Phalanx Dislocations are common traumatic injury of the hand involving the proximal interphalangeal joint (PIP) or distal interphalangeal joint (DIP). J AmAcad Orthop Surg, 2001. Your doctor will take follow-up X-rays to make sure that the bone is properly aligned and healing. Hand (N Y). In most cases, this is done by simply adjusting the direction of traction to correct any shortening, rotation, or malalignment. Stress fractures can occur in toes. Anteroposterior and oblique radiographs generally are most useful for identifying fractures, determining displacement, and evaluating adjacent phalanges and digits. Most broken toes can be treated without surgery. They most often involve the metatarsals and toes. Pediatr Emerg Care, 2008. Remodeling of the fracture callus generally produces an almost normal appearance of the bone over a matter of months (Figure 26-36). Patients typically present with pain, swelling, ecchymosis, and difficulty with ambulation. For several days, it may be painful to bear weight on your injured toe. Immobilization of the distal interphalangeal joint is required for 2 weeks post-operatively, High rates of post-operative infection are common, Open reduction via an approach through the nail bed leads to significant post-operative nail deformity, Range of motion of the DIP joint in the affected finger is usually less than 10 degrees post-operatively, Type in at least one full word to see suggestions list, Management of Proximal Phalanx Fractures & Their Complications, Middle Finger, Proximal Phalangeal Head - Bicondylar Fracture - Fixation, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, PIP Fracture & Dislocation: Case of the Week - Shaan Patel, MD, Ring Finger Proximal Phalanx Fracture in 16M, Fracture of the base of proximal phalanx of 5th finger. The distal phalanx and proximal phalanx connect via the interphalangeal (IP) joint, which allows you to bend the tip of your thumb. Surgery may be delayed for several days to allow the swelling in your foot to go down. After the splint is discontinued, the patient should begin gentle range-of-motion (ROM) exercises with the goal of achieving the same ROM as the same toe on the opposite foot. angel academy current affairs pdf . On exam, he is neurovascularly intact. A 26-year-old professional ballet dancer presents with insidious onset of right midfoot pain which began 6 months ago. High-impact activities like running can lead to stress fractures in the metatarsals. Toe fractures, especially intra-articular fractures, can result in degenerative joint disease, and osteomyelitis is a potential complication of open fractures. Although referral rarely is required for patients with fractures of the lesser toes, referral is recommended for patients with open fractures, fracture-dislocations (Figure 5), displaced intra-articular fractures, and fractures that are difficult to reduce. You can rate this topic again in 12 months. Petnehazy, T., et al., Fractures of the hallux in children. A walking cast with a toe platform may be necessary in active children and in patients with potentially unstable fractures of the first toe. ROBERT L. HATCH, M.D., M.P.H., AND SCOTT HACKING, M.D. Dislocation refers to displacement in which the two articular surfaces are no longer in contact, in contrast to subluxation, in which there is some contact (may be referred to as complete versus simple dislocation in some texts). Ribbans, W.J., R. Natarajan, and S. Alavala, Pediatric foot fractures. Examination of the metatarsals should include palpation of the metatarsal base, shaft, and head, as well as examination of the proximal tarsometatarsal and distal metatarsophalangeal joints. Stress fractures are typically caused by repetitive activity or pressure on the forefoot. He states he has a 30-year-old lumberjack who earlier today was playing softball in the county championship when he slid into home plate in the bottom of the 9th inning. Kay, R.M. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. Ulnar side of hand. This joint sits between the proximal phalanx and a bone in the hand . This content is owned by the AAFP. 24(7): p. 466-7. toe phalanx fracture orthobullets While celebrating the historic victory, he noticed his finger was deformed and painful. They are common in runners and athletes who participate in high-impact sports such as soccer, football, and basketball. They can also result from the overuse and repetitive stress that comes with participating in high-impact sports like running, football, and basketball. Content is updated monthly with systematic literature reviews and conferences. (Left) X-ray shows a Jones fracture at the base of the fifth metatarsal (arrow). Copyright 2003 by the American Academy of Family Physicians. combination of force and joint positioning causes attenuation or tearing of the plantar