1/8/2010

A Black Box
Anatomy and Dysfunction
of the DRUJ and TFCC

Input Output

Diane Coker, PT, DPT, CHT

South County Hand Center
Laguna Woods, CA
dacoker@cox.net

Outline Bony Architecture

 Joint biomechanics
 Osteology  Articulations
 Soft Tissue Stability  Arthrokinematics
 Extrinsic support  Pathology
 Intrinsic support  Traumatic
 TFCC Anatomy  Degenerative
DRUJ
 Diagnostic imaging

The Distal Pole of the Ulna The Sigmoid Notch

 Radius
 Ulna
 Seat
 Hyaline cartilage
 TFCC
FOVEA

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An Inherently Unstable Joint

The Sigmoid Notch

Articular Contact

42% 14%

At extremes of pronation & supination, there may be as little as

30% 14%
2mm, or < 10%, articular contact between radius & ulna
Tolat 1996

Extrinsic Stabilizers
of the DRUJ
Soft Tissue Stabilizers
 1: Tendon of ECU
 2: Sixth dorsal
compartment subsheath
 3: Pronator quadratus
 4: Interosseous ligament

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Contributions of Pronator Quadratus

 ECU only motor unit w/ a the ECU  Some texts describe a 2-
relationship to the TFCC headed composition
 Tendon sheath blends with TFCC  Medial & anterior surface
 ECU held close to center of of ulna
rotation of wrist by the TFCC  Lateral & anterior surface
 TFCC is an important pulley for of radius
the ECU  Only muscle that attaches
 Disruption of the ECU may to radius at one end & ulna
contribute to abnormal loading at the other
& force transmission through  Activation of PQ may
TFCC contribute to ulnar
impingement syndrome
Gordon 2003

The Dorsal Oblique

The Interosseous Membrane Bundle
 Distal 3 ligaments in
 Combination of ligaments and constant tension during f/a
membranes rotation
 3 portions: proximal, middle,  Dorsal oblique bundle
distal (DOB) has continuity with
 Distal 3 ligaments in constant fibers of TFCC
tension during f/a rotation  DOB present in 40%
 Central band (CB) widest, population
stoutest  Possible secondary
stabilizer of the DRUJ

Intrinsic Stabilizers of the DRUJ Triangular Fibrocartilage Complex

 Joint capsule
 Ligamentous attachments include  Palmar and Werner
 Volar ulnolunate introduced term TFCC 1981
 Ulnotriquetral  Structures include
 DOB  Articular disc
 Meniscus homologue
 Prestyloid recess
 Dorsal & volar radioulnar
ligaments

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Cross Section
View
Coronal
View

Vascularity Intrinsic Stabilizers of the DRUJ

 Anterior interosseous &
ulnar arteries
 Central disc relatively
avascular
 Peripheral 15-20% well
vascularized, will heal

Innervation
 Volar, ulnar portions: ulnar N
 Dorsal portion: PIN, dorsal
sensory branch
 Central disc relatively aneural
Attachments
 Originates from medial
border of distal radius
 Inserts into base of ulnar
styloid (fovea)

Axis of Rotation of the Forearm

Joint Biomechanics
Radial head Fovea

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Ulnar Variance Affected by

Forearm Rotation Ulnar Variance

A Controversy
Functions of the TFCC
 Ekenstam/Hagert,1985: dorsal radioulnar fibers tighten in
 Provides a continuous gliding surface across the entire distal supination, palmar fibers tighten in pronation
face of the 2 forearm bones for flexion-extension and  Schuind,1991: dorsal fibers tighten in pronation, palmar
translational movements fibers tighten in supination
 Provides a flexible mechanism for stable rotational  Hagert 1994: both theories are correct
movements of the radiocarpal unit around the ulnar axis
 Suspends the ulnar carpus from the dorsal ulnar face of the
radius
 Cushions the forces transmitted through the ulnocarpal axis
 Solidly connects the ulnar axis to the volar carpus

pronation neutral supination

Superficial and Deep Fibers

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Deep Fibers Have the Mechanical Advantage

A “Buckboard” analogy Ulnar Head Translation

Pronation Supination The Controversy continues….

