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    Language of Medicine

    In order to appreciate various injuries that occur to the body, it is helpful to also learn the language of medicine. Terms referencing the human body are frequently described in what is known as the anatomic position. This means when the body is standing tall with the face forward, the arms at the sides and with the palms of the hands facing forward. With that position in mind, superior, or also is known as cranial or cephalic, means toward the head. Inferior or caudal means towards the feet. Anterior means towards the front. Posterior or dorsal means towards the back. Medial means towards the midline. Lateral means towards the side. External means towards the surface. Internal means away from the surface. Proximal means towards the main mass of the body. Distal means away from the main mass of the body. Central means towards the center of the body. Peripheral means away from the center of the body. This language is utilized to determine where a certain part of the body is in relation to other parts of the body.

    Sometimes, medical professionals also describe planes of the body in relation to anatomic position. Three of those planes are sagittal, coronal, and transverse. Sagittal and coronal planes are both vertical planes along the long axis of the body while the transverse plane is at right angles to the longitudinal axis of the body.

    The skeletal system has more than two hundred bones. It also is comprised of many cartilaginous parts which are described as hyaline, elastic and fibrous. Bones provide support for the body and protect its organs. Their cavities inside the bones contain marrow and is where blood formation and storage of minerals occurs, especially calcium and phosphorous. Muscles attach to bones and assist in providing movement of body parts. Most bones can be described as either long, short, flat or irregular.

    The contact or union between two or more bones or cartilages is referred to as articulations. This term also describes the degree of motion occurring at joints. The joints are sometimes described by the type of tissue between the boney surfaces. Bones joined by a small amount of fibrous tissue are called fibrous joints. Joints united by cartilage are often referred to as primary or secondary cartilaginous joints. These often are viewed as suggestive of growth. Synovial joints are often encapsulated by an outer sleeve of connective tissue and are freely movable. The term range of motion in joints is suggests the degree of laxity of the joint capsule and the amount of give present in the ligaments that unites adjacent bones. Range of motion indicates the freedom of motion of a joint.

    Normally, three types of muscle tissue are present in the body. Blood vessels and organs usually have smooth muscle. The walls of the heart contain what is called cardiac muscles. The muscles of the body are usually referred to as skeletal muscle. The control that we exercise over our body is conducted by approximately six hundred and fifty skeletal or voluntary muscles. Collagen fibers are present at the end of a muscle and they help form tendons which unite the muscle to a bone, for example, that allows movement.

    Terms used to describe the specific movement of a muscle away from the anatomic position indicates the direction the muscle moves a part of the body. The terms used for these movements include flexion, extension, abduction, adduction, medial or lateral rotation, circumduction, suppination, pronation, inversion, and eversion. Flexion means bringing a muscle towards the body. Extension means taking the extremity away from the body. External rotation means turning the hand so that the thumb and palm are away from the body. Internal rotation means turning the hand and thumb and palm of the hand towards the body. Abduction means closing fingers together. Adduction means opening fingers. Circumduction means rolling the hand over completely. Suppination means turning the hand away from the body as it extends downward. Pronation means turning the hand towards the body. Inversion means turning the foot onto its outside surface. Eversion means turning the foot on its inside surface or big toe.

    The movement of blood to and from capillary beds for the exchange of respiratory gasses, nutrients and metabolites is what is normally referred to as the cardiovascular system. The heart, arteries, capillaries, veins and lymphadics comprise the circulatory system. Frequently, the heart is discussed as if there are two hearts. Venous blood is received in the right chamber of the heart. It is low in oxygen content. It is pumped towards the lungs to be oxygenated. The oxygenated blood is received from the lungs into the left chamber of the heart which in turn pumps it to the rest of the body by way of the aorta. Blood is carried away from the ventricles of the heart by arteries to the beds of the capillary vessels. When there is a weakened section of the wall of an artery or vein that bulges outward this is called an aneurysm. Sometimes this phenomena causes a permanent dilation of the blood vessel. Eventually, if the aneurism continues to dilate the vessel wall becomes so thin it bursts and can cause massive hemorrhage with shock, pain, stroke or death. Varicose veins of the lower extremities is caused by increase venous pressure with dilation of the veins, due mostly to valvular incompetence and gravity from the upright position. This is another common disorder of the vascular system.

    Lymph channels and lymph nodes make up what is called the lymphatic portion of the vascular system. This system does not have pumping apparatus and does not form a complete circuit. Lymph nodes are usually found along the course of the lymph vessels and act as small filtering stations for the lymph. Surgeons need to understand the location of the lymph nodes and the direction of the lymph flow because of its relationship to the diagnosis of cancer metastasis. It is commonly thought that cancer cells spread through the lymphadic system. When the cancer cells accumulate they can produce tumor cells at that location. As a result, physicians can often approximate where secondary tumor sites may be located because of our knowledge of lymph flow.
    The nervous system and the endocrine system provide for the body’s ability to coordinate its functions. Various stimuli provide for voluntary and reflex actions between various parts of the body. Environmental changes affect how the nervous system responds. The fundamental aspect of the nervous system is the neuron or what is sometimes referred to as the nerve cell. The neurons can transmit nerve impulses from various organs or structures of the body to the brain and spinal cord or they can transmit impulses away from the brain or spinal cord towards the parts of the body. A receptor ending located at the end of each nerve cell respond to sensations such as pain, temperature and pressure. In injury situations involving intractable pain, a neurosurgeon may cut or ablate the sensory nerve roots to eliminate the pain from reaching those nerve endings and hence being transmitted to the brain or spinal cord. Immediate relief can be achieved sometimes below the level of the section ablated. Cutting the nerve endings is called a rhizotomy. When there is sectioning of the pain pathways in the spinal cord, this is called a cordotomy.

    The peripheral nervous system includes the distributing nerves of the body and small clusters of nerve cell bodies located in ganglia. Referred pain, that pain on a body surface often far removed from the organ involved, is a function of the peripheral nervous system being activated by pain. Some of the examples of referred pain are: cardiac arrest with pain in the chest wall and also radiating down the inside of the left upper extremity, or gallbladder disease with pain in the right upper abdominal area. Shingles (herpes zoster) is a type of a viral infection of a sensory root ganglion.

