Nanthini S<br />ThyeCheeKeong<br />Lynette Lee<br />NurNadiatulAsyikin<br />NursheilaIzrin<br />Oon Li Keat<br />HurulAini...
	History<br /><ul><li>Mr. M
25 year old motorcyclist
Thrown off in a collision with a lorry
Brought to A&E unit in a hospital</li></li></ul><li>		On examination<br />No head and spinal injury<br />Stabilized<br />V...
	Question 1:<br />In the Accident & Emergency Room while waiting to be admitted to the ward, describe FIVE (5) other proce...
Continuation of the primary survey<br />Disability (D) of the central nervous system<br />Basic neurologic assessment with...
Continuation of the primary survey<br />Exposure/Environmental control/X-Rays (E)<br />Full exposure of the patient<br />A...
IMAGING<br />
X-rays:<br />Cervical spine: lateral view of C1-T1<br />Chest : Anteroposterior view<br />Pelvis : Anteroposterior view<br...
Adjunct to primary survey<br />Vital signs <br />Oxygen saturation e.g. pulse oxymetry, blood gases<br />Electrocardiograp...
Secondary survey<br />Complete history and physical examination<br />Each region of the body to be fully examined:<br />Ch...
Head<br />Check for bruising, swellings<br />Look for signs of basal skull fracture:<br />Battle’s sign<br />Racoon’s eyes...
Chest<br />Respiratory distress - Grunting, stridor<br />Bruising and skin imprinting<br />Mediastinal shift<br />Penetrat...
Abdomen and pelvis<br />External injuries<br />Abdominal distension by gas or fluid<br />Tenderness and guarding<br />Blee...
Limbs<br />Check the neurovascular status of each limb<br />Analgesia – orthopaedic injuries are extremely painful<br />Co...
Name of procedure and Purpose<br />
Skeletal traction of left proximal tibia<br />Purpose:<br /><ul><li>To reduce a fracture or dislocation
To prevent or reduce muscle spasm
To immobilize a joint or part of the body
To treat joint pathology</li></li></ul><li>PRIOR TO APPLICATION<br /><ul><li>Ensure adequate analgesia / sedation
Place patient in supine position
Record baseline neurovascular observations:
Pulses
Skin colour and temperature
Capillary refill time
Movement of joints
Swelling and sensation
Observe affected limb for any:
Wounds
Swelling
Infection
Soft tissue damage</li></li></ul><li>Principles of Skeletal Traction<br />Align the distal to the proximal fragment<br />R...
LOCAL ANAESTHESIA<br />Inject local anaesthetic into the skin, subcutaneous tissue, and periosteum of both sides, making s...
Bohler’s Stirrup<br />
Cord/ Rope is then attached to the pin’s holder and passed over a pulley, and fixed to a weight. <br />The weight may pull...
Complications<br /><ul><li>Due to procedure itself
Infection of the pin tract
Injury to common peroneal</li></ul>	nerve<br /><ul><li>Excessive traction
Due to prolonged bed rest
Thromboembolism
Decubiti
Pneumonia
Atelectasis</li></li></ul><li>Compartment Syndrome<br />
9) The problem you suspected in QXN (8), describe 4 other symptoms and/or signs would you look for ?<br />6 “P”s?<br /> us...
Symptoms<br />Pain out of proportion to apparent injury (early and common finding)<br />Persistent deep ache or burning pa...
Signs<br />Pain with passive stretch of muscles in the affected compartment (early finding)<br />Tense compartment with a ...
Late signs<br />Pallor from vascular insufficiency (uncommon)<br />Muscle weakness (onset within approximately two to four...
10) What first aid in the ward can you immediately give after you suspect the problem in QXN 8?<br />relieving all externa...
Capillary blood flow becomes compromised at 20 mmHg.<br /> • Pain develops at pressures between 20 and 30 mmHg.<br /> • Is...
<ul><li>11) Describe the pathophysiology of the problem you suspected in QXN 8?</li></ul>Compartment Syndrome<br />
Compartment Syndrome<br />Anatomy<br /><ul><li> Muscle groups -including the nerves and blood vessels that flow through th...
a tough membrane (fascia) that does not readily expand-this area is called a “compartment”</li></li></ul><li>PATHOPHYSIOLO...