 Sigmoid notch migrates  Sigmoid notch migrates
volarly to <10% articular dorsally to <10% articular  Xu et al, (2009)
contact contact  Validates conclusions of other
studies that dorsal superficial and
 Superficial dorsal fibers  Superficial palmar fibers
palmar deep ligaments tighten
ineffective in pronation ineffective in supination
during pronation, and vice versa
 Deep palmar ligamentum  Deep dorsal ligamentum  However, all 4 ligaments are
subcruentum tightens subcruentum tightens important stabilizers, playing
different roles during the arc of
forearm rotation
The deep RUL are considered more important to  To maintain an entirely stable
the stability of the DRUJ than the superficial DRUJ, integrity of all 4 ligaments
ligaments likely required

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Pathology Affecting the

DRUJ & TFCC
 Anatomical variations  Chronic overuse
Pathology  Congenital ulnar +  ECU tendonitis
 Acute trauma  FCU tendonitis
 Fractures  Degeneration
 Distal radius  Arthritis
 Ulnar styloid
 Malunion of radius
 Radial shaft
 Madelung’s deformity
 Radial metaphysis
 Growth disturbance
 Ligament
disruptions/dislocations
 Lunatotriquetral
 DRUJ

Ulnar Variance Dynamic Ulnar Variance

26% 51% 23%

Abnormal Ulnar Variance = Ulnar Impaction Syndrome

Abnormal WB Distribution

80% 20%

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Ulnar Styloid Length

Trauma: Colles’ Fracture Galeazzi Fracture

 Abraham Colles, MD, 1814
 Nonarticular metaphyseal
fracture with dorsal tilt
 LOOSH (land on an
outstretched hand)

Fracture of radial shaft, dislocation of distal ulna

Essex Lopresti Fracture

Monteggia Fracture
Ulnar shaft fracture, dislocation of
proximal radius

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Palmer Classification of TFCC Abnormalities

Traumatic Lesions

 Class 1A
 Most common traumatic
tear
 Dorsal palmar tear 1-2mm
to radial origin of TFCC
 Minimal healing potential
2° poor vascularity

Palmar 1989

Traumatic Lesions Traumatic Lesions

 Class 1C
 Class 1B
 Traumatic avulsion of the
TFCC from its insertion into
the distal ulna.
 May or may not be associated
with an ulnar styloid fracture
 Includes peripheral tears in
the vascular zone
 TFCC avulsed distally from its
bony insertion to lunate by the
ulnohamate ligament &/or
triquetrum by the ulnotriquetral
ligament
 Rare, high energy injury
 Results in ulnocarpal instability &
palmar translocation of ulnar
carpus
 Well-vascularized, better healing
potential

Traumatic Lesions Degenerative Lesions

 Nontraumatic lesions have been
 Class 1D noted in fetuses
 Avulsion of TFCC from its  Seldom in 1st 2 decades
radial origin  No normal appearance of TFCC
 Seen with or without sigmoid by 6th decade Mikic 1978
notch fracture  Degeneration linked to + ulnar
variance
 Degeneration ↑’s w/ rotational
and loading activities

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Degenerative Lesions Degenerative Lesions

 Class 2B
 Class 2A
 Both proximal & distal
 Both proximal and distal
aspects show degenerative
aspect show degenerative
changes
changes
 Cartilage erosion of ulnar
head beneath TFCC or
medial border of lunate
distal to TFCC

Degenerative Lesions Degenerative Lesions

 Class 2D
 Class 2C
 Through and through
 Large central perforation
perforation of horizontal
of the TFCC portion of TFCC
 Underlying cartilage
 Cartilage abnormalities of
abnormality of the ulnar ulnar head, medial border of
head, medial aspect of lunate
lunate
 Disruption of lunatotriquetral
ligament

Diagnostic Imaging MRI Arthrography

 Plain films
 Abnormal ulnar variance  A specialized technique
 Loss of radial tilt  Contrast dye leaking into
 Joint widening DRUJ (white arrow),
 Sclerosis indicating a tear of the
 Dynamic stress or grip TFCC
view

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Diagnostic Arthroscopy
 Sensitive for identifying acute
Medical Management tears or degeneration in the
central portion of the disc,
chondromalacia, and ulnocarpal
ligament injuries.
 More sensitive and accurate than
non-invasive imaging modalities