capsular-ligamentous complex, tear to capsular-ligamentous-seasmoid complex, tear occurs off the proximal phalanx, not the metatarsal, cartilaginous injury or loose body in hallux MTP joint, articulation between MT and proximal phalanx, abductor hallucis attaches to medial sesamoid, adductor hallucis attaches to lateral sesamoid, attaches to the transverse head of adductor hallucis, flexor tendon sheath and deep transverse intermetatarsal ligament, mechanism of injury consistent with hyper-extension and axial loading of hallux MTP, inability to hyperextend the joint without significant symptoms, comparison of the sesamoid-to-joint distances, often does not show a dislocation of the great toe MTP joint because it is concentrically located on both radiographs, negative radiograph with persistent pain, swelling, weak toe push-off, hyperdorsiflexion injury with exam findings consistent with a plantar plate rupture, persistent pain, swelling, weak toe push-off, used to rule out stress fracture of the proximal phalanx, nonoperative modalities indicated in most injuries (Grade I-III), taping not indicated in acute phase due to vascular compromise with swelling, stiff-sole shoe or rocker bottom sole to limit motion, more severe injuries may require walker boot or short leg cast for 2-6 weeks, progressive motion once the injury is stable, headless screw or suture repair of sesamoid fracture, joint synovitis or osteochondral defect often requires debridement or cheilectomy, abductor hallucis transfer may be required if plantar plate or flexor tendons cannot be restored, immediate post-operative non-weight bearing, treat with cheilectomy versus arthrodesis, depending on severity, Can be a devastating injury to the professional athlete, Posterior Tibial Tendon Insufficiency (PTTI). About OrthoInfoEditorial Board Our ContributorsOur Subspecialty Partners Contact Us, Privacy PolicyTerms & Conditions Linking Policy AAOS Newsroom Find an FAAOS Surgeon. A positive metatarsal loading test, which involves manual axial loading of the metatarsal, may exacerbate the pain and help differentiate a fracture from a soft tissue injury.3. What is the most likely diagnosis? Bony deformity is often subtle or absent. During the procedure, your doctor will make an incision in your foot, then insert pins or plates and screws to hold the bones in place while they heal. Which of the following is responsible for the apex palmar fracture deformity noted on the preoperative radiographs? Referral should be strongly considered for patients with nondisplaced intra-articular fractures involving more than 25 percent of the joint surface (Figure 4).4 These fractures may lose their position during follow-up. A 55 year-old woman comes to you with 2 months of right foot pain. Patients with closed, stable, nondisplaced fractures can be treated with splinting and a rigid-sole shoe to prevent joint movement. Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. During the exam, the doctor will look for: Your doctor will also order imaging studies to help diagnose the fracture. If you experience any pain, however, you should stop your activity and notify your doctor. The image shows a diagram of where these bones lie in the footthe midpoint of the proximal phalanges being where to the toes branch off from the main body of the foot. Referral is indicated in patients with circulatory compromise, open fractures, significant soft tissue injury, fracture-dislocations, displaced intra-articular fractures, or fractures of the first toe that are unstable or involve more than 25 percent of the joint surface. Clin OrthopRelat Res, 2005(432): p. 107-15. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Although adverse outcomes can occur with toe fractures,3 disability from displaced phalanx fractures is rare.5. Follow-up should occur within three to five days to allow for reduction of soft tissue swelling. All rights reserved. . (OBQ11.63) Mounts, J., et al., Most frequently missed fractures in the emergency department. There are 3 phalanges in each toe except for the first toe, which usually has only 2. Indirect pull of the central slip on the distal fragment and the interossei insertions at the base of the proximal phalanx, Intrinsic muscle fibrosis and intrinsic minus contracture, PIP joint volar plate attenuation and extensor tendon disruption, Rupture of the central slip with attenuation of the triangular ligament and palmar migration of the lateral bands, Flexor tendon disruption with associated overpull of the extensor mechanism. Spiral fractures often lead to rotation or shortening, and transverse fractures lead to angulation.6. Unlike an X-ray, there is no radiation with an MRI. Referral is recommended for patients with first-toe fracture-dislocations, displaced intra-articular fractures, and unstable displaced fractures (i.e., fractures that spontaneously displace when traction is released following reduction). Bicondylar proximal phalanx fractures usually are treated with plate fixation. Clinical Features Fractures of the talus include fractures of the neck, body, medial or lateral process, and osteochondral injuries. Follow-up/referral. See permissionsforcopyrightquestions and/or permission requests. Pain is worsened with passive toe extension. Proximal phalanx fractures often present with apex volar angulation. However, if you have fractured several metatarsals at the same time and your foot is deformed or unstable, you may need surgery. and C.W. The choice of immobilization device depends on the patient's ability to ambulate with the device with minimal to no pain. Common presenting symptoms include bruising, swelling, and throbbing pain that worsens with a dependent position, although this type of pain also may occur with an isolated subungual hematoma. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. Pain that persists longer than a few months may indicate malunion, which may limit a patient's future activities significantly. Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. While you are waiting to see your doctor, you should do the following: When you see your doctor, they will take a history to find out how your foot was injured and ask about your symptoms. Your foot may become swollen and discolored after a fracture. 118(2): p. e273-8. Deformity, decreased range of motion, and degenerative joint disease in this toe can impair a patient's functional ability. The most common symptoms of a fracture are pain and swelling. Diagnosis is made clinically with the inability to hyperextend the hallux MTP joint without significant pain and the inability to push off with the big toe. J Pediatr Orthop, 2001. Patients with displaced fractures of the first toe often require referral for stabilization of the reduction. Since the fragment is pulled away from the rest of the bone, this type of injury is called an avulsion fracture. If the bone is out of place, your toe will appear deformed. Hallux fractures. Percutaneous Reduction and Fixation of Displaced Phalangeal Neck Fractures in Children Stable, nondisplaced toe fractures should be treated with buddy taping and a rigid-sole shoe to limit joint movement. A fracture that is not treated can lead to chronic foot pain and arthritis and affect your ability to walk. (OBQ05.209) Copyright 2023 American Academy of Family Physicians. Proximal phalanx fractures - displaced or unstable If a proximal phalanx fracture is displaced or if the fracture pattern is unstable it is likely that surgery will be recommended. Foot phalanges. Type in at least one full word to see suggestions list, 2019 Orthopaedic Summit Evolving Techniques, He Is Playing With Nonoperative Treatment - Michael Coughlin, MD, He Is Out! Objective Evidence X-rays provide images of dense structures, such as bone. Patient examination; . A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. A 20-year-old male military recruit slams his index finger on a tank hatch and sustains the injury seen in Figure A. Patients have localized pain, swelling, and inability to bear weight on the. and S. Hacking, Evaluation and management of toe fractures. If you need surgery it is best that this be performed within 2 weeks of your fracture. Healing of a broken toe may take 6 to 8 weeks. RESULTS: Stable fractures can be successfully treated nonoperatively, whereas unstable injuries benefit from surgery. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Patients have localized pain, swelling, and inability to bear weight on the lateral aspect of the foot. And finally, the webinar will cover fixation techniques, including various instrumentation options.Moderator:Jeffrey Lawton, MDChief, Hand and Upper ExtremityProfessor, Orthopaedic SurgeryAssociate Chair for Quality and Safety, Orthopaedic SurgeryProfessor, Plastic SurgeryUniversity of MichiganAnn Arbor, MichiganFaculty: Charles Cassidy, MDHenry H. Banks Professor and ChairmanDepartment of OrthopaedicsTufts Medical CenterBoston, MassachusettsChaitanya Mudgal, MD, MS (Ortho), MChHand Surgery ServiceDepartment of OrthopedicsMassachusetts General HospitalChairman, AO NA Hand Education CommitteeAssociate Professor, Orthopedic Surgery, Harvard Medical SchoolBoston, MassachusettsAmit Gupta, MD, FRCSProfessorDepartment of Orthopaedic SurgeryUniversity of LouisvilleLouisville, KentuckyRebecca Neiduski, PhD, OTR/L, CHTDean of the School of Health SciencesProfessor of Health SciencesElon UniversityElon, North Carolina, Ring Finger Proximal Phalanx Fracture in 16M. Examination reveals a well-aligned foot with ecchymosis and swelling on the plantar aspect of the 1st MTP joint. It ossifies from one center that appears during the sixth month of intrauterine life. Therefore, phalanges and digits adjacent to the fracture must be examined carefully; joint surfaces also must be examined for intra-articular fractures (Figure 3). This is followed by gradual weight bearing, as tolerated, in a cast or walking boot. This website also contains material copyrighted by third parties. Smooth K-wires or screw osteosynthesis can be used to stabilize the fragment. This procedure is most often done in the doctor's office. Proximal phalanx fractures occur in an apex volar angulation (dorsal angulation). fractures of the head of the proximal phalanx. 