PATHOPHYSIOLOGY<br />↑ Compartmental volume<br /> (↑ fluid content)<br />↓ Compartment volume <br />(constriction of the c...
Compartment Syndrome:Sequela After Initial Injury<br />Tissue damage- irreversible tissue death within 4-12 hours<br />per...
Muscle infarcted<br />Replaced by inelastic fibrous tissue<br />( Volkmann’s ischaemic contracture)<br />Necrosis of <br /...
12) If the problem still continues despite first aid in QXN 10, elaborate what would you do?<br />
Fasciotomy<br />Fasciotomy -definitive and only treatment for acute compartment syndrome (ACS) <br />If intra-compartment ...
Cross section of a forearm.Palm up.<br />
the thick, fibrous bands that line the muscles are filleted open,<br /> allowing the muscles to swell and relieve the pres...
Hyperbaric oxygen -considered as an adjunct treatment after surgery to promote healing  and reducing repetitive surgery<br...
13) You did a secondary survey, he complained of pain in left hip; you found he was tender in the left iliac region.What i...
Anatomy of the pelvic bone<br />
14) What did the investigation in Figure 2 show ? <br />( 1 mark )<br />ISOLATED FRACTURE OF LEFT ILIUM WITH INTACT PELVIC...
15) IN THE SAME NIGHT after admission to A&E ( 10 HOURS after admission ), his pulse rate became 140 beats a minute and bl...
16) Name 3 investigations / actions / procedures you would do to stabilize the above situation.( 3 marks)<br />Resuscitati...
17) Name 3 investigations / monitoring procedures to help you know that you really stabilized the above problem adequately...
The intended operation on the femur was delayed…<br />On DAY 3 after the accident, the patient was noted to have ↓ level o...
Name 1 diagnosis you suspect & what other 4 symptoms and/or signs would you look for<br />
Fat Embolism<br />Presence of fat globules obstructing arteries in the lung parenchyma & peripheral circulation after long...
GURD’s Criteria for Diagnosis<br />Major<br />Axillary or subconjunctivalpetechiae<br />Hypoxaemia PaO2 <60mmHg<br />CNS d...
4 Symptoms and/or Signs<br />Respiratory distress: SOB<br />CNS abnormalities: Confusion, restlessness, coma<br />Changes ...
Elaborate what investigations would you do?<br />
Clinically: <br />	-tachycardia>110bpm, tachypnea>30bpm,  pyrexia>38.5◦<br />	_ confused / restless<br />	- petechiae<br /...
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Cpc orthopaedics

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  • First of all, it was stated that the vital signs had been stabilized and there was absence of head and spinal injury, so we assumed that airway, breathing and circulation had been performed which are part of primary survey
  • local anaesthesia, sedate him, and apply iodine to the skin where the pin will go in and come out.
  • Capillary basement membranes become leaky
  • Cpc orthopaedics

    1. 1. Nanthini S<br />ThyeCheeKeong<br />Lynette Lee<br />NurNadiatulAsyikin<br />NursheilaIzrin<br />Oon Li Keat<br />HurulAini<br />CPC OrthopaedicsWITH PROF. RAZIF ALI<br />
    2. 2. History<br /><ul><li>Mr. M
    3. 3. 25 year old motorcyclist
    4. 4. Thrown off in a collision with a lorry
    5. 5. Brought to A&E unit in a hospital</li></li></ul><li> On examination<br />No head and spinal injury<br />Stabilized<br />Vital signs stable<br />Initial assessment:<br />closed fracture of his left femur<br />closed distal extraarticular fracture of his right radius<br />soft tissue injury of his right shoulder<br />Decision was made for:<br />internal fixation of his left femur<br />closed reduction and POP of his right radial fracture as a semi emergency.<br />
    6. 6. Question 1:<br />In the Accident & Emergency Room while waiting to be admitted to the ward, describe FIVE (5) other procedures / actions you would do as part of treatment or investigation not mentioned above?<br />(10 marks)<br />
