Radiological Assessment and Functional Outcomes of Hand and Wrist in Patients with Distal End Radius Fractures

/in

Vol 7 | Issue 2 | July-December 2021 | page: 04-08 | Yogesh Pethapara, Vishwajeet Singh, Ronak Patel

DOI-10.13107/ti.2021.v07i02.016

Author: Yogesh Pethapara [1], Vishwajeet Singh [1], Ronak Patel [1]

[1] Department of Orthopedics, Maruti Superspeciality Orthopaedic Hospital, Morbi, Gujarat, India.


Address of Correspondence
Dr. Yogesh Pethapara, Maruti Superspeciality Orthopaedic Hospital, Morbi, Gujarat, India. 363641.
E-mail: matrixyp1@gmail.com

Abstract

Background: Fractures of distal end of radius are the most common fractures among the patients treated at emergency rooms. Despite a considerable progress in medical field over the last several years, distal end of radial fracture outcomes seem to be unsatisfactory in fairly large number of cases. The aim of this study was to determine the functional outcome of hand and wrist after distal end of radius fractures managed by different treatment modalities, to determine the complications of each methods used for treatment of distal end of radius fractures, to compare anatomical outcome with functional outcome after management of fracture distal end of radius.
Methods: A clinical, observational, prospective type of study was carried out on 40 cases with fractures of distal end of radius. The fractures were classified according to AO classification. After initial evaluation patients were taken up for either conservative or operative treatment. All the cases were followed up and assessed for minimum of 6 months. Patients with complications were followed up more frequently. Results: Anatomical results were evaluated according to Sarmiento’s modification of Lindstrom Criteria. Clinical and functional results were evaluated according to demerit point system of Gartland and Werley with Sarmiento modification
Conclusions: There is direct relationship between anatomical result and functional outcome. Therefore, every effort should be made to restore normal length and alignment, as well as articular surface congruency of distal radius.
Keywords: Distal end of radius, Demerit point system of Gartland and Werley with Sarmiento modification, Sarmiento’s modification of Lindstrom Criteria, Functional evaluation

References

1. Sarmiento A, Pratt GW, Berry NC, Sinclair WF. Colles’ fractures, functional bracing in supination. J Bone Joint Surg Am. 1975 apr;57(3)311–7.

2. Gartland JJ, Jr, Werley CW. Evaluation of healed Colles’ fracture. J Bone Joint Surg Am. 1951;oct 33-a(4)895–907.

3. Jupiter JB. Fractures of the distal end of the radius. J Bone Joint Surg [Am] 1991 mar;73-A:461-9.

4. Van Der Linden W, Ericson R. Colles‟ fracture: how should its displacement be measured and how should it be immobilized? J Bone Joint Surg [Am] 1981;63-A:1285-8.

5. Porter M, Stockley I. Fractures of the distal radius: intermediate and end results in relation to radiologic parameters. ClinOrthop 1987;220:241-52.

6. Cooney WP 3rd, Lindscheid R, Dobyns J. External pin fixation for unstable Colles‟ fracture. J Bone Joint Surg [Br] 1979; 61-B:840-5.

7. Solgaard S. Function after distal radius fracture. ActaOrthopaedicaScandinavica. 1988;59(1):39-42.

8. altissimi m, antenucci r, fiacca c, mancini g. Long-term Results of Conservative Treatment of Fractures of the Distal Radius. Clinical Orthopaedics and Related Research. 1986;&NA;(206):202-210.

9. Baruah R, Islam M, Haque R. Immobilisation of extra-articular distal radius fractures (Colles type) in dorsiflexion. The functional and anatomical outcome. Journal of Clinical Orthopaedics and Trauma. 2015;6(3):167-172.

10. Arora R, Gabl M, Erhart S, Schmidle G, Dallapozza C, Lutz M. Aspects of Current Management of Distal Radius Fractures in the Elderly Individuals. Geriatric Orthopaedic Surgery & Rehabilitation. 2011;2(5-6):187-194.

11. Ayhan KILIC, Yavuz KABUKCUOGLU, Ufuk OZKAYA, Murat GUL, Sami SOKUCU, Umit OZDOGAN. Volar locking plate fixation of unstable distal radius fracturesActaOrthopTraumatolTurc 2009;43(4):303-308

12. Chung, Kevin C, Watt, Andrws, Kotsis, Sandra VMPH, Margaliot, ZVI, Hase, Steven, Kim H. Myra. Treatment of unstable distal radius fractures with volar loking compression plate. The J Bone & Joint Surg 2006 Dec; 88-A(12): 2687-2694.

