspect of the
scapula and glenoid.
The reference by Obremskey et al argues the approach "combines
several important goals including: 1) exposure of all bony elements
of the scapula which have adequate bone stock for internal
fixation; 2) minimal trauma to the rotator cuff musculature; and 3)
protection of the major neurologic structures (suprascapular nerve
superiorly and axillary nerve laterally)." They believe "the main
advantage of the exposure is limiting muscular dissection, which
can potentially improve rehabilitation and limit morbidity of the
operation."
417-A patient sustains a displaced scapular neck fracture.
What is the internervous plane for a posterior approach to the
glenohumeral joint?
QID: 783
Dr.Wael Abboud (Trauma OB Part 5)
1.
2.
3.
4.
5.
lateral pectoral-axillary
subscapular-musculocutaneous
suprascapular-axillary
long thoracic-spinal accessory
suprascapular-subscapular
PREFERRED RESPONSE ▼ 3
Surgical fixation of a scapular neck fracture is performed via the
Judet approach, a posterior approach to the scapula/glenoid. The
internervous plane is between the infraspinatus (suprascapular
nerve) and the teres minor (axillary nerve). As outlined by Ball et
al, the posterior branch of the axillary nerve has intimate
association with the inferior aspects of the glenoid and shoulder
joint capsule, which may place it at particular risk during a
posterior approach to the shoulder.
418-A 35-year-old male is involved in a motor vehicle accident
and suffers the fracture shown in Figure A. This is an isolated
shoulder injury, and he has no neurologic deficits on physical
exam. CT scan of the scapula shows the glenoid to be
translated medially 3mm, and anglulated 20 degrees from its
anatomic axis. What is the most appropriate initial treatment
for this injury?
Dr.Wael Abboud (Trauma OB Part 5)
FIGURES: A
1.
2.
3.
4.
5.
Immobilization in sling x 2 weeks then PT
Immobilization in sling x 8 weeks then PT
ORIF via a deltopectoral approach
ORIF via a posterior approach
ORIF via a lateral approach
PREFERRED RESPONSE ▼ 1
The radiographs are consistent with a Type I extra-articular glenoid
neck fracture, which by definition is not significantly displaced.
Type I fractures are best treated with a sling (2 weeks) and early
mobilization. Significantly displaced fractures (Type 2), as defined
by Goss, have translational displacement greater than or equal to
1 cm or angulatory displacement greater than or equal to 40°.
These typically need ORIF. A schematic of the fracture types is
shown in Illustration A.
McGahan et al review the epidemiology of scapula fractures and
advocate conservative treatment with early mobilization.
Van Noort et al reviewed 13 scapular neck fractures and found that
non-operative treatment in the absence of ipsilateral shoulder
injury and associated neurological impairment lead to good
Dr.Wael Abboud (Trauma OB Part 5)
functional outcomes, with or without significant translational
displacement of the fracture.
419-In trauma patients with multiple injuries, patients with
scapula fractures have been shown to have an association
with which of the following, as compared to patients without
scapula fractures?
QID: 277
1.
2.
3.
4.
5.
Increased length of hospital stay
Increased mortality rate
Increased rate of extremity fracture(s)
Increased Injury Severity Scores
Increased length of intensive care unit stay
PREFERRED RESPONSE ▼ 4
Dr.Wael Abboud (Trauma OB Part 5)
According to the reference by Veysi et al, patients presenting to a
trauma center with scapula fractures have an increased rate of
pulmonary complications and increased Injury Severity Scores
(ISS), but have no difference in mortality, length of ICU stay, or
overall hospital stay. No differences were seen in abdominal or
head injury rates either. A lower rate of extremity fractures was
seen as compared to non-scapular fracture patients in their series.
According to the referenced study by Brown et al, rib fx (44%) are
the most common associated injury with scapula fractures.
420-A 30-year-old male sustains a right shoulder injury with
initial radiographs shown in Figures A and B. What single
piece of additional information would best assist in
determining this patient's functional outcome?
FIGURES: A
B
Dr.Wael Abboud (Trauma OB Part 5)
1.
2.
3.
4.
5.
Lower extremity injury
Neurological deficit
Contralateral upper extremity injury
Proximal humerus fracture
Worker's compensation
PREFERRED RESPONSE ▼ 2
Figures A and B show a scapulothoracic dissociation, with
significant lateralization of the scapula and widening of the
acromioclavicular joint to over 4 cm (Figure A). This can be
thought of as an internal disarticulation of the scapulothoracic
association and acromioclavicular joints.
The referenced article by Riess et al revealed that functional
outcomes are worse with brachial plexus injuries and concomitant
scapulothoracic dissociation than with isolated brachial plexus
injuries. In fact, at 2 year follow-up, only 57% of the dissociation
patients could carry anything over 5 lb with the injured side.
Dr.Wael Abboud (Trauma OB Part 5)
The other referenced article by Zelle et al found that complete
brachial plexus injuries portended the worst outcome for
scapulothoracic dissociation injuries.
421-A patient presenting with scapulothoracic dissocation and
ipsilateral extremity neurologic injury is most likely to have
which of the following outcomes?
QID: 3140
1.
2.
3.
4.
5.
Glenohumeral arthritis
Return of 3/5 motor strength in distal extremity
Full return of extremity sensory function only
Flail extremity
Death
PREFERRED RESPONSE ▼ 4
Scapulothoracic dissociation is a high-energy injury resulting from
massive traction injury to the shoulder girdle with disruption of the
scapulothoracic articulation. The most common long term result
from this injury is complete loss of motor and sensory function of
the extremity (flail limb), with death in the acute or semi-acute
period also common. The referenced study by Althausen et al
found that outcomes from this injury were: a flail extremity in 52%,
early amputation in 21%, and death in 10%. The other referenced
study by Ebraheim et al found that 12/15 patients had a complete
brachial plexus injury and that none recovered any function (the
other 3 patients died in the acute period).
Good Luck
…………………
Dr.Wael Abboud (Trauma OB Part 5)
Regards……………………..