Linda de Haas PT, MPT, OCS, CHT

Whittier, CA
lldehaas@msn.com

Diagnostic Arthroscopy Trampoline Test

 Standard portals are mostly
 Loss of the TFC
dorsal. “trampoline” effect during
 Relative lack of arthroscopic ballotment
neurovascular structures on with a probe strongly
the dorsum of the wrist suggests a destabilizing
 Dorsal portals are named in injury to the periphery of
relation to the extensor the TFCC.
compartments

Surgical Procedures – for Ulnar

Arthroscopic Procedures Impaction and DRUJ Instability
 TFCC repairs  Arthroscopic assisted internal
 Ganglionectomy fixation: scaphoid
 Synovectomy  Arthroscopic assisted fixation:
 Chondroplasty and loose
distal radius
bodies  Radial styloidectomy
 Avascular necrosis  Proximal pole of hamate

 Dorsal radiocarpal ligament

resection
repair  Ulnocarpal impaction
 Arthroscopic release of wrist  Capsular shrinkage
contracture

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Darrach Procedure Wafer Osteotomy

 Excision of the distal ulna through its
neck
 Ulnar styloid and soft tissue
attachments retained to preserve
some TFCC function
 Often combined with a soft tissue
stabilization with FCU and/or ECU
 The distal 2-4 mm of the
distal ulna is resected
while preserving the distal
radioulnar joint and the
styloid process of the ulna
and the ligaments attached
to it

Hemiresection With Tendon

Interposition Ligament Reconstruction
 Resects DRUJ at sigmoid
notch
 Portion of ulna retained
to maintain TFCC
 Portion of tissue
interposed to prevent
impingement between
radius and ulna.  Tendon graft passed through the bone tunnel parallel to the
sigmoid notch and reinserted into
the fovea. The capsule is then closed.

Suave-Kapandji Procedure Ulna Styloid Fixation

 Retains the distal ulna

 Fuses the ulnar head to the

sigmoid notch

 Creates a pseudoarthrosis
at the ulnar neck.

 Preserves TFCC and ECU

tendon

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Ulnar Hemiarthroplasty Physical Therapy Management

Evaluation
 Inspection
 Patient’s posture and carriage of affected UE
 Swelling, erythema, scars, nodules, masses
 Range of Motion
 Active and Passive ROM
 Palpation
 Bones and soft tissues
 Provocative Tests

General Inspection TFCC Diagnosis:

 Inspect for swelling about the DRUJ, ECU sheath and carpus  Classic symptoms are ulnar sided wrist pain that is associated with
popping or clicking
 ECU subluxation is most apparent with the forearm and wrist in
supination and ulnar deviation. The tendon subluxates ulnarly.  Palpable tenderness over the TFCC

 Pain and crepitus with compression of the pisiform against the

triquetrum suggest pisotriquetral arthritis.
 Reduced grip strength strongly suggests intraarticular pathology.
 Combined ulnar deviation and pronation/supination will produce
popping or clicking and reproduce the patient’s pain
 “Press Test” in which the patient is asked to lift himself out of a chair
bearing weight on extended wrists has been shown to have 100%
sensitivity for detecting tears

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Provocative Maneuvers Distal Radio-Ulnar Joint

The Ulnar Fovea Sign

Ulnar Fovea Sign
The fovea lies between
 The ulnar styloid (US) process
 Flexor carpi ulnaris (FCU)
tendon
 Distally it is bounded by the
Pisiform (P) bone
 Proximally by the volar
 The elbow is in 90° to 110° of
flexion, forearm in neutral rotation and
wrist in neutral position.
 The examiner’s thumb tip is then
pressed distally and deep into the
interval “soft spot”
The ulnar fovea sign is positive
when there is exquisite tenderness
compared with the contralateral side.
 95.2% sensitive
 86.5% specific

surface of the ulnar head.

Dorsal Ulnar Zone

L-T Instability Tests
 L-T Instabilities

TFCC Load Test

 TFCC Stress Test
 Ballottement Test
 Lunotriquetral shear test  Ulnar deviation
 Shuck
 Triquetrum squeeze test
 Axial Load
 ECU subluxation

 ECU Synergy Test  Rotation

 Piano KeyTest

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L-T Instability Tests L-T Instability Tests