13. RE Anakwe, LAK Khan,RE Cook, and JE McEachan Locked volar plating for complex distal radius fractures: Patient reported outcomes and satisfaction J OrthopSurg Res. 2010; 5: 51.

14. Sanjay Meena, Pankaj Sharma, Abhishek Kumar Sambharia,1 and Ashok Dawar2 Fractures of Distal Radius: An Overview J Family Med Prim Care. 2014 Oct-Dec; 3(4): 325–332. doi: 10.4103/2249-4863.148101

How to Cite this article: Pethapara Y, Singh V, Patel R | Radiological Assessment and Functional Outcomes of Hand and Wrist in Patients with Distal End Radius Fractures | July-December 2021; 7(2): 04-08.

 

(Article Text HTML)   (Download PDF)

Comparison of Functional Outcome Between Trans– 2nd Metacarpal Fixation and Trans-Trapezius Fixation with K-Wire for Bennett Fracture

/in

Vol 7 | Issue 2 | July-December 2021 | page: 01-03 | Vishal V. Navale, Manasee Gulati

DOI-10.13107/ti.2021.v07i02.015

Author: Vishal V. Navale [1], Manasee Gulati [2]

[1] Department of Orthopaedics, Mysore Medical College and Research Institute, Mysore, Karnataka, India.
[2]Department of Physical Therapy, Manipal Academy of Higher Education, Manipal Hospitals, Bengaluru, Karnataka, India.

Address of Correspondence
Dr. Vishal V. Navale, Department of Orthopaedics, Mysore Medical College and Research Institute, Mysore, Karnataka, India.
E-mail: nvvishal2010@gmail.com

Abstract

Introduction: An articular fracture of the base of the thumb metacarpal consisting of a single, variable-sized, volar-ulnar fracture fragment is termed Bennett fracture. In the studies conducted so far there has been paucity in the knowledge about the methods of k wire fixation for the Bennett fracture and hence the purpose of this study is to compare functional outcome between the trans – 2nd metacarpal fixation and trans – trapezius fixation with K wire for Bennett fracture.
Methods: Patients were 18 years and above with no previous injury on the 1st metacarpal . Final assessment was performed from six months to nine months after the treatment with the DASH Score, VAS scale for pain, Hand Grip strength by Dynamometer. Radiographic images were taken at 6 months post-op in two separate views to evaluate post-traumatic arthritis of the first CMC joint.
Results: Statistical analysis showed a correlation between Pain and DASH score to be 0.946 in TTZ group and 0.966 in T2MC group and hence signifies that patients in T2MC group had a better functional outcome with lower DASH score and lower pain score. Significant correlation was seen between Pain and Grip strength, with -0.587 in TTZ group and -0.482 in T2MC group. Higher pain score correlated with higher DASH score and lower Grip strength and hence we can conclude that T2MC had a better functional outcome post-surgery than TTZ technique of fixation. Post op radiographs showed that T2MC group of patients had a better outcome with less arthritic complications and less pain and better grip strength.
Conclusion: This study gives us the overview about the two fixation methods of Bennett fracture , and that when trans 2nd metacarpal fixation is done , there are less chances of arthritis of the CMC joint as well as better functional outcomes post operatively as compared to trans trapezial fixation and hence guides a surgeon to make a decision about the technique of fixation to be employed during fixing such fracture.
Keywords: Bennett fracture, Trans-trapezial, Trans- 2nd metacarpal, Functional outcome