    7. 7. Continuation of the primary survey<br />Disability (D) of the central nervous system<br />Basic neurologic assessment with AVPU score:<br />A – Alert<br />V – Responds to verbal stimuli<br />P – Responding to painful stimuli<br />U – Unconscious<br />Pupil size, inequality and reactivity to light<br />GCS score<br />
    8. 8. Continuation of the primary survey<br />Exposure/Environmental control/X-Rays (E)<br />Full exposure of the patient<br />Assess from head to toe for injuries not recognized and managed<br />Keep patient warm<br />
    9. 9. IMAGING<br />
    10. 10. X-rays:<br />Cervical spine: lateral view of C1-T1<br />Chest : Anteroposterior view<br />Pelvis : Anteroposterior view<br />Focused abdominal sonography for trauma (FAST) scan on ‘5Ps’:<br />Perihepatic – liver lacerations<br />Perisplenic – splenic lacerations and rupture<br />Pelvic – free fluid e.g. haematoma<br />Pleural – haemothorax, pneumothorax<br />Pericardial – pericardial effusion<br />
    11. 11. Adjunct to primary survey<br />Vital signs <br />Oxygen saturation e.g. pulse oxymetry, blood gases<br />Electrocardiography<br />Urine catheterization – hourly urine output<br />Nasogastric aspiration output<br />
    12. 12. Secondary survey<br />Complete history and physical examination<br />Each region of the body to be fully examined:<br />Chest<br />Abdomen<br />Pelvis<br />Limbs<br />Reassessment of all vital signs<br />
    13. 13. Head<br />Check for bruising, swellings<br />Look for signs of basal skull fracture:<br />Battle’s sign<br />Racoon’s eyes<br />Examine nose and ears for CSF leakage<br />Pupil size and responsiveness<br />
    14. 14. Chest<br />Respiratory distress - Grunting, stridor<br />Bruising and skin imprinting<br />Mediastinal shift<br />Penetrating injuries<br />
    15. 15. Abdomen and pelvis<br />External injuries<br />Abdominal distension by gas or fluid<br />Tenderness and guarding<br />Bleeding from urethral meatus<br />Presence of palpable bladder<br />PR exam: blood, high-riding prostate, anal tone<br />
    16. 16. Limbs<br />Check the neurovascular status of each limb<br />Analgesia – orthopaedic injuries are extremely painful<br />Correct obvious deformity by temporary splinting<br />
    17. 17. Name of procedure and Purpose<br />
    18. 18. Skeletal traction of left proximal tibia<br />Purpose:<br /><ul><li>To reduce a fracture or dislocation
    19. 19. To prevent or reduce muscle spasm
    20. 20. To immobilize a joint or part of the body
    21. 21. To treat joint pathology</li></li></ul><li>PRIOR TO APPLICATION<br /><ul><li>Ensure adequate analgesia / sedation
    22. 22. Place patient in supine position
    23. 23. Record baseline neurovascular observations:
    24. 24. Pulses
    25. 25. Skin colour and temperature
    26. 26. Capillary refill time
    27. 27. Movement of joints
    28. 28. Swelling and sensation
    29. 29. Observe affected limb for any:
    30. 30. Wounds
    31. 31. Swelling
    32. 32. Infection
    33. 33. Soft tissue damage</li></li></ul><li>Principles of Skeletal Traction<br />Align the distal to the proximal fragment<br />Remain constant<br />Allow for adequate exercise and diversion<br />Allow for optimum nursing care<br />
    34. 34.
    35. 35.
    36. 36.
    37. 37. LOCAL ANAESTHESIA<br />Inject local anaesthetic into the skin, subcutaneous tissue, and periosteum of both sides, making sure it goes under the periosteum.<br />
    38. 38. Bohler’s Stirrup<br />
    39. 39. Cord/ Rope is then attached to the pin’s holder and passed over a pulley, and fixed to a weight. <br />The weight may pull the patient out of the bed, thus need to exert countertraction by raising the foot off his bed.<br />
    40. 40. Complications<br /><ul><li>Due to procedure itself
    41. 41. Infection of the pin tract
    42. 42. Injury to common peroneal</li></ul> nerve<br /><ul><li>Excessive traction
    43. 43. Due to prolonged bed rest
    44. 44. Thromboembolism
    45. 45. Decubiti
    46. 46. Pneumonia
    47. 47. Atelectasis</li></li></ul><li>Compartment Syndrome<br />
    48. 48.