    The body also has what is known as an autonomic nervous system which is part of the peripheral nervous system. This system gives motor innervation to smooth muscles, cardiac muscles and glands. The autonomic nervous system has two essential parts, the sympathetic and parasympathetic system. The sympathetic portion of the autonomic nervous system can be found in the thoracic and upper two lumbar segments of the spinal cord. The parasympathetic portion of the autonomic nervous system can be found in the brain stem or in the lateral horn of the second, third and fourth sacral segments of the spinal cord.

    The elastic covering of the body is known as the skin. This protects against injury and disease, loss of body fluids and temperature changes. The skin has nerve endings that provide information to the brain about the surrounding environment. It also consists of four appendages including the hair, nails, oil glands and sweat glands.
    The muscles of the back are layered. The upper limbs are attached to the vertebral column by muscles. For example, a very large muscle called the trapezius muscle is located over the upper portion of the back. The latissimus dorsi muscle is located laterally to the chest. The lavator scapulae and the rhomboidei minor and major are found posteriorly near the medial edge of the scapula. These muscles assist in elevation of the scapula. The serratus anterior muscle is also located near the medial border of the scapula. It provides adherence for the scapula onto the ribcage. There are three muscles that cover the scapula: the superspinatus, infraspinatus and subcapularus. Several tendons that cross the scapula provide the main stability of the shoulder joint. The tendons that cross the scapula form what is called the rotator cuff which acts as a strength for the joint itself. The inferior aspect of this joint is also where dislocations and subluxations can occur.

    S-shaped bones called the clavical acts as a strut between the shoulder and the sternum. This bone permits to swing outward from the body. The clavical breaks easily during a fall where the arm is extended as a brace against the fall. The pectoralis major, pectoralis minor and subclavius muscles are the main muscles of the pectoral region.
    The female breast is found in the fascia of the pectoral region. It is considered a modified sweat gland and covers the pectoralis major muscle. The female breast is normally located between the second and sixth rib. The patient frequently is the first person to notice any signs of cancer of the breast. Personal exam can sometimes reveal a mass present in the breast. It is important to recognize when a mass exists because any mass could be malignant. Depression or dimpling of the skin occurs when the cancer cells located in the gland enlarge and attach to ligaments thereby causing shortening of the ligaments. As a result of this process, the nipple can retract or invert. In more severe cases, if the cancer is deeper and invades the pectoralis major muscle, upper movement of the whole breast can occur as a result of contraction of this major muscle. Statistics reveal that the most common metastatic neoplasm in women is cancer of the breast. The cancer can also spread to other surrounding tissues. Studies reflect that cancer cells frequently travel through the lymphatics and blood vessels to other parts of the body. A radical mastectomy is often the operation chosen to remove the cancer. This involves taking out a wide margin of tissue and the corresponding lymph nodes. In addition it includes the removal of the breast and the pectoralis major and minor muscles.

    The arm is comprised of the biceps muscle, brachia muscle and the triceps muscle. Part of the brachial plexus and cervical plexus innervate the arm The arm is supplied by the ulnar, median, and radial nerves, all of which assist in the cutaneous innervation of hand. The area of the skin supplied by a spinal nerve is called a dermatome. Treating physicians often refer to dermatome patterns to verify the existence of objective manifestation of injury. For example, a part of the forearm and hand is supplied by the eighth cervical spinal nerve. A treating physician attempts to determine whether there is a correlation between a subjective complaint and the corresponding dermatome pattern by testing sensory loss or areas provided by spinal nerves. This assists in obtaining a working diagnosis of specific neurological involvement. Erb-Duchenne paralysis, or what is called upper arm birth palsy (paralysis of the abductors and lateral rotators of the shoulders and the flexors of the elbow), is one of the most common types of injury during childbirth. It can be caused by widening of the angle between the head and the shoulder by force by pulling on the head at birth or using forceps to rotate the fetus in utero. Similarly, it can also be caused by direct force to the shoulder by falling on it for example. This injury can be catastrophic and involves the C5 and C6 vertebrae area of the cervical spine. Damage to the lower cervical spine in the C8-T1 area can cause lower arm injuries (Klumpke’s paralysis). Often, this happens when the arm is stretched upward very forcefully, often resulting in a claw-hand appearance. Fractures of bones near related nerves and blood vessels such as the humerus are often serious as well. Tennis elbow, or what is also called lateral epicondylitys, indicates an inflammation of the lateral epicondyle of the humerus or tissues surrounding it. Physicians usually prescribe rest to cure the problem. Serious injuries to the media nerve, ulnar nerve or radial nerve can also occur in a traumatic incident. For example, a nerve injury to the median nerve can cause loss of sensation for most of the palm and middle fingers and the ring finger. Moreover, an injury to the ulnar nerve can cause motor and sensory loss to the hand. Loss of extension with wrist drop can occur with a radial nerve injury. This could result in the injured person not being able to extend the wrist against gravity.

    The hand has basically three muscle groups- thenar, hypothenar and interossein lumbricales. Synovial sheathes surround the tendons at the wrist and in the hand. An injury that occurs frequently is what is called tendo synovitis which is an infection of the synovial tendon sheath. Wounds from a sharp object which carries germs into the sheath can cause this infection. A symptom the injured person feels is tenderness over the sheath and significant pain at the tip of the finger.

    Compression of the median nerve by the transverse carpal ligament can cause carpal tunnel syndrome which is very painful. A burning sensation or numbness is felt in fingers as well as weakness or atrophy of the thenar muscles. Inflammation from chronic irritation of the transverse carpal ligament, often from repetitive motion, can cause this problem. Trauma can also cause carpal tunnel syndrome. A surgeon will attempt to divide the transverse carpal ligament can in order to decompress the carpal tunnel and median nerve. If successful, function to the area can occur. Unfortunately, the longer carpal tunnel injury goes untreated, the more difficult it is to obtain full recovery.

    Shoulder Joint

    The ball and socket shoulder joint consists of the head of the humerus, articulating with a much smaller flat glenoid fascia of the scapuli. It has the greatest freedom of movement of any joint in the body. It is an inherently unstable joint. Dislocation of the shoulder joint is not uncommon. The stability of the joint depends on the strength of the tendons of the scapula muscles.

    Elbow Joint

    The elbow is a double-hinged joint. The most common injury to the elbow is inflammation or what is commonly called epicondylitys.

    Wrist Joint

    When one falls on an outstretched arm, the radius bears most of the force of the fall, transmitted through the hand. Frequently, one obtains a Colles’ fracture of the lower end of the radius. The hand in this type of an injury is displaced backward and upward.