36(1)p. 60-3. Epub 2012 Mar 30. Avertical Lachman test will show greater laxity compared to the contralateral side. Primary care physicians are often the first clinicians patients see for foot injuries, and fractures are among the most common foot injuries they evaluate.1 This article will highlight some common foot fractures that can be managed by primary care physicians. If a fracture is present, it will typically be one of two types: a tuberosity avulsion fracture or a Jones fracture (i.e., proximal fifth metatarsal metadiaphyseal fracture). Referral also is recommended for children with first-toe fractures involving the physis.4 These injuries may require internal fixation. Patients usually cannot bear full weight and sometimes will ambulate only on the medial aspect of the foot. Patients typically present with varying signs and symptoms, the most common being pain and trouble with ambulation. Maffulli, N., Epiphyseal injuries of the proximal phalanx of the hallux. These rules have been validated in adults and children.16 If radiography is indicated, a standard foot series with anteroposterior, lateral, and oblique views is sufficient to make the diagnosis. A stress fracture, however, may start as a tiny crack in the bone and may not be visible on a first X-ray. Clin J Sport Med, 2001. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx ( Figure 2). Displaced fractures of the lesser toes should be treated with reduction and buddy taping. As the name implies a phalangeal fracture involves a fracture of any of the bones in the lesser toes. Phalanx fractures are classified by the following: Phalangeal fractures are the most common foot fracture in children. A collegiate soccer player presents as a referral to your office after sustaining an injury to the right foot, which he describes as hyperdorsiflexion of the toes. Stress fractures are small cracks in the surface of the bone that may extend and become larger over time. After that, nonsurgical treatment options include six to eight weeks of short leg nonweight-bearing cast with radiographic follow-up to document healing at six to eight weeks.2,6,20 If evidence of healing is present (callus formation and lack of point tenderness) at that time, weight-bearing activity can progress gradually, along with physical therapy and rehabilitation. AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. Proximal articular. Application of a gentle axial loading force distal to the injury (i.e., compressing the distal phalanx toward the foot) may distinguish contusions from fractures. He came to the ER at that point to be evaluated. Acute fractures to the proximal fifth metatarsal bone: Development of classification and treatment recommendations based on the current evidence. To minimize the possibility of future disability, the position of the bone fragments after reduction should be as close to anatomic as possible. If you have an open fracture, however, your doctor will perform surgery more urgently. When this happens, surgery is often required. The video will appear on the video dashboard once complete. Narcotic analgesics may be necessary in patients with first-toe fractures, multiple fractures, or fractures requiring reduction. The use of musculoskeletal ultrasonography may be considered to diagnose subtle metatarsal fractures. (SBQ17SE.89) All material on this website is protected by copyright. myAO. Most fifth metatarsal fractures can be treated with weight bearing as tolerated, and immobilization in a cast or walking boot. Fractures of the toes and forefoot are quite common. Nondisplaced fractures usually are less apparent; however, most patients with toe fractures have point tenderness over the fracture site. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. 