References

1. Drelich M, Godlewski P. Metacarpal fractures. Orthop Traumatol Rehabil 2004;6:331–335. 2. Kahler DM. Fractures and dislocations of the base of the thumb.J South Orthop Assoc 1995;4:69 –76. 3. Gedda KO, Moberg E. Open reduction and osteosynthesis of the so-called Bennett fracture in the carpo-metacarpal joint of the thumb. Acta Orthop Scand 1952;22:249–57. 4. Yin Y, Wang Y, Wang Z, Qu W, Tian W, Chen S. Accuracy of fluoroscopic examination in the treatment of Bennett fracture. BMC Musculoskelet Disord. 2021 Jan 4;22(1):3. doi: 10.1186/s12891-020-03867-1. PMID: 33397336; PMCID: PMC7783999. 5. Fractures of the Metacarpals and Phalanges: Charles S. Day. Greens Operative Hand surgery –Elsevier, 7th edition 2016, pg 272. 6. Fischborn T, Beckenbauer D, Held M, Daigeler A, Medved F. Analysis of operative techniques of fractures of the first metacarpal base. Ann Plast Surg 2018;80:507–14. 7. Hand – surgical treatment: Thomas P Ruedi. AO principles of fracture management – AO Publishing , second edition 2007, pg 683. 8. Kamphuis SJM, Greeven APA, Kleinveld S, Gosens T, Van Lieshout EMM, Verhofstad MHJ. Bennett fracture: Comparative study between open and closed surgical techniques. Hand Surg Rehabil. 2019 Apr;38(2):97-101. 9. Crosby CA, Wehbe MA, Mawr B. Hand strength: normative values. J Hand Surg Am 1994;19:665–70. 10. van Niekerk JL, Ouwens R. Fractures of the base of the first metacarpal bone: results of surgical treatment. Injury 1989;20:359–62. 11. Kamphuis SJM, Greeven APA, Kleinveld S, Gosens T, Van Lieshout EMM, Verhofstad MHJ. Bennett fracture: Comparative study between open and closed surgical techniques. Hand Surg Rehabil. 2019 Apr;38(2):97-101. doi: 10.1016/j.hansur.2018.11.003. Epub 2019 Jan 9. PMID: 30639054. 12. Greeven APA, Van Groningen J, Schep NWL, Van Lieshout EMM, Verhofstad MHJ. Open reduction and internal fixation versus closed reduction and percutaneous fixation in the treatment of Bennett fractures: A systematic review. Injury. 2019 Aug;50(8):1470-1477. doi: 10.1016/j.injury.2019.06.027. Epub 2019 Jun 28. PMID: 31288938.

How to Cite this article: Navale VV, Gulati M | Comparison of Functional Outcome Between Trans– 2nd Metacarpal Fixation and Trans-Trapezius Fixation with K-Wire for Bennett Fracture | July-December 2021; 7(2): 01-03.

 

(Article Text HTML)   (Download PDF)

Volar Radiocarpal Subluxation an Unusual Complication Following Distal Radius Fracture Fixation with Locking Plate- A Case Report

/in

Vol 7 | Issue 2 | July-December 2021 | page: 09-11 | Chirag Thonse, Darshan Kumar A Jain, Akshay S Dudhanale, Anant Chaugule,
Madihah Faisal

DOI-10.13107/ti.2021.v07i02.017

Authors: Chirag Thonse [1], Darshan Kumar A Jain [2], Akshay S Dudhanale [1], Anant Chaugule [1],
Madihah Faisal [1, 2]

[1] Department of Orthopedics, Vikram Hospital, Millers Road, Bangalore, Karnataka, India.
[2] Department of Orthopedics, M.S. Ramaiah Medical College, MSRIT Post, Bangalore, Karnataka, India.
Address of Correspondence
Dr Akshay S. Dudhanale,
Fellow in Arthroscopy and Arthroplasty, Vikram Hospital Bangalore, Karnataka, India.
E-mail: akshay3664@gmail.com

Abstract

Introduction: Distal radius fractures are commonly treated by fixation using a volar locking plate. In some fracture patterns, this mode of fixation is not adequate. This case report aims to describe one such case.

Case report: We report a case of a 28-year-old gentleman who presented with volar subluxation of the radiocarpal joint early in the postoperative period following fixation of the distal end radius volar locking plate.

Conclusion: Volar locked plates have become the most common fixation strategy for distal radius fractures. In certain fracture patterns where a volar locking plate would be inappropriate, an alternative fixation strategy should be considered such as rim plate.

Keywords: Volar locking plate, Volar rim plate, Radiocarpal dislocation

References

1. International Journal of Research in Medical SciencesChavhan AN et al. Int J Res Med Sci. 2017 Feb;5(2): 574-582.

2. Alter, Todd H. and Ilyas, Asif M., “Complications Associated with Volar Locking Plate Fixation of Distal Radial Fractures.” (2018). Rothman Institute Faculty Papers. Paper 109. https://jdc.jefferson.edu/rothman_institute/109.