    Throax

    The thoracic cage is formed by the sternum, the ribs and the thoracic vertebrae. It gives protection for the lungs and heart and attaches to muscles of the thorax, upper extremity and diaphragm. There are generally twelve pair of ribs in the body. What is known as intercostal muscles, intercostal arteries and nerves serve the thoracic area of the body. The thorax contains two pleural sacs and a midline pericardial cavity. The pleural cavity and lung extend into the neck. Therefore, a puncture wound from a knife, needle or bullet superior to the clavicle can penetrate the pleura and the lung and produce air in the pleural cavity which is known as pneumothorax. The lungs are organs of respiration. Inspiration is an active process whereas expiration usually is passive. The trachea functions as the air conduction system for the body. A tracheotomy is a life-saving procedure that is used to provide inspiration and expiration which bypasses an obstruction. This is usually performed by making a midline skin incision above the jugular knotch and deepened so that a metal or plastic tracheal tube can be inserted into the trachea and breathing is re-established.

    The pericardial cavity surrounds the heart and proximal portions of the great cardiac vessels. Inflammation of the pericardium can be life-threatening as it results in compression of the heart and circulatory failure. Insufficient blood supply to the heart muscle (myocardial ischemia) can cause a heart attack. This is usually preceded by severe chest pain (angina pectoris) over the area of the heart. A common cause for the reduced blood supply is reduction of the diameter of the lumen of one or more of the coronary arteries caused by accumulation of athlerosclerotic plaques within the inner wall of the artery. Another cause can be a blood clot in the coronary artery. If blood flow is of significant time, local tissue in and around the heart may result, causing permanent loss of muscle fiber. If the damage covers a substantial portion of the heart wall, the heart is unable to maintain function and cardiac arrest or heart attack results. The aorta has a higher incidence of aneurysms than any other artery.

    Abdomen

    The abdomen consists of the lumbar plexus, diaphragm, abdominal cavity, gastrointestinal tract, small intestine, large intestine, liver, pancreas, spleen, kidney, ureter, and suprarenal gland. The lumbar plexus is formed by the first four lumbar spinal nerves and the twelfth thoracic nerve. The femoral nerve is the larger branch of the lumbar plexus. The diaphragm is a movable, musculotendinous partition between the thoracic and abdominal cavities. It forms the concave roof of the abdominal cavity and the convex floor of the thoracic cavity. A hiatal hernia (esophageal hernia) is the most common site of a diaphragm hernia. It is usually associated with heartburn and often accompanied by regurgitation of gastric contents into the mouth.

    The abdominal cavity is the largest cavity in the body. The peritoneum is a membrane that lines the walls of the abdominal cavity. Peritonitis is an inflammation of the peritoneum.

    The stomach is the first abdominal subdivision of the alimentary canal which is part of the gastrointestinal tract. A gastric ulcer usually involves bleeding, recurrent pain and gastric outlet obstruction. The small intestine is a tube that is located centrally in the abdominal cavity and is surrounded by the large intestine. The small intestine gradually gets smaller as it descends. A duodenal ulcer can occur in the small intestine. Often patients with serious complications are treated surgically. The large intestine extends from the ilium to the anus.

    The liver is the largest gland in the body. The gall bladder is a small sac that serves as a reservoir for bile. Bile secreted by the liver cells is carried away from the liver. The pancreas is an elongated endocrine and exocrine gland that lies on the posterior abdominal wall. Insulin is essential in carbohydrate metabolism. Diabetes mellitus is a deficiency of insulin production from the cells of the pancreas. Loss of carbohydrate metabolism results in increased blood sugar levels, increased sugar in the urine and increased urine output, thirst, hunger and weakness. This is controlled by strict dieting, proper injection of insulin and/or anti-diabetic drugs.

    The spleen is a flattened, highly vascular organ. The spleen is usually well protected from traumatic injuries. It is often damaged from blunt abdominal trauma, especially significant blows over the lower left chest or upper abdomen. If the spleen is injured it may rupture and cause hemorrhage and shock. This requires a prompt splenectomy to keep the patient from bleeding to death.

    The kidney is a structure that lies on the posterior abdominal wall. It is made up of a left and right kidney. The kidney is surrounded by fat that helps stabilize the organ. If injured, urine may accumulate in the renal pelvis and result in distention of the pelvis, permanent damage to the kidney may result. A blow to the kidney from a blow to the lumbar region of the back or jarring of the body may cause mobility of the kidney leading to permanent damage. The supra renal (adrenal) gland is an endocrine organ next to the kidney.
    The ureter carries urine from the renal pelvis to the urinary bladder. The pelvic ureters are the most vulnerable organs in surgery performed on other pelvic areas such as the uterus. The ureter may accidentally be cut with the ovarian vessels. It may be crushed by a clamp or a tie.

    Inferior Extremity

    The inferior extremity consists of the hip, thigh, knee, leg, ankle and foot. Injury can occur to the bones, muscles, ligaments, tendons and nerves in these respective anatomical parts. Phantom pain, for example, is often felt by patient who have a limb amputated. They still experience pain in the extremity as if it were still there. Apparently stimuli from those nerves are interpreted by the brain as coming from the non-existent limb. The gluteal region is a common site for needle injections. However, care must be given to not injure the sciatic nerve. The injection should be made in the upper, outer quadrant of the buttocks which is not nearly as close to the sciatic nerve and large blood vessels.

    A femoral hernia may result from weakness of the lower abdominal wall. This may allow entrance of tissue into the thigh. A herniated disc is a protusion of the nucleus pulposus and pressure on a spinal nerve. This frequently causes pain in the lower back which is usually a result of spasm of the muscles of the back. The level of the disc involved is frequently determined by the sensation deficit of the involved dermatome to the lower extremity and/or by loss of specific muscle reflexes.

    Foot drop can be caused by lack of nerve supply to the extensor muscles in the leg. The patient will be unable to extend his foot against resistance. This is frequently due to herniated discs or trauma to the common peroneal nerve which is the most frequently damaged nerve in the lower extremity.

    Dislocation of the hip is fairly rare. The hip has stability at the ball and socket joint. It is strong and tough. The ligaments surrounding it are usually strong as well as the musculature. Dislocation of the hip, however, must be reduced surgically and a cast or traction is used to prevent reccurring dislocation.