Ballottement Test Lunotriquetral Shear test
 Grasp the Pisiform and Triquetrum
 Stabilize Lunate bone between  The contralateral thumb and index finger
thumb and index finger of one hold the Lunate and radial carpus.
hand  Move the Triquetrum while the lunate and
 The other hand moves piso- radial wrist remain stationary.
triquetral complex in a volar and  The force is transmitted across the
dorsal direction. lunotriquetral joint.
 Sensitivity .69  Sensitivity .66
 Specificity .44  Specificity .44

Reagan Shuck Test L-T Instability Tests

 Grasp the whole piso-triquetral unit. Linscheid Compression Test
 The contralateral thumb and index finger Squeeze Test
hold the lunate.
 Apply a dorsally directed force with one  Ulnar border of the Triquetrum
hand and volarly directed force with the  Push in radial direction
other hand.
 Compression force across the
 This force is switched in the opposite
directions in both hands. lunotriquetral joint.
 This creates a shear stress at the
lunotriquetral joint, and if painful, the result
is positive.

ECU Subluxation The ECU Synergy Test

 ECU Tendinitis
 This test is performed by having the
 Supination patient radially deviate the thumb
against resistance.
 Ulnar deviation
 Note that the ECU tendon
 Wrist flexion bowstrings against the skin (large
arrow).

Robert T. Ruland, MD, Christopher J. Hogan, JHS Vol 33A,

December 2008

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Piano Key Test
 Patients hand pronated on
the table.
 Ballottement of the ulna is
performed by the examiner
applying a dorsal-to-volar
load with his or her hand 4
cm proximal to the distal
radioulnar joint.
 Sensitivity .59
 Specificity .96
Volar Ulnar Zone
 Flexor carpi ulnaris (FCU)
tendinitis
 Pisiform
 Hook of Hamate
 Guyon’s canal
Hook of Hamate
1/8/2010
Ulnar Compression Test
 Compress the ulnar head
against the sigmoid notch.
 A positive result is
exacerbation of pain, which
suggests arthritis or
instability.
 In addition, with ulnar
compression, dorsal or volar
subluxation may be noted.
Pisiform Shear Test
 Pisotriquetral arthritis
 Pisiform instability
Guyon’s Canal
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GRIT Test
Gripping Rotatory Impaction Test Therapeutic Management
 Quantifiable measurement  Wound care

 Expressed as a ratio:  Edema reduction

Supination strength
 Protective splinting
Pronation strength
 Around hardware
 Immobilize joints
 1.0 is normal, > 1.0  To increase joint mobility
predicts ulnar impaction
problems

Therapeutic Management  During rehab, isolate the actions of wrist extensors from finger
extensors
 Maintain/improve ROM  Limits cheating with finger extensors
 finger motion
 Uninvolved Joints
 Composite flexor or extensor
tightness
 Joint mobilization?
 Grades I & II for pain
 Grades III & IV to increase ROM
 Goal = maximum pain-free wrist &
forearm AROM  Consider supinated position to start grip strengthening
exercises in those with ulnar impaction syndrome.

Nonoperative Versus Operative

Management
 Initial treatment begins with activity modifications, splinting,
and anti-inflammatory medications.
 Failure to respond to non-operative treatment is an
indication for surgery.
 Goals for surgery is to decrease the loading across the ulnar
side of the wrist.

Rehab of the Hand pg. 1162

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Corrective Splinting
Prefabricated - TFCC Corrective Splinting
 Universal Wristlet  Wrist Widget
Custom - TFCC

Pre-Cut Long Arm Splints

Corrective Splinting
Custom - TFCC

Custom bivalve Custom Muenster

Thermoplastic Orthosis Thermoplastic Orthosis Corrective Splinting
Custom Pronation/Supination

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Corrective Splinting Research on Dynamic Splinting

Prefabricated Pronation/Supination Average forearm rotation in all 15 patients was 83°before and 126° after DFRS,
Splints an increase of 52%. Dynamic forearm rotational splinting produced significant
increases in both pronation (p.05) and supination (p.05).

The Journal of Hand Surgery, 27A(3).

Corrective Splinting
Splints to Increase Flexion/Extension Rehabilitation Guidelines
 JAS
 Custom  Note: The following guidelines arise from the Indiana Hand Therapy
Protocol.
Please refer to this publication for additional information.