3 Patients with phalanx fractures typically present with pain at or near the site of injury, edema, ecchymosis, and erythema. Great toe fractures are generally treated with a short leg walking cast with a toe plate (Figure 1311 ) that extends past the great toe or with a short leg walking boot for two to three weeks.6 After this time, and in the absence of significant symptoms, the patient can progress to buddy taping and use of a rigid-sole shoe for three to four weeks.6,23,24 Range-of-motion exercises can generally be initiated at four weeks. Continue to learn and join meaningful clinical discussions . Smith, Epidemiology of lawn-mower-related injuries to children in the United States, 1990-2004. More sensitive than an X-ray, an MRI can detect changes in the bone that may indicate a fracture. Copyright 2023 Lineage Medical, Inc. All rights reserved. Go to: History and Physical The main component to focus on assessment are: History - handedness, occupation, time of injury, place of injury (work-related) One of the most common foot fractures in children, Open fractures require irrigation & debridement, Nail-bed injuries involving the germinal matrix should be repaired, Displaced intra-articular fractures of the hallux require reduction. Phalanx fractures: The most common foot fractures Phalanx fractures typically occur by crush injury, hyperextension, or direct axial force (eg, stubbing the toe). Despite theoretic risks of converting the injury to an open fracture, decompression is recommended by most experts.5 Toenails should not be removed because they act as an external splint in patients with fractures of the distal phalanx. Which of the following is true regarding open reduction and screw fixation of this injury? While many Phalangeal fractures can be treated non-operatively, some do require surgery. An X-ray can usually be done in your doctor's office. In some practice sites, family physicians manage open toe fractures; a discussion about the management of this type of injury can be found elsewhere.3,4 Patients also may require referral because of delayed complications such as osteomyelitis from open fractures, persistent pain after healing, and malunion. Data Sources: We searched the Cochrane database, Essential Evidence Plus, and PubMed from 1900 to the present, human studies only, using the key words foot fractures, metatarsal, toe, and phalanges fractures. Others use a cast that fixates the wrist, metacarpophalangeal joint and proximal phalanx but allows movement of the interphalangeal joints. Proximal hallux. MB BULLETS Step 1 For 1st and 2nd Year Med Students. Radiographic evaluation is dependent on the toe affected; a complete foot series is not always necessary unless the patient has diffuse pain and tenderness. The metatarsals are the long bones between your toes and the middle of your foot. Copyright 2023 Lineage Medical, Inc. All rights reserved. The same mechanisms that produce toe fractures may cause a ligament sprain, contusion, dislocation, tendon injury, or other soft tissue injury. The next bone is called the proximal phalanx. The injured toe should be compared with the same toe on the other foot to detect rotational deformity, which can be done by comparing nail bed alignment. If it does not, rotational deformity should be suspected. Adjuvant imaging techniques to analyze fracture geometry and plan implant placement, will be discussed in detail. In children, toe fractures may involve the physis (Figure 2). The first toe has only two phalanges; the second through the fifth toes generally have three, but the fifth toe sometimes can have only two (Figure 1). A radiograph taken at the time of injury is shown in Figure A, and a current radiograph is shown in Figure B. 2 ). In many cases, anteroposterior and oblique views are the most easily interpreted (Figure 1, top and bottom). Nondisplaced or minimally displaced (less than 2 mm) fractures of the lesser toes with less than 25% joint involvement and no angulation or rotation can be managed conservatively with buddy taping or a rigid-sole shoe. The proximal phalanx is the toe bone that is closest to the metatarsals. Minimally displaced (less than 3 mm) fractures of the second to fifth metatarsal shafts (Figure 2) and fractures with less than 10 of dorsoplantar angulation in the absence of other injuries can generally be managed in the same manner as nondisplaced fractures.24,6 Initial management includes immobilization in a posterior splint (Figure 311 ), use of crutches, and avoidance of weight-bearing activities. Referral is indicated if buddy taping cannot maintain adequate reduction. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Treatment typically includes surgery to replace the fractured bone with an artificial implant, or to install hardware and screws to hold the bone in place. Kensinger, D.R., et al., The stubbed great toe: importance of early recognition and treatment of open fractures of the distal phalanx. Non-narcotic analgesics usually provide adequate pain relief. Nondisplaced or minimally displaced (less than 3 mm) fractures of the second to fifth metatarsal shafts with less than 10 of angulation can be treated conservatively with a short leg walking boot, cast shoe, or elastic bandage, with progressive weight bearing as tolerated. Because of the first toe's role in weight bearing, balance, and pedal motion, fractures of this toe require referral much more often than other toe fractures. Joint hyperextension and stress fractures are less common. 