    The integrity of the knee joint depends on the strength of the femoral tibial ligaments and the muscles surrounding the joint, especially the quadriceps femoris. This muscle is capable of functionally assisting the joint even if ligaments are damaged. One of the most common athletic injuries is the rupture of the medial collateral ligament which is frequently accompanied by tearing of the medical meniscus. As the medical meniscus is torn, it may become stuck between the surface of the femur and tibia causing a locking of the joint. Trauma to the lateral side of the knee may damage the anterior and posterior cruciate ligaments.
    An uncommon but serious injury to the ankle joint is called Pott’s fracture. The lower part of both the tibia and fibular are broken in this trauma. A physician needs to be very careful that necrosis of the distal end of the fibula does not occur because of poor blood supply.

    Head & Neck

    The neck is made up of a series of triangles such as the anterior triangle, the muscular triangle, the carotid triangle, the submandibular triangle and the submental triangle. An example of an injury to the head and/or neck is an injury to the external laryngeal nerve. This may occur during a thyroidectomy. If the nerve is involved in the ligature used for the superior thyroid artery, the nerve to a muscle is interrupted and the vocal cord cannot be lengthened. With this loss of tension on the vocal cord, the voice may become weak, hoarse and easily fatigued. Similarly, during a thyroidectomy, the inferior laryngeal nerve may be injured. This nerve must be identified and dissected away from the thyroid before removing the gland, otherwise permanent post-operative hoarseness may result. In addition, if only one nerve is involved, the speech is not totally affected and the vocal cord is still functional. However, bilateral cutting of the nerves results in loss of speech and impaired breathing. Horner’s syndrome is a condition that is caused by paralysis of the cervical sympathetic nerves. It may result from pressure of a malignant tumor in the neck or upper lung, surgery or penetrating injuries to the neck. A drooped shoulder may be caused from a wound in the posterior triangle because it can sever a spinal nerve. This in turn denervates the trapezius muscle. Cervical rib syndrome may result from compression of the brachial plexus and sumclavian artery. This condition may cause pain, numbness and weakness if not corrected and may result in muscular atrophy and reflex disorders.
    A parathyroid tetany results from the inappropriate removal of all or most of the parathyroids during a total thyroidectomy. Accordingly, a surgeon must identify and leave the parathyroid glands which are usually four in number during the surgery. Removal of the parathyroids may cause muscular spasm, weakness, and nervousness as well as death unless adequate calcium or vitamin D or a parathyroid hormone is provided promptly.

    The vertebral column forms the central portion of the axial skeleton of the body. In its normal form, it presents primary and secondary curvatures. An abnormal curvature of the spine is a condition in which a lateral bending of the vertebral column in the thoracic region is present. This is called scoliosis. It may be congenital or acquired from severe sciatica.

    The component parts of the typical vertebra are the body and number of processes that surround the centrally located vertebral foramen. This gives strength to the vertebral column and is separated by vertebral bodies and the intervertebral discs. This transverse processes project from the junction of the pedicles and laminae. Intervertebral discs unite adjacent unfused vertebral bodies. These consist of an annulus fibrosus and a nucleus pulposus. This is a soft, gelatinous mass that separates the discs. A herniated intervertebral disc may come from a degenerative process or trauma. If a compression force is excessive, a rupture of the disc occurs. The nucleus pulposus herniates partially or completely through the annulus fibrosis to impinge on a spinal nerve that emerge from the vertebral column adjacent to the disc in this region. This frequently is accompanied by nerve compression, a painful neuralgia, (sciatica) down the back and the lateral side of the leg and into the sole of the foot. Often traction, bedrest and analgesia relieve the pain. If this treatment is ineffective then surgical decompression of the spinal nerves by laminectomy or removal of some of the nucleus pulposus may be necessary to relieve pain.

    Another procedure performed for various purposes is called a lumbar puncture. Usually performed at the L4-L5 level, since the spinal cord does not extend inferior to the second lumbar vertebrae. The spinal cord is considerably shorter than the vertebral column. It is important for the surgeon to know the origin of the nerves from the spinal cord and their exit through intervertebral foramina of the vertebral canal. These do not necessarily correspond numerically. For example, in the lower cervical and upper thoracic region, the spinal cord segment is approximately two vertebra proximal to the vertebral level, therefore, the spinus process at C6 overlies spinal segment C8. In the lower thoracic and upper lumbar regions, T11 and T12 spinus process overlie the 5 lumbar spinal cord segments while L1 spinus process overlies the five sacral segments. A surgeon must know this in order to locate a tumor, loss of sensation and similar problems. Loss of sensation over the thumb, an area intervated by C6, would therefore suggest a lamienectomy be performed on vertebra C4.

    Face

    Excruciating pain over the face, especially areas near the mandibular and maxillary divisions of the fifth cranial nerve, is associated with trigeminal neuralgia. Injections are frequently used to treat this pain. Nerve block is a term signifying loss of sensation in a region. A good way of thinking about this is considering the injection a dentist might perform in order to work on a tooth. Such an injection blocks sensations carried centrally by this nerve. The same procedures are used for nerves extending to the cervical, thoracic and lumbar regions.
    Partial or complete surgical removal of the parotid gland and the facial nerve may be damaged thereby causing facial paralysis (Bell’s paralysis). A physician must be careful to identify, dissect and preserve the facial nerve. This is done by seeing where the nerve exits from the stylomastoid foramen and then follow it through the parotid gland. Although sometimes removal of the facial nerve may be necessary, for example, in a malignant tumor. Usually an attempt is made to salvage the nerve if possible. The parotid gland is the largest of the three major salivary glands. Mumps is a common viral inflammatory lesion of the parotid gland and it may spread to the testes and cause sterility. Another injury to the head area is what is called a contrecout fracture. It is a term applied to the fracture of the skull at some distance from the point of contact from the blow. This is because part of the skull is hollow and elastic. The force of the blow may be transmitted to the opposite side. On the other hand, an extradural hemorrhage can result from a trauma to the side of the head over the inferior part of the parietal bone causing fracture of the bone. A subdural hemorrhage is a blood collection in the space between the dura and the arachnoid. It results from a rupture of the large veins that return blood from the surface of the brain. It often is caused by trauma on the front or back of the head, causing significant movement of the brain within the cranium. A subarachnoid hemorrhage often comes from leakage of blood vessels. Aneurysms of the cerebral arteries often occur in or near the circle of Willis. Rupture of such an aneurysm bleeds into the subarachnoid space and is a common cause of a cerebrovascular accident in a young person. Blood detected in cerebral spinal fluid aspirated during a lumbar spinal puncture may be due to hemorrhage of this nature.