    49. 49. 9) The problem you suspected in QXN (8), describe 4 other symptoms and/or signs would you look for ?<br />6 “P”s?<br /> use them as criteria is Not reliable<br />Only pain & paraesthesia useful<br />The rest are uncommon or late signs<br />Eg. Paralysis or even muscle weakness indicate irreversible muscle damage <br />
    50. 50. Symptoms<br />Pain out of proportion to apparent injury (early and common finding)<br />Persistent deep ache or burning pain<br />Paresthesias (onset within approximately 30 minutes to 2 hours of ACS; suggests ischemic nerve dysfunction)<br />
    51. 51. Signs<br />Pain with passive stretch of muscles in the affected compartment (early finding)<br />Tense compartment with a firm "wood-like" feeling<br />Diminished sensation (two point discrimination found to be earliest)<br />
    52. 52. Late signs<br />Pallor from vascular insufficiency (uncommon)<br />Muscle weakness (onset within approximately two to four hours of ACS)<br />Paralysis (late finding)<br />
    53. 53. 10) What first aid in the ward can you immediately give after you suspect the problem in QXN 8?<br />relieving all external pressure on the compartment. Any dressing, splint, cast, or other restrictive covering should be removed<br />Maintain perfusion: <br />Hypotension reduces perfusion, exacerbating tissue injury, and should be treated with intravenous isotonic saline.<br />The limb should not be elevated. Elevation can diminish arterial inflow and exacerbate ischemia [62].<br />Analgesics should be given and supplementary oxygen provided. Further research <br />
    54. 54.
    55. 55. Capillary blood flow becomes compromised at 20 mmHg.<br /> • Pain develops at pressures between 20 and 30 mmHg.<br /> • Ischemia occurs at pressures above 30 mmHg.<br />Traditional recommendations for decompression include absolute pressure readings above 30 mmHg [49], or above 45 mmHg [1].<br /> <br />The delta pressure is found by subtracting the compartment pressure from the diastolic pressure. Many clinicians use a delta pressure of 30 mmHg to determine the need for fasciotomy. Others use a difference of 20 mmHg [15].<br />
    56. 56. <ul><li>11) Describe the pathophysiology of the problem you suspected in QXN 8?</li></ul>Compartment Syndrome<br />
    57. 57. Compartment Syndrome<br />Anatomy<br /><ul><li> Muscle groups -including the nerves and blood vessels that flow through them- are covered by
    58. 58. a tough membrane (fascia) that does not readily expand-this area is called a “compartment”</li></li></ul><li>PATHOPHYSIOLOGY<br />complex pathophysiology<br />the final common pathway is cellular anoxia [15]<br />prerequisite for the development of increased compartment pressure is a fascial structure (prevents adequate expansion )<br />widely believed hypothesis : arteriovenous pressure gradient theory [2]<br />[2] Elliott, KG, Johnstone, AJ. Diagnosing acute compartment syndrome. J Bone Joint Surg Br 2003; 85:625.[15] Olson, SA, Glasgow, RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg 2005; 13:436.<br />
    59. 59. PATHOPHYSIOLOGY<br />↑ Compartmental volume<br /> (↑ fluid content)<br />↓ Compartment volume <br />(constriction of the compartment)<br />↑ INTRACOMPARTMENTAL PRESSURE<br />Due to inelasticity of fascia<br />venous outflow is reduced (obstruction)<br />oedema<br />Inadequate venous drainage<br />But early-Lymphatic Drainage <br />compensate<br />Vascular congestion<br />Muscle and nerve ischaemia,necrosis<br />Further ↑ intracompartmentalpressure (venous pressure )<br />( arteriovenous pressure gradient)<br />↓ capillary perfusion<br />Compromise arterial circulation (late)<br />
    60. 60. Compartment Syndrome:Sequela After Initial Injury<br />Tissue damage- irreversible tissue death within 4-12 hours<br />permanent disabilities can develop from undiagnosed compartment syndrome<br /> Amputation- sometimes tissue beyond repair and only measure to prevent gangrene and death is amputation<br />
    61. 61. Muscle infarcted<br />Replaced by inelastic fibrous tissue<br />( Volkmann’s ischaemic contracture)<br />Necrosis of <br />the nerve and muscle <br />within the compartment<br />Vicious circle that <br />Ends after<br /> ~12 hours<br />Nerve<br />-capable to regenerate<br />
    62. 62. 12) If the problem still continues despite first aid in QXN 10, elaborate what would you do?<br />
    63. 63. Fasciotomy<br />Fasciotomy -definitive and only treatment for acute compartment syndrome (ACS) <br />If intra-compartment pressure > 40mmHg<br />Immediate open fasciotomy<br />Morbidity from delay is significant, so the operation should be performed immediately. <br />The wound should not be stitched until a post-surgical assessment has been done at 48 hours. <br /> subsequent skin grafts may be needed for successful healing<br />
    64. 64. Cross section of a forearm.Palm up.<br />
    65. 65.