3. Wilson J, Viner JJ, Johal KS, Woodruff MJ. Volar Locking Plate Fixations for Displaced Distal Radius Fractures: An Evaluation of Complications and Radiographic Outcomes. Hand (N Y). 2018 Jul;13(4):466-472. DOI: 10.1177/1558944717717505. Epub 2017 Jul 9. PMID: 28691543; PMCID: PMC6081777.

4. Rohit Garg, Chaitanya S. Mudgal, When a volar locking plate is not the right choice in fractures of the distal radius: Case-based technical considerations, Journal of Clinical Orthopaedics and Trauma, Volume 11, Issue 4, 2020, Pages 542-553, ISSN 09765662, https://doi.org/10.1016/j.jcot.2020.05.040.(https://www.sciencedi rect.com/science/article/pii/S0976566220302320).

5. Alter, Todd H. and Ilyas, Asif M., “Complications Associated with Volar Locking Plate Fixation of Distal Radial Fractures.” (2018). Rothman Institute Faculty Papers. Paper 109. https://jdc.jefferson.edu/rothman_institute/109.

6. Harikrishnan Balakrishna Pillai, Suraj Sankar, Surendra Singh Rawat, Samarth Arya, Pradeep Jadhav. The functional outcome volar Barton fracture treated by open reduction and internal fixation with T plate – a prospective study. International Journal of Contemporary Medical Research 2020;7(6): F7-F11.

7. Müller ME, Koch P, Nazarian S, Schatzker J. Principles of the Classification of Fractures. In: Müller ME, Koch P, Nazarian S, Schatzker J, editors. The Comprehensive Classification of Fractures of Long Bones. Berlin, Heidelberg: Springer; 1990. p. 4–7.

8. Jupiter, Jesse B. MD Complex Articular Fractures of the Distal Radius: Classification and Management, Journal of the American Academy of Orthopaedic Surgeons: May 1997 – Volume 5 – Issue 3 – p 119-129.

9. Ilyas, Asif M. MD; Mudgal, Chaitanya S. MD Radiocarpal Fracturedislocations, Journal of the American Academy of Orthopaedic Surgeons: November 2008 – Volume 16 – Issue 11 – p 647-655.

How to Cite this article: Thonse C, Jain DKA, Dudhanale AS, Chaugule A, Faisal M | Volar Radiocarpal Subluxation an Unusual Complication Following Distal Radius Fracture Fixation with Locking Plate- A Case Report | Trauma International | July-December 2021; 7(2): 09-11.

 

(Article Text HTML)   (Download PDF)

Chronic Tibial Tunnel Infection Following ACL Reconstruction: A Case Report and Review of the Literature

/in

Vol 7 | Issue 1 | January-June 2021 | page: 19-21 | Bishnu Pokharel, Rosan Prasad Shah Kalawar, Ashish Kumar Goyal

Author: Bishnu Pokharel [1], Rosan Prasad Shah Kalawar [1], Ashish Kumar Goyal

[1] Department of Orthopaedics, BPKIHS, Dharan, Nepal. [2] Department of Orthopaedics and Joint Replacement Surgery, Indrparastha Apollo Hospitals, Sarita Vihar, New Delhi, India.
Address of Correspondence
Dr. Ashish Kumar Goyal
Senior Registrar; Department of Orthopaedics and Joint Replacement Surgery Indrparastha Apollo Hospitals, Sarita Vihar, New Delhi, India.
Email: drgoyal41@gmail.com

Abstract

Introduction: Rupture of the anterior cruciate ligament (ACL) is a common injury in active people and one of the most common knee injuries in sports. Foreign body granuloma with concomitant infection is a rare complication in ACL surgery. Very few cases have been reported on it. We present a young patient with a chronic discharging sinus at a surgical site on the tibia in a diabetic patient and its successful management.  