    There are many lesions of the cerebrum. Usually the symptoms involve vomiting, dizziness, headache, convulsions, partial or complete paralysis. Where the lesion is located usually causes specific symptoms to specific areas of the body. Lesions of the cerebellum may be from tumors, abscesses, cysts or inflammation. These usually involve instability of equilibrium and locomotion with dizziness. Hydrocephalus (water on the brain) is due to an abnormally large accumulation of cerebrospinal fluid within the ventricles of the brain. If this occurs in infants when the cranial bones are not yet united, the internal pressure greatly enlarges the skull as well as the ventricles of the brain. The cerebral cortex becomes thinned out and degenerates causing severe mental retardation. Hydrocephalus may be caused by obstruction of some part of the ventricular system, excessive production of fluid or interference with the absorption of the fluid. It is most commonly caused by scar tissue produced by inflammation, or a tumor.
    A stroke or cerebrovascular accident (CVA) is the rupture or occulsion of certain cerebral arteries leading to the internal capsule of the brain. Frequently, a lesion of this nature produces hemiplegia on the opposite side of the body. If the hemorrhage is significant, the portion of the brain supplied by the ruptured artery will degenerate and the neurological deficits will be permanent. Early dissolution of a blood clot and release of the pressure on the cerebral cortex may allow partial or complete return of function. Another common injury to the face caused by trauma is detachment of the retina. The tear in the retina causes blindness in the corresponding field of vision. The retina may be reattached by surgical procedure.

    Diagnosis & Treatment of Traumatic Injuries

    Although musculoskeletal disorders can be caused by single traumatic injury, they can also be caused by poor posture, faulty body mechanics, loss of flexibility and a general decline of physical fitness. There are limitations as to what can be accomplished when degenerative processes are obvious. There are different approaches available to determine the basis for evaluation, assessment and treatment of musculoskeletal disorders. One approach is to assess and treat a patient based upon the specific pathology determined in an evaluation. The pathology presents an unique clinical picture which, when clear and specific, can be treated based upon previous successful experiences. Unfortunately, a clear clinical picture does not always present itself. At that point, the treatment of signs and symptoms becomes important.
    Various treatment regimens, when administered appropriately, allow proper treatment of signs and symptoms. For example, initially to treat pain, immobilization and rest may be used. Similarly, modality therapy can relieve pain. Different modalities such as electrical stimulation, ultrasound, hot packs, cold packs are examples of modality therapy. Moreover, mobilization can sometimes relieve pain. This might include traction, massage or spinal manipulation. In addition to treating pain, it is important to increase mobility. Failure to treat mobility may lead to early degenerative changes. Exercises, correction of postural or biomechanical stresses are examples of treatment to increase mobility. On the other hand, sometimes it is important to use treatment to reduce mobility. This is done at times by muscle strengthening, isometric exercise and heavy contractions with few repetitions. A skilled therapist might also use treatment to restore anatomical relationships. Traction, exercises, posture and mobilization can assist in this regard. Treatment may also be used to restore active function such as muscle strengthening, re-education techniques, muscle energy techniques. Moreover, treatment regimens may include treatment that promotes healing. Mechanical injuries often involve inflammatory processes that require healing. Immobilization and rest, ice, heat, electrical stimulation, whirlpool, massage and other modalities are useful for this purpose. Other treatment might include correcting poor posture, improving general physical and mental fitness, and training and instructing the patient in proper care of their body.

    It is important that the medical provider collect data which is relevant, accurate and measurable in order to treat the patient properly. Subjective information is important. In other words, the provider must listen to the patient’s complaints. Objective findings are also important. These are obtained through various physical tests, examinations and/or diagnostic tests. It has become common practice for the medical provider to use what is known as S-O-A-P notes. These letters stand for subjective, objective, assessment, and plan. It is a format that is universally used to summarize various portions of the overall goal of healing the patient. The sequence of the evaluation depends on the nature of the complaint and injury involved. It is important for the provider to listen to the patient’s complaints, the nature of the symptoms, the location of the symptoms, the behavior of the symptoms, the duration of the symptoms, the affect of any previous treatment and other related medical problems. An examination may consist of things such as a postural assessment, active range of motion of the cervical or lumbar spine, forward, backward and lateral bending, resisted muscle tests of the cervical spine, resisted shoulder elevation, resisted shoulder abduction, active shoulder flexion and rotation, resisted elbow flexion, resisted elbow extension, active range of motion of the elbow, resisted wrist flexion, resisted wrist extension, resisted thumb extension, resisted finger abduction, Babinski reflex test, toe raises, heel walking, active rotation of the lumbar spine, straight leg raise, sacroiliac sprig test, resisted hip flexion test, passive range of motion to hip, resisted knee extension, knee flexion, medial and lateral tilt, femoral nerve stretch.

    The medical provider should also perform a neurological exam which will consist of a series of tests to determine if there is impingement or encroachment upon a spinal nerve root, entrapment of a peripheral nerve, or central nervous system involvement. Resisted muscle tests, for example, are performed to determine if there is neurological involvement. If it produces pain or weakness, this provides the medical provider with symptoms that are important. Neurological involvement of C4-C7 is suggestive of nerve root disorder such as a herniated disc or encroachment of the nerve root within the intervertebral foramen. Thoracic outlet syndrome is more frequently seen involving level C9 and T1.

    In addition to resisted muscle tests, muscle stretch reflexes, sensation testing, distraction tests, compression tests, Valsalva tests, Babinski tests and peripheral nerve entrapment tests are included in the cervical spine neurological examination. The thoracic spine rarely involves nerve root impingement and peripheral nerve entrapment. Sensation testing can be performed to determine the dermatome patterns of the thoracic spinal nerves. Neurological involvement in the thoracic spine may cause weakness of abdominal muscles. A significant test for the lumbar spine is the straight leg raise test. It is used to determine if there is nerve root involvement of the sciatic nerve. As the straight leg is raised, progressive tension is applied to the sciatic nerve which places tension on the nerve roots. Symptoms will be exacerbated by this maneuver. It is important for the provider to understand that any acute painful condition in the lumbar spine or sacroiliac may be aggravated by the straight leg raising test. Piriformis syndrome may also be affected by the straight leg raise test. The positive straight leg raise test indicates more severe pathology when it is positive at twenty to forty degrees of hip flexion and there is less severe pathology if positive at fifty to seventy degrees. It is difficult to interpret a straight leg raise as being positive at ranges over seventy degrees. Sometimes symptoms are enhanced if the opposite leg is raised. This suggests a disc herniation with protusion medial to the nerve root. If symptoms are relieved as the opposite leg is raised, a bulge lateral to the nerve root may be present.