    66. 66. the thick, fibrous bands that line the muscles are filleted open,<br /> allowing the muscles to swell and relieve the pressure within the compartment <br />Depending upon the amount of swelling (edema), a second operation may be required later to close the skin after the swelling has resolved.<br />If muscle necrosis, do debridement<br />
    67. 67. Hyperbaric oxygen -considered as an adjunct treatment after surgery to promote healing and reducing repetitive surgery<br />Treatment will also be directed to the underlying cause of the compartment syndrome <br />try to prevent other associated complications including kidney failure due to rhabdomyolysis<br />
    68. 68. 13) You did a secondary survey, he complained of pain in left hip; you found he was tender in the left iliac region.What investigation will you order ? ( 1 mark ) <br />ANTEROPOSTERIOR RADIOGRAPH OF PELVIS<br />VITAL SIGNS<br />
    69. 69. Anatomy of the pelvic bone<br />
    70. 70.
    71. 71.
    72. 72. 14) What did the investigation in Figure 2 show ? <br />( 1 mark )<br />ISOLATED FRACTURE OF LEFT ILIUM WITH INTACT PELVIC RING<br />
    73. 73. 15) IN THE SAME NIGHT after admission to A&E ( 10 HOURS after admission ), his pulse rate became 140 beats a minute and blood pressure became 70 / 40 mm Hg. He looked pale, there is pallor of conjunctivae and sweaty palms and forearms but he is still conscious. Explain briefly what pathophysiology may be happening here.(2 marks)<br />Tachycardia<br />Hypotensive<br />Anaemic<br />Sweaty palms<br />* HYPOVOLAEMIC SHOCK(CLASS III)<br />PELVIC FRACTUREBLOOD VESSEL INJURYBLEEDINGHYPO VOLAEMIC SHOCK<br />
    74. 74.
    75. 75.
    76. 76. 16) Name 3 investigations / actions / procedures you would do to stabilize the above situation.( 3 marks)<br />Resuscitation:<br />a)Vascular access:Insert TWO large bore cannula,Arterial line?<br />b)Blood investigation<br />c)Fluid therapy,oxygen<br />Stabilization of the fracture:<br />-pelvic binder/external fixator<br />Repeat FAST scan <br />Refer to orthopaedic team for further management of the fracture<br />
    77. 77. 17) Name 3 investigations / monitoring procedures to help you know that you really stabilized the above problem adequately.( 3 marks)<br />a)Vital signs,Pulseoxymetry and CVP monitoring if available<br />b)ABG<br />C)CBD-urine output monitoring<br />
    78. 78. The intended operation on the femur was delayed…<br />On DAY 3 after the accident, the patient was noted to have ↓ level of consciousness in the ward round<br />
    79. 79. Name 1 diagnosis you suspect & what other 4 symptoms and/or signs would you look for<br />
    80. 80. Fat Embolism<br />Presence of fat globules obstructing arteries in the lung parenchyma & peripheral circulation after long bone or other major trauma<br />More frequent in closed than in open #<br />Incidence ↑ with no. of # involved<br />Can occur in relation to other trauma<br />Pathogenesis: mechanical & biochemical theory<br />
    81. 81. GURD’s Criteria for Diagnosis<br />Major<br />Axillary or subconjunctivalpetechiae<br />Hypoxaemia PaO2 <60mmHg<br />CNS depression disproportionate to hypoxaemia<br />Minor<br />Tachycardia >110bpm<br />Pyrexia >38.5<br />Retinal emboli on fundoscopy<br />Fat globules in urine and sputum<br />Increased ESR, decreased haematocrit and platelet<br />For diagnosis, at least 1 MAJOR and 4 MINOR criteria must be present<br />
    82. 82. 4 Symptoms and/or Signs<br />Respiratory distress: SOB<br />CNS abnormalities: Confusion, restlessness, coma<br />Changes in V/S: ↑ temperature, ↑ PR<br />Petechiae: neck, chest, axilla, subconjunctiva<br />
    83. 83. Elaborate what investigations would you do?<br />
    84. 84. Clinically: <br /> -tachycardia>110bpm, tachypnea>30bpm, pyrexia>38.5◦<br /> _ confused / restless<br /> - petechiae<br />Lab Ix:<br /> - ABG (PaO2<60mmHg)<br /> - FBC: ↓ hematocrit, thrombocytopenia<br /> - LFT, RP, serum electrolytes, ↑ ESR<br /> - Urine & sputum for fat globules<br />
    85. 85. IMAGING<br />
    86. 86. Chest radiograph: may be normal / snow-storm appearance / diffuse, ground glass appearance<br />Head CT-evidence of microvascular injury<br />Spiral CT<br />Others:<br /> -ECG, TEE <br /> -D-dimers<br /> -ventilation/perfusion scan<br />
    87. 87.