 

 

Case Report: A thirty-two-year-old male presented to us with a persistent discharging sinus at the surgical site following an Anterior Cruciate Ligament (ACL) reconstruction two years back. Since then, he developed wound infection at the incision site created for graft harvesting, which kept on discharging sero-purulent discharge even with several antibiotics and local dressing courses. There was no stiffness or instability in the knee. We did a follow-up arthroscopic evaluation of the joint and debridement of the wound. A portion of hamstring graft and non-absorbable suture with unhealthy granulation tissues were found subcutaneously during the surgery. A partially resorbed bioscrew with unhealthy granulation tissue was observed in the tibial tunnel. After thorough debridement of the site, the wound completely healed.
Conclusion: Surgical site infection and foreign body granuloma should be considered and treated accordingly if the patient presents with persistent discharging sinus at the surgical site in ACL reconstruction
Keywords: Anterior cruciate ligament reconstruction, ACL, Surgical site infection, Tibial tunnel.

References

1) Miyasaka KC, Daniel D, Stone M, and Hirshman P. The incidence of knee ligament injuries in the general population. Am J Knee Surg. 1991; 4: 3-8.
2) Weiss KS, Weatherall JM, Eick J, and Ross JR. (2017). Delayed Tibial Osteomyelitis after Anterior Cruciate Ligament Reconstruction with Hamstrings Autograft and Bioabsorbable Interference Screw: A Case Report and Review of the Literature. Case Reports in Orthopedics. 2017; 1-7. doi:10.1155/2017/6383526.
3) Barber FA. Complications of Biodegradable Materials. Sports Medicine and Arthroscopy Review. 2015; 23(3):149-155. doi:10.1097/jsa.0000000000000076.
4) Barber FA. Complications of biodegradable materials: anchors and interference screws. Sports Medicine and Arthroscopy Review. 2015;3(3):149–155.
5) Frank M, Schmucker U, David S, et al. Devastating femoral osteomyelitis after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthr. 2008;16: 71–74. https://doi.org/10.1007/s00167-007-0424-7.
6) McAllister DR, Parker RD, Cooper AE, Recht MP, and Abate J. Outcomes of postoperative septic arthritis after anterior cruciate ligament reconstruction. Am J Sports Med. 1999;27 : 562- 570.
7) Van Tongel A, Stuyck J, Bellemans J, and Vandenneucker H. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction: a retrospective analysis of incidence, management and outcome. Am J Sports Med. 2007; 35 : 1059 – 1063.
8) Numazaki H, Kobayashi H, Yoshida K, Hakozaki M, and Konno SI. Prolonged infection at the tibial bone tunnel after anterior cruciate ligament reconstruction. Fukushima J Med Sci. 2017; 63(2):121-125. doi:10.5387/fms.2017-02. 9) O’Neill BJ, Molloy AP, and McCarthy T. Osteomyelitis of the tibia following anterior cruciate ligament reconstruction. International Journal of Surgery Case Reports. 2013;4(2): 143-145. doi: https://doi.org/10.1016/j.ijscr.2012.10.020.
10) Chua CG and Zubair M. A Modified Technique To Treat Infected Tibial Tunnel Post ACL Reconstruction: A Case Report. Malaysian Orthopedic Journal. 2019;13supplA.

How to Cite this article: Pokharel B, Kalawar RPS, Goyal AK | Chronic Tibial Tunnel Infection Following ACL Reconstruction: A Case Report and Review of The Literature | Trauma International | January-June 2021; 7(1): 19-21.

 

(Article Text HTML)   (Download PDF)

Acute Scaphoidectomy and Lunocapitate Fusion for the Surgical Treatment of Compound Trans Styloid, Trans-Scaphoid, Peri-Lunate Fracture- Dislocation with Extensor Tendon Injury

/in

Vol 7 | Issue 1 | January-June 2021 | page: 15-18 | Divyesh V. Bukalsaria, Sachin Kale, Prakash D. Samant, Arvind Vatkar, Sanjay Dhar, Prasad Chaudhari

Author: Divyesh V. Bukalsaria [1], Sachin Kale [1], Prakash D. Samant [1], Arvind Vatkar [1], Sanjay Dhar [1], Prasad Chaudhari [1]

[1] Department of Orthopaedic Surgery, D Y Patil Medical College and Research Centre, Navi Mumbai, Maharashtra, India.
Address of Correspondence
Dr. Divyesh Vinod Bukalsaria,
Resident Physician, Department of Orthopaedic Surgery, D Y Patil Medical College and Research Centre, Navi Mumbai, Maharashtra, India.
E-mail: divyeshbukalsaria7@gmail.com

Abstract

Compound fracture-dislocations of proximal carpal bones are very rare. We report a 54-year-old male, laborer, who sustained a compound Gustilo Anderson type III-A dorsal wound with trans styloid, trans-scaphoid, peri-lunate dislocation with an extensor tendon injury. The patient underwent primary scaphoidectomy with Lunocapitate fusion with extensor tendon repair. On follow-up after 3 months, the patient had partial recovery of range of motion around the wrist without any significant discomfort.  