    The femoral nerve stretch test is used to determine if there are symptoms in the L1-L3 dermatomal region. In addition to the various tests, the skilled examiner will also use palpation to obtain valuable information about the condition of the structures and tissues involved. The skin is palpated and examined for tenderness, color, temperature, moisture and texture. Because pain is often referred, the site of the primary disorder may not be the same place that the patient describes the symptoms. The subcutaneous tissue may be palpated to determine if there are abnormal amounts of fat, tissue fluid, tension, swelling or nodules.
    Examination of the extremities involves close observation of boney, joint and muscular structures of the involved part of the body. This is sometimes an easier examination than other parts of the body because there is the other extremity to use for comparison. Looking at the size of the muscle might give a hint to peripheral nerve injury or atrophy; if it does not compare favorably to the similar muscle on the other extremity. Mobility examination of the extremities consists of active, passive, resisted and special mobility tests. In addition, muscle strength testing may be used as well as ligament stress tests. Neurological tests sometimes are performed on extremities. However, these are usually performed to observe whether there is impingement upon the nerve roots which innervate them.
    Carpal tunnel syndrome, for example, is established by noting the presence of one or more of three major clinical signs. These signs are hyposthesia, restricted to the media nerve distribution in the hand, Tinels sign or a tingling sensation radiating into the hand, on percussing the media nerve at the wrist; or Phelan’s test which is the reproduction or exaggeration of symptoms after holding the wrist in a complete flexion or extension for thirty to sixty seconds. Ulnar groove entrapment is usually located at the ulnar groove of the elbow. Most often the symptoms will include parathesia in the ulnar distribution and discomfort in the epicondylar area. Piriformis syndrome where the sciatic nerve and buttock musculature become tender often occurs as a result of referred pain from a lower back disorder. Common peroneal syndrome often is caused by scar tissue resulting from a fracture of the fibular head. surgery for Baker’s cyst, sprain of the joint or direct nerve injury.

    Generally speaking, the spine has four distinct curves. These include the sacral area, which is curved convex posteriorally, the lumbar area which is concave posteriorally, the thoracic area which is convex posteriorally and the cervical area which is concave posteriorally. These normal curves reciprocate and balance one another and provide added strength for the vertebral column to withstand compressive blows. For example, in a radiologic finding, one often sees language where it is stated that the normal “S” curvature of the spine is reversed. This suggests the presence of spasm as a result of trauma. The functional components of the vertebral column include the vertebral bodies, the discs, the intervertebral foramen, articular processes, ligaments and muscles. The intervertebral discs consists of two parts: an inter-gelatinous center called the nucleus pulposus and an outer structure made up of layers of concentric fibers called the annulus fibrosus. The nucleus is basically water, the fibers of the annulus are oriented diagonally. The disc is flexible allowing motion in all directions and serves to dissipate forces and stresses transmitted to it. Thus, injury to a disc may cause severe pain. A disc is often compared to a shock absorber. Forward bending (flexion) rotation, extension, lateral tilt or rotation can all cause various stresses on the spinal column.

    There is an interconnection of movement between the spine and the pelvis. This is especially true in forward bending of the spine. During forward bending, the lumbar curve reverses itself from concave to flat to convex. Similarly, the sacroiliac joints move during various lumbosacral movements.

    Primary muscle disorders may be classified as strains, contusions, and inflammations. Any muscle has a normal resting length. If that length is disrupted by severe movement, or stretching, it can cause pain. The muscle adapts to its environment. Muscle guarding also accompanies pain, regardless of the underlying cause or whether it is referred from elsewhere in the body. Prolonged muscle guarding leads to inflammation and localized tenderness as well as muscle spasm. Treatment becomes necessary to reduce the pain and stiffness caused by muscle guarding and spasm. Effective treatment may include medication, heat, cold, massage, electrical stimulation, rest, active and stretching exercises and relaxation techniques.

    Muscle strains and contusions are usually preceded by trauma. This might include injury to the body, a tearing sensation, aggravation or constant repetition of a new activity. Massage is a useful modality for treatment of muscular disorders especially of the chronic strain variety. A particularly helpful method of relieving such pain is high voltage electrical stimulation. Restoration of full function including strength and mobility and normal posture should be the most important aspects of treatment.

    Facet joint impingement is a disorder that has made chiropractors popular because manipulation is usually an effective treatment. The mechanism of injury is usually a sudden, unguarded movement involving backward bending, side bending, and/or rotation even if there is little or no trauma. A patient with facet impingement usually gets relief from rest, and will identify pain caused by movement and may even feel locked into a certain posture. Facet joint sprain, on the other hand, indicates a history of moderate to severe trauma that may involve joint sprain with effusion in and around the joint itself. Facet joint impingement may be treated with mobilization. Facet joint sprain is usually treated with a more conservative approach using physical therapy modalities, pain-free movements, support and rest. The joint sprain needs time to heal.

    Joint inflammation frequently follows acute joint sprain or chronic postural sprain. It may occur secondary to aggravation of degenerative joint disc disease such as by trauma. Like most inflammatory disorders, movement may cause pain. Joint hypomobility is a disorder that involves the entire spinal segment and usually results from immobilization secondary to injury. It often results from acute facet joint sprain if normal mobility is not restored as healing occurs. It can occur as well as a result of disc herniation. Joint hypermobility or instability usually involves the entire spinal segment and may be the result of severe trauma such as whiplash. Degenerative joint disc disease otherwise sometimes referred to as osteoarthritis or spondylosis is a chronic and progressive degeneration of the facet joints and/or the intervertebral discs. It can occur with neurological complications as well. Generally there are four characteristics of degenerative disc disease in the synovial joints. These include proliferation of calcific deposits in or around the perhiphia of the joint, wearing away of the hayaline cartilage, thickening of the synovial lining and joint capsule and thickening of the subchondrial bone. It is characterized by dehydration of the nucleus pulposus, narrowing of the intervertebral space, weakening and degeneration of the annular ring and approximation of the facet joints. Although it is a natural process of aging, it is also often not symptomatic until trauma occurs.
    Herniated nucleus pulposus (HNP) is classified as a disorder in which there is displacement of the nuclear material and other disc components beyond the normal confines of the annulus. Four degress of displacement are recognized, namely, intraspongy nuclear herniation, protusion, extrusion, and sequestration. Protusion frequently occurs over a period of time but is usually asymptomatic in its early stages. Trauma can aggravate this condition. Nuclear herniation refers to the displacement of the nucleus into the vertebral body through the endplate. It is similar to a Schmorl’s node except that it is a traumatic defect rather than a developmental one like a Schmorl’s node. Indeed, Schmorl’s nodes are thought to stabilize the nucleus and diminish the intra-articular centrifugal force thus rendering posterior displacement less likely.