    88. 88. What further treatment would this patient receive?<br />
    89. 89. Supportive Mx<br />Maintenance of adequate oxygenation & ventilation<br />Maintain stable hemodynamics<br />Fluids & blood products as clinically indicated<br />Prophylaxis of DVT & stress-related GI bleeding<br />Nutrition<br />
    90. 90. The right shoulder<br /> When En. M recovered from the operation and ICU, he began to ambulate. He complained of a right shoulder problem when examined as shown in Figure 3A and 3B<br />
    91. 91. Figure 3A<br />Figure 3B<br />
    92. 92. Question 21<br /> Name ONE clinical test which describe the method of examination shown in the figures<br />Shoulder impingement test<br />
    93. 93. Question 22<br /> Name TWO diagnoses possible for the above problem<br />1. Rotator cuff impingement<br />2. Rotator cuff tear<br />
    94. 94. The rotator cuff muscles<br />
    95. 95. Rotator cuff impingement<br /> “Mechanical impingement of rotator cuff tendon beneath the anteroinferior portion of the acromion, especially when the shoulder is placed in the forward-flex and internally rotated position.”<br />NeerCS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am. Jan 1972;54(1):41-50.<br />
    96. 96. Neer’s classification<br />Stage I: oedema and haemorrhage<br />Stage II: fibrosis and tendinopathy<br />Stage III: partial or complete tear<br />
    97. 97. Clinical features<br />Pain<br />Gradual onset<br />In the anterolateral part of shoulder<br />On overhead movement<br />Worse at night<br />Associated with weakness and stiffness<br />Clicking or creaking sounds during movement<br />Joint instability<br />Positive Impingement test<br />Normal range of movement and strength<br />
    98. 98. Rotator cuff tear<br />Partial tears frequently occur with supraspinatus tendinitis<br />Complete tear may result from sudden shoulder strain or as complication of tendinitis or partial rupture<br />
    99. 99. Clinical features<br />History of trauma to the shoulder<br />Pain<br />Sudden onset<br />In anterolateral part of shoulder<br />Associated with gross weakness of abduction<br />Joint instability<br />Persistent painful arc of abduction<br />Decreased strength on involved muscle group<br />Decreased range of movement<br />
    100. 100. Conservative Treatment<br />NSAIDS<br />Rest, activity modification (avoid irritating activities)<br />Ice on affected area<br />Physical therapy for stretching/ ROM<br />Rotator cuff strengthening and scapular stabilization<br />
    101. 101. Physical therapy<br />Strengthening the rotator cuff tendons<br />Stretching and regaining lost motion caused by pain and inflammation<br />Allowing the humerus to be better positioned under the acromion, thus reducing compression of the bursa<br />
    102. 102. Examples of physical therapy<br />Cross arm push<br />External rotation on elastic resistance cord<br />
    103. 103. Surgical treatment<br />Arthroscopic subacromial decompression to expand the space between acromion and rotator cuff tendons<br />Rotator cuff repair in rotator cuff tears<br />
    104. 104. THANK YOU<br />QUESTIONS?<br />
    105. 105. HAPPY CHINESE NEW YEARANDHAPPY HOLIDAY!!<br />

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