 Dynasplint

Conservative Management of TFCC Injuries

Phase I for Central Debridement:
Days 3-5
 0-6 weeks
 Goals: Control edema and pain
Splinting in a long arm cast or splint with the elbow in 90° flexion and
the forearm neutral for 0-6 weeks to reduce the symptoms  Protect repair
 6 weeks  Minimize deconditioning
Active and active-assistive ROM exercises are initiated to the wrist and  Intervention:
forearm 6 times a day for 10 minute sessions. A wrist immobilization
 Bulky compressive dressing is removed
splint is fabricated for comfort and protection.
 Edema control begun with light compressive dressing to hand and
 8 weeks forearm
If patient is asymptomatic, progressive strengthening to the hand and  Active ROM exercises for wrist and forearm are begun 6-8 times a day
wrist, avoiding a torsion load at the wrist. for 10 minute sessions.
 A wrist splint is fabricated to wear between exercises and at night for
 If the patient’s symptoms are not alleviated in 4-6 weeks surgical comfort
repair or debridement is suggested.

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Phase II for Central Debridement:

Days 10-14 Phase III for Central Debridement:
Weeks 3-4
 Goals: Control edema and pain
 Continue to protect repair  Goals: Control edema and pain
 Continue to minimize deconditioning  Improve ROM
 Begin scar management  Intervention:
 Passive ROM of wrist and forearm may be initiated
 Intervention:
 Dynamic wrist splinting may be initiated to improve ROM
 Scar management begun within 48 hours of suture removal
 Weighted wrist stretches may be initiated to increase ROM
 Initiation of active-assistive ROM for wrist and forearm

Considerations
Phase IV for Central Debridement:  It is important to keep in mind that the goal of therapy is to
Week 6 eliminate pain.
 Aggressive PROM which increases pain is not appropriate.
 Goals: Continue with ROM gains
 In patients with positive ulnar variance additional surgical
 Begin strengthening
procedures may be required and this will change the post op
 Intervention:
 Progressive strengthening may be initiated if patient is pain free. This may
therapy. These may include a wafer resection or ulnar
include using putty or a hand exerciser and progressing to hand weights. shortening to decrease the variance
 The wrist immobilization splint may be discontinued if the patient is
asymptomatic.

Phase II for Peripheral Repair:

Phase I for Peripheral Repair: Week 2
Week 1  Goals: Edema and pain control
 Continue to protect repair
 Goals: Edema control  Limit deconditioning
 Protect repair  Intervention:
 Removal of bulky dressing
 Intervention:  Edema control with retrograde massage, Isotoner glove, and/or Coban wrapping
 Patient remains in bulky post-op dressing  Daily pin care as needed
 Instructions in edema control  Long arm cast with 90° elbow flexion and wrist in neutral or wrist cock-up splint fabricated
 Active and passive ROM for wrist and digits, include tendon glides (lumbrical grip, hook fist,
full fist)
 Isometric exercises for forearm/hand: 10 repetitions 4 times/day
 Low-grade isotonic exercises can be initiated (i.e., lightest putty)
 Light ADLs with 5 pound limit