Keywords: Compound fracture-dislocation, Primary proximal row carpectomy, Trans-styloid trans scaphoidperilunate dislocation

References

1. Ali, Nadeem, et al. “Compound Transstyloid, Transscaphoid, Perilunate Fracture Dislocation.” Journal of the Scientific Society, vol. 40, no. 2, 2013, p. 111., doi:10.4103/0974-5009.115485.
2. Herzberg, G., and D. Forissier. “Acute Dorsal Trans-Scaphoid Perilunate Fracture-Dislocations: Medium-Term Results.” Journal of Hand Surgery, vol. 27, no. 6, 2002, pp. 498–502., doi:10.1054/jhsb.2002.0774.
3. Calandruccio, James H., et al. “Capitolunate Arthrodesis with Scaphoid and Triquetrum Excision.” The Journal of Hand Surgery, vol. 25, no. 5, 2000, pp. 824–832., doi:10.1053/jhsu.2000.16364.
4. Oehmke, M. J., et al. “The Blood Supply of the Scaphoid Bone.” Journal of Hand Surgery (European Volume), vol. 34, no. 3, Dec. 2009, pp. 351–357., doi:10.1177/1753193408100117.
5. Mayfield, Jack K. “Patterns of Injury to Carpal Ligaments.” Clinical Orthopaedics and Related Research, & NA; no. 187, 1984, doi:10.1097/00003086-198407000-00006.
6. Herzberg G, Comtet JJ, Linscheid RL, et al. Perilunate dislocations and fracture-dislocations: a multicenter study. J Hand Surg Am.1993;18:768–79.
7. Herzberg, G., and D. Forissier. “Acute Dorsal Trans-Scaphoid Perilunate Fracture-Dislocations: Medium-Term Results.” Journal of Hand Surgery, vol. 27, no. 6, 2002, pp. 498–502., doi:10.1054/jhsb.2002.0774.
8. Herzberg, G., et al. “Perilunate Dislocations and Fracture-Dislocations: A Multicenter Study.” The Journal of Hand Surgery, vol. 18, no. 5, 1993, pp. 768–779., doi:10.1016/0363-5023(93)90041-z.
9. E. Hagert, M. Garcia-Elias, S. Forsgren, B.O. LjungImmunohistochemical analysis of wrist ligament innervation in relation to their structural composition
10. J Hand Surg, 32 (2007), pp. 30-36
11. Moody, Lisa, and Andrew Y. Zhang. “Treatment of an Unusual Trans-Scaphoid Perilunate Avulsion Fracture Dislocation: A Case Report.” Hand, vol. 10, no. 2, Mar. 2014, pp. 328–332., doi:10.1007/s11552-014-9634-x.
12. Sotereanos DG, Mitsionis GJ, Giannakopoulos PN, et al.Perilunate dislocation and fracture-dislocation: a critical analysis of the volar-dorsal approach. J Hand Surg Am. 1997;22:49–56.
13. Yao, Yu-Cheng, et al. “Lunocapitate Fusion with Scaphoid Excision for the Treatment of Scaphoid Nonunion Advanced Collapse or Scapho-Lunate Advanced Collapse Wrist.” Journal of the Chinese Medical Association, vol. 80, no. 2, 2017, pp. 117–120., doi:10.1016/j.jcma.2016.10.001

How to Cite this article: Bukalsaria DV, Kale S, Samant PD, Vatkar A, Dhar S, Chaudhari P | Acute Scaphoidectomy and Lunocapitate Fusion for the Surgical Treatment of Compound Trans Styloid, Trans-Scaphoid, Peri-Lunate Fracture-Dislocation with Extensor Tendon Injury | Trauma International | January-June 2021; 7(1): 15-18.

 

(Article Text HTML)   (Download PDF)