50(3): p. 183-6. Toe fracture (Redirected from Toe Fracture) Contents 1 Background 2 Clinical Features 3 Differential Diagnosis 3.1 Foot and Toe Fractures 3.1.1 Hindfoot 3.1.2 Midfoot 3.1.3 Forefoot 4 Management 4.1 General Fracture Management 4.2 Immobilization 5 Disposition 6 See Also 7 References Background Bones of the foot. Referral is recommended for children with fractures involving the physis, except nondisplaced Salter-Harris type I and type II fractures (Figure 6).4. Epidemiology Incidence Comminution is common, especially with fractures of the distal phalanx. Patients with lesser toe fractures with angulation of more than 20 in the dorsoplantar plane, more than 10 in the mediolateral plane, or more than 20 rotational deformity should also be referred.6,23,24. An avulsion fracture is also sometimes called a "ballerina fracture" or "dancer's fracture" because of the pointe position that ballet dancers assume when they are up on their toes. 68(12): p. 2413-8. Treatment for a toe or forefoot fracture depends on: Even though toes are small, injuries to the toes can often be quite painful. These bones comprise 2 bones in the hindfoot (calcaneus, talus), [ 1, 2] 5 bones in the midfoot (navicular, cuboid, 3. A fifth metatarsal tuberosity avulsion fracture can be treated acutely with a compressive dressing, then the patient can be transitioned to a short leg walking boot for two weeks, with progressive mobility as tolerated after initial immobilization. Taping your broken toe to an adjacent toe can also sometimes help relieve pain. The most common phalanx fractures involve the border digits, namely, the index and small finger rays (Fig. Physicians should consider referring patients with fractures of the great toe that have any degree of displacement, angulation, or rotational deformity 6,24 (Figure 12). In this type of injury, the tendon that attaches to the base of the fifth metatarsal may stretch and pull a fragment of bone away from the base. If this maneuver produces sharp pain in a more proximal phalanx, it suggests a fracture in that phalanx. An unmineralized physis is biomechanically weaker compared with the surrounding ligamentous structures and mature bone, which makes fractures about the physis likely. As your pain subsides, however, you can begin to bear weight as you are comfortable. The localized tenderness of a contusion may mimic the point tenderness of a fracture. Hatch, R.L. Open fractures, Infection, Compartment syndrome 3; References, Classification, Courses 3; Distal articular. Displaced spiral fractures generally display shortening or rotation, whereas displaced transverse fractures may display angulation. An AP radiograph is shown in FIgure A. Injury. hand fractures orthoinfo aaos metatarsal fractures foot ankle orthobullets phalanx fractures hand orthobullets fractures of the fifth metatarsal physio co uk 5th metatarsal . A radiograph, bone scan, and MRI are found in Figures A-C, respectively. Like toe fractures, metatarsal fractures can result from either a direct blow to the forefoot or from a twisting injury. Radiographs are shown in Figure A. A combination of anteroposterior and lateral views may be best to rule out displacement. This is called a "stress fracture.". Most children with fractures of the physis should be referred, but children with selected nondisplaced Salter-Harris types I and II fractures may be treated by family physicians. Am Fam Physician, 2003. Early surgical management of a Jones fracture allows for an earlier return to activity than nonsurgical management and should be strongly considered for athletes or other highly active persons. Flexor and extensor tendons insert at the proximal portions of the middle and distal phalanges. Evidence has shown that, depending on symptoms, short leg walking boots are superior to short leg walking casts.18,19 Immobilization in a cast or boot is typically only needed for two weeks, with progressive ambulation and range of motion thereafter as tolerated. X-rays. If an avulsion fracture results in a large displaced fracture fragment, however, your doctor may need to do an open reduction and internal fixation with plates and/or intramedullary screws. Metatarsal fractures usually heal in 6 to 8 weeks but may take longer. If the reduction is unstable (i.e., the position is not maintained after traction is released), splinting should not be used to hold the reduction, and referral is indicated. Copyright 2023 Lineage Medical, Inc. All rights reserved. PMID: 22465516. Patients with circulatory compromise require emergency referral.
John Ruiz Attorney Net Worth,
Clark County Ky School Jobs,
Articles P