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Phase III for Peripheral Repair:
Weeks 3-6
 Goals: Edema and pain control
 Increase ROM
 Scar management
 Improve strength
 Intervention:
 Scar management with scar massage, scar pad
 Discontinue splint (unless patient is still symptomatic)
 Increase isotonic exercises up to 10 pounds maximum for upper arm, forearm
 Wrist mobility/weighted stretches with less than 5 pounds 3-4 times/day for
20 minutes
 ADLs with less than 10 pounds
References
 Adams BD, Berger RA: “An Anatomic Reconstruction of the Distal
Radioulnar Ligaments for Posttraumatic Distal Radioulnar Joint
Instability”. The Journal of Hand Surgery, 27A:2,243-251.
 Cannon NM (ed.): Diagnosis and Treatment Manual for Physicians and
Therapists: upper extremity rehabilitation 4th ed. The Hand
Rehabilitation Center of Indiana. Indianapolis. 2001:163-165.
 Chidgey, J 1995. “The Distal Radioulnar Joint: Problems and
Solutions” J Am Acad Orthop Surgery 3:2, 95-109.
 Dodds, S,Yeh, P, Slade, J 2008. “Essex-Lopresti Injuries” Hand Clinics
24: 125-137
 Garcia-Elias M 1998. “Soft Tissue Anatomy and Relationships about the
Distal Ulna.” Journal of Hand Surgery 14:2, 165-176.
References
 LaStayo P, Weiss, S. 2001: “The GRIT: A Quantitative Measure of
Ulnar Impaction Syndrome. Journal of Hand Therapy, 14:173-179.
 Mackin E, Callahan A, Hunter J. Rehabilitation of the hand and
upper extremity. St Louis, Mosby, 2002
 Monasterio M, Brou K.E. Modified Anti-Pronation DRUJ Instability
Splint. Journal of Hand Therapy Oct-Dec 2007.
 Moritomo H, Noda K, Goto A, Murase T, Yoshikawa H, Sugamoto K
2009. “Interosseous Membrane of the Forearm: Length Change of
Ligaments During Forearm Rotation.” Journal of Hand Surgery,34A;
685-691.
 Palmer, A 1989. “Triangular Fibrocartilage Complex Lesions: A
Classification” Journal of Hand Surgery, 14A:4, 594-606.
1/8/2010
Phase IV for Peripheral Repair:
Weeks 8 - Discharge
 Goals: Continue to improve ROM
 Continue to increase strength
 Simulate work requirements
 Intervention:
 Dynamic splinting as necessary to increase ROM
 Progress strengthening with putty, hand exerciser, free weights
 Simulate work tasks as able
References
 Green’s Operative Orthopedics, on line edition:
www.greenshandsurgery,com, 2009, Retrieved 12-28-2009.
 Gordon, Karen, Dunning, Cynthia, Johnson, James, King, Graham,
2003. “Influence of the Pronator Quadratus and Supinator Muscle Load
on DRUJ Stability” Journal of Hand Surgery28A:6, 943-950
 Ishii S, Palmer A, Werner F, Short W, Fortino M. 1998. “An Anatomic
study of the Triangular Fibrocartilage Complex” Journal of Hand Surgery
23A:6, 977-985.
 Jaffe R, Chidley L, LaStayo P, 1996: “The Distal Radioulnar Joint:
Anatomy and Management of Disorders” Journal of Hand Therapy, April-
June:129-138.
Kleinman W. 2007: “Stability of the Distal Radioulnar Joint:
Biomechanics, Pathophysiology, Physical Diagnosis, and Restoration of
Function. What We Have Learned in 25 Years”. The Journal of Hand
Surgery, 32A:7.1086-1106.
References
 Ruland RT, Hogan, CJ (2008): “The ECU Synergy Test: An aid
to diagnose ECU Tendinitis”. The Journal Of Hand Surgery, 33:10.
 Shah MA, Lopez JK: Escalante A, Green DP: Dynamic Splinting of
Forearm Rotational Contracture After Distal Radius Fracture The
Journal of Hand Surgery, 27A(3).
 Sachar, K.(2008): “Ulnar sided wrist pain. Evaluation and treatment of
triangular fibrocartilage complex tears, ulnocarpal impaction
syndrome, and lunotriquetral ligament tears of the wrist”.
The Journal of Hand Surgery, 33A:9, 1669-1679.
 Shin AY, Deitch MA, Sachar K, Boyer MI (2004): “Ulnar sided wrist
pain: Diagnosis and treatment”. Journal of Bone and Joint Surgery, 86-A:7,
1560-1574.
 Slutsky DJ, Nagle DJ: “Wrist Arthroscopy: Current Concepts”. Journal
of Hand Surgery, 33A, 1228-1243.
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References
 Tang, Jin Bo, Ryu, Jai Young, Kish, Vincent 1998. “The Triangular
Fibrocartilage Complex: An Important Component of the Pulley for
the Ulnar Wrist Extensor” Journal of Hand Surgery, 23A:6. 986-991.
 Tay SC, Tomita K, Berger RA (2007): “The Ulnar fovea sign for
defining ulnar wrist pain: An analysis of sensitivity and specificity”.
The Journal of Hand Surgery, 32:4, 438-444.
 Trumble TE, Budoff JE, Cornwall R. 2006: Hand, Elbow & Shoulder
Core Knowledge in Orthopedics. Mosby Elsevier Philadelphia, PA.
 Xu J, Tang J 2009. “In Vivo Changes in Lengths of the Ligaments
Stabilizing the Distal Radioulnar Joint.” Journal of Hand Surgery, 34A,
40-45.
 Yu, Chase, Strauch 2004. Atlas of Hand Anatomy and Clinical
Implications. Mosby, St. Louis.

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