    Herniated nucleus pulposus without spinal nerve root involvement involves the condition in which there is displacement of the nuclear material beyond the normal confines of the inner annulus producing a discreet bulge in the outer annulus. No nuclear material escapes however. Discogenic pain arises from the outermost rings of the annulus. In the lumbar spine, HNP protusion is most common in the L4-L5 and L5-S1 discs and is rarely seen above those levels. This disorder can be caused by a single injury or incident. It can also be caused by accumulated effects of months or years of forward bending and lifting, especially if symptoms are known to persist over a period of time prior to a trauma. Herniated nucleus pulposus with nerve root involvement is a condition in which the nucleus is bulging but is still contained within the annulus and/or posterior longitudinal ligament. The bulge is large enough to encroach into the spinal canal and/or the intervertebral foramen and is capable of impinging upon or irritating the nerve root. This condition can be sudden with no previous history of spinal pain. It can also result from gradually worsening condition. A discogram or MRI is often used to determine the amount of disc protrusion.
    Herniated nucleus pulposis, extrusion or sequestration is a disorder in which the displaced nuclear material extrudes into the spinal canal through disrupted fibers of the annulus. This nuclear material escapes as free fragments which may migrate to other locations. This problem might involve more peripheral signs and symptoms as predominant as opposed to spinal signs.

    Surgical correction of disc problems often involves a laminectomy or discectomy. These surgical procedures may remove or dissolve the disc herniation but follow up treatment and/or therapy may also be performed to correct posture, faulty body mechanics, stressful living, working habits, loss of flexibility, physical fitness and other underlying causes of the problem. The therapy program should start with restoration and maintenance of posture with extension principles and eventually involve full flexibility, strengthening, and fitness.

    Nerve root swelling and inflammation (neuritis) can be severe enough to cause impingement or irritation and produce positive neurological signs. This is often seen within a few days following severe injury as an inflammatory protective response to the injury. Nerve root adhesions or entrapped scar tissue can also cause pain. This is sometimes seen following spinal surgery and also may follow an episode of disc herniation as the body attempts to heal the bulge or defect in the annulus, collagen tissue is laid down. If the nerve root is lying in proximity, it may become entrapped by scar tissue. Physical therapy helps reduce the formation of scar tissue and/or minimize it. If trauma is involved in any way, a radiological exam is the standard of care required to determine whether or not a fracture is present.

    Spondylolisthesis is a defect involving the neural arch of the vertebra. When a defect in the neural arch is bilateral, separation of the anterior and posterior elements at the site of these defects may occur which is called spondylolisthesis. This often occurs at the L5-S1 level. The defect sometimes occurs as a stress fracture. This condition can be symptom free but can be made symptomatic by trauma. If this condition is the true cause of the patient’s symptoms, it is probably because the segment is unstable and the aggravation is due to the physical activities that are attempted.
    Spinal stenosis suggests encroachment upon the cervical spinal cord resulting from a stenotic cervical spinal canal. This disorder is characterized by neurological symptoms, it may also occur in the lumbar spinal canal. Generally speaking, it is thought to be a narrowing of the spinal canal which produces compression of the nerves. A patient with lumbar spinal stenosis may have pain in the lower back and one or both legs, numbness and tingling in the feet and legs, decreased muscle reflexes and motor weakness in the legs. Spinal stenosis may not be symptomatic but may become symptomatic as a result of trauma. Trauma may also aggravate a pre-existing painful spinal stenosis.
    Sacroiliac disorders are often present with a lumbar spine and hip joint problems. The sacroiliac is sometimes difficult to assess properly. Ankylosing spondylitis is a progressive joint sclrosis and ligamentous ossficiation which first appears in the sacroiliac joint and later spreads to the lumbar and thoracic spine and rib cage. Onset usually occurs between twenty-five and thirty-five years of age. This can lead to serious complications if not treated properly.

    Rupture of the supraspinatus tendon is a common cause of shoulder disability. This is usually referred to as a tear of the rotator cuff. Frequently this is caused by a fall or direct blow to the shoulder. Spontaneous tears in patients under fifty years of age are unusual. Complete or extensive tears need to be repaired surgically. Physical therapy, at times, may promote healing prior to surgery. A considerable length of time is required for healing. Frozen shoulder or adhesive capsulitis is a disorder which develops when collagen fibers adhere to each other as the result of scar tissue. It is often more common in women than men and may occur during periods of immobilization, inactivity or inflammation. Frequently this injury involves loss of function. Another pathological injury is known as the shoulder-hand syndrome. This involves swelling and pain in the entire extremity and may result from a frozen shoulder, a lesion, myocardial infaraction, vascular accident, trauma, or cervical nerve root syndrome.

    Meniscus injuries to the knee are very common. Twisting of a semi-flexed knee under stress may cause this injury. It usually occurs during weight-bearing. The patient frequently experiences immediate deep pain with giving way of the joint or locking of the joint. There may be a persistent clicking of the joint. Tear to the body of the meniscus is usually repaired by surgery and if left untreated may lead to early degenerative changes. If the tear or sprain is localized to the periphery, surgery may not be required. Diagnostic arthroscopy will assist the physician in determining the course of management.
    Chondromalacia of the patella is a degenerative process that involves the cartilage of the articular surface of the patella. These changes may follow acute, severe trauma. Descending stairs is often difficult for patient with this disorder. Chondromalacia may be asymptomatic until trauma causes it to become symptomatic. Plica syndrome is a permanent fold of the synovium of the knee. Injury to the plica may occur as a contusion or a strain from a single, traumatic event. Inflammation, edema and thickening may result. Conservative treatment may be attempted, surgery may be indicated if the symptoms do not subside in a short course of physical therapy.

    Chronic foot strain may develop when excessive stress is repeatedly placed on the foot. As a result, degenerative arthritic changes may take place. Ligaments exposed to the strain elongate and undergo inflammatory changes which result in pain. The ligaments degenerate and lose their supporting function and permit degenerative joint disease to develop.
    Temporal mandibular joint presents with many symptoms. The roof of the TMJ consists of a temporal bone divided into four parts known as the post-glenoid spine, the mandibular fascia, the articular eminence, and the articular tubercle. The ends of the mandible are composed of condyles which form the floor of the TMJ. The temporal bone is separated from the mandibular condyle by the articular disc. The disc separates the TMJ into a larger upper joint space and a smaller lower joint space and is composed of fibro cartiligenous tissue. The articular disc is divided into three bands or zones and has various attachments. A fibrous capsule surrounds the TMJ. The most prominent ligament of the temporal mandibular joint articulation is the temporal mandibular ligament. This ligament provides support to the lateral wall of the capsule with which it is associated. One end of the temporal mandibular ligament is inserted into the posterior and lateral margins of the condylar neck and the other end is inserted into the zygomatic process and tubercle of the temporal bone. The innervative tissues of the TMJ are supplied by three nerves which are part of the mandibular division of cranial nerve V. The TMJ does not have hyaline cartilage.

    Any treatment procedure that is performed to the TMJ must keep the functional requirements of this joint in mind. The function of the TMJ occurs with the condyle translating along the slope of the articular eminence, with the non-innervative portion of the disc between the two articulating surfaces. Movement of the mandible are a result of the action of the cervical and jaw muscles. These stabilize the head to increase the efficiency of the mandibular movements. Altered muscle activity can be the result of a TMJ affliction. The TMJ is a simple hinge joint in which the articular surfaces glide over or slide against each other during movement. The TMJ allows the mandible to perform opening and closing movements as well as lateral movements, all of which assist in chewing and talking.

    Trauma to the TMJ joint includes injury resulting in fractures and dislocations of the TMJ. The signs of dysfunction include viscondyle derangement, anterior disc dislocation, subluxation, translation occurring too soon in opening. TMJ imaging is often performed by arthrography which is the injection of a contrast material into the synovial space followed by radiography of the joint. This is used to identify disc dislocation. TMJ problems should not be treated by a regular dentist. A patient should be sent to a TMJ specialist so that permanent conditions do not develop.

    Various spinal orthotics are used in the treatment of patients with orthopedic problems. These provide immobilization of the intervertebral joints, increased motion of intervertebral joints adjacent to those that are immobilized, transfer of part of the vertical load from the spine to other structures, increase in the intra-abdominal pressure (lumbar supports), decrease in intradiscal pressure, decrease in the venous return from the lower extremities, control of lordosis of kyphosis, providing the user with an awareness of correct posture, providing the user with a placebo effect, decrease of abdominal and/or spinal muscular activity and increase of spinal muscular activity. Examples of spinal orthoses include lumbosacral corset, chair back brace, knight spinal brace, Williams brace, sacroiliac belt, dorsal-lumbar corset, Taylor brace, Knight-Taylor brace, hyperextension brace, soft foam collar, hard plastic collar, Philadelphia collar, two and four poster braces and Somi brace. These orthoses, if fitted properly, can provide significant assistance to the patient.

    MAGNETIC RESONANCE IMAGING (MRI) AND COMPUTED TOMOGRAPHY IMAGING (CT SCAN)

    Radiographic examination is an objective essential part of any physical examination. Radiographic examination is used to detect fractures and dislocations that would suggest performance of standard orthopedic modalities might be inappropriate depending on circumstances. Moreover, the radiographic report assists a doctor from a medico-legal standpoint. It can provide an objective record of the patient’s bone and ligamentous integrity after an accident. Even a patient who may appear normal in a regular examination, may have delayed instability and develop significant problems. Usually the neutral lateral view is performed first in a post-traumatic situation. A large number of fractures may be visualized with this view, however, some fractures may not be observed from this view such as small, non-displaced fractures. Often an anteroposterior view should be used to supplement the neutral lateral view as it delineates the structures that were superimposed on the lateral view. There are lines that can be visualized on the radiograph that can be utilized by the medical provider in determining the degree of potential instability. It must be noted, however, that x-rays are primarily used to determine boney (osseus) structures. They do not demonstrate soft tissue to any significant degree such as ligaments, tendons, muscles.

    A hyperextension/ hyperflexion injury (whiplash) is a phenomenon of motion. A complete post-traumatic series of x-rays should include the neutral lateral, flexion and extension laterals, right and left obliques, AP open mouth, AP lower cervical, and right and left pillar views. Each of these views is necessary for a complete examination in post traumatic cases as each impacts specific function in the spine. If spasm is present in a post-traumatic situation, studies should be done subsequently in the absence of spasm in order to reveal any other damage. The biomechanics of the spine is very important. Any loss of the normal lordotic curve of the cervical spine should be re-evaluated at the end of treatment since permanent loss of the cervical curve can be a precursor to future degenerative joint disease and will affect the injured person’s prognosis. Comparitive radiographic studies are often used to follow the healing progress of known injury.
    State of the art cervical magnetic resonance and computed tomography imaging has become the gold standard for many in determining an appropriate diagnosis. Unlike the single x-rays views, especially in an injury situation that may be complicated, and therefore not always representative; a thorough review of a CT scan or MRI provides much more information. The muscles, ligaments, tendons and soft tissues can often be visualized in these enhanced diagnostic tools. Many believe that the MRI will replace the CT scan altogether.

    The MRI and CT scans appear to be of approximate equal value in diagnosing disc abnormalities in the lumbar spine. In the cervical spine, however, there are more distinct differences and the MRI is usually the clear choice as a diagnostic tool. It involves no invasive intrathecal installation of contrast material as would be the case with the CT. Moreover, the MRI scan is capable of intrinsically evaluating the spinal cord for focal enlargements, diagnosed cord cavitation and increased signal intensity. Evaluation of disc abnormalities in the cervical region is also very well done with the MRI. It can demonstrate internal physiological degenerative changes of the disc space, signal intensity and other demonstrative concepts. The MRI scan is not technically a radiograph as there is no x-ray utilized.


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