CASE WRITE-UP

YEAR 4

FACULTY OF MEDICINE
UNIVERSITI TEKNOLOGI
MARA
ORTHOPEDICS POSTING
CASE WRITE UP (II)

CONFIDENTIAL
NAME

: HAKIMAH KHANI BINTI SUHAIMI

MATRIC NO

: 2008409718

YEAR OF STUDY : 4
SESSION
SUPERVISOR

: 2011/2012

: DR. YOHAN A KHIRUSMAN

DEMOGRAPHIC DETAILS
Patients Name: Mr. Yanashekaran
MRN: 00258735
Sex: Male
Ward: Sungai Buloh Hospital, Ward 5A
Age: 57 years old
Religion: Hindu
Race: Indian
Address: Batang Berjuntai
Occupation: Pensioner (Ex-guard)
Date of Admission: 12th December 2011
Date of Clerking: 13th December 2010
Date of Discharge: History taken from: The patient and his wife
Reliability: Fair (slight language barrier)
PRESENTING COMPLAINT
Mr Yanashekaran, a 57 year-old Indian gentleman was referred from Tanjung Karang Hospital with the chief complaint of lower back pain after an alleged fall
from tree on the day of admission.
HISTORY OF PRESENTING ILLNESS
He was otherwise well until 6 hours prior to admission in Sungai Buloh Hospital when he had an alleged fall about 10 feet from rambutan tree while plucking
the fruits at 11am. According to him, the fall was due to slippery (aluminium) ladder and he denies any preceding dizziness or vertigo.
He fell on the buttock in sitting position. Consequently, he had a lower back pain which was described as constant, dull aching pain, localized and nonradiating. It was moderate to severe in intensity. He tried to stand up and bear his weight; however, it aggravated the pain. This then demanded him to lie
supine and the pain was partially relieved. He denies any other associated symptoms to the lower back pain such as shooting pain, lower limb weakness and
numbness or tingling sensation, or loss of bladder and bowel control.

Upon questioning whether he has any pain elsewhere particularly over the buttock, he said that yes, there was pain localized to the tailbone and the gluteal
muscles, non-radiating, dull in nature, exacerbated by sitting, relieved by lying on lateral position. However, it was just mild and he barely noticed the pain.
Other than that, he denies any episode of loss of consciousness, blurring of vision, retrograde amnesia, neck pain, ENT bleeding, chest pain, shortness of
breath, abdominal pain, nausea or vomiting, hematuria, or any pain or weaknesses over other areas including the upper and lower limbs and no bruises.
Following the trauma, he called two of his friends who helped him walking, supported him over the shoulder and brought him to the Tanjung Karang Hospital
by car. As soon as they arrived in the Tanjung Karang Hospital, he was given painkillers which relieved the pain partially and x-ray was done on him. He was
then transferred to Sungai Buloh Hospital for further management of his problem.
SYSTEMIC REVIEW
No other significant symptoms
PAST MEDICAL HISTORY
He was diagnosed to have hypertension one year ago, when he presented with . Currently he undergoes a regular follow up at Klinik Kesihatan Batang
Berjuntai every three months. He is on amlodipine 10mg OD. He is compliant to the medication. There is no known complications regarding the hypertension
and the blood pressure is under controlled.
Other than that, he does not have any other chronic medical illnesses like diabetes mellitus.
PAST SURGICAL HISTORY
In 2010, he had a domestic injury (cut his little finger by zinc) which resulted in amputation of the distal phalanx of the little finger of the left hand.
DRUGS HISTORY
No other drugs that what has been mentioned.
ALLERGY HISTORY
No known allergies.
FAMILY HISTORY
Both of his parents passed away. His father passed away because of stroke whereas his mother passed away because of severe asthma.
He is the second out of 8 siblings. Two of his brothers passed away; one was due to suicide and the other was due to
His other siblings are well and healthy.
He has no family history of malignancy.

SOCIAL HISTORY
He is a pensioner, previously worked as a security guard.
He is married with 5 children. Currently he stays with his wife, 2 sons and one daughter in a house in - storey
His two sons are already working; one as a
He has good family and financial support.
He does not have any insurance or SOCSO.
He is an ex-smoker, stopped smoking 7 years ago. He denies consuming alcohol, taking illicit drugs, and risky behavior.
PHYSICAL EXAMINATION
General condition
Height :
Weight :
BMI :
Vital signs
Temperature: 0C
Blood pressure: 159/106mmHg
Pulse rate: 91beats/min with regular rhythm, normal volume
Respiratory rate: cycles/min
Impression:
Mr Yanashekaran is an Indian gentleman with medium body built, lying comfortably supine flat on the bed, not supported with any pillows. He is alert,
conscious and oriented to time, place and person. He looks in pain and not comfortable as evidenced by frowning of the forehead. He is not in respiratory
distress. He is pink, not cyanotic, and not jaundice. His hydrational status is adequate. Tattoos were noted on chest, forearm.
Spine examination
(Since the patient was on strict CRIB complete rest in bed, not allowed to stand / sit / log roll, examination during standing, sitting and examination of the
back cannot be done)
*However according to the ED record, there was no cervical tenderness, he was able to flex, extend and turn neck. There was tenderness at the
thoracolumbar junction.
On inspection of the back, there is a well healed vertical scar extending over the midline of the spine from L4 to L5 measuring about 4 cm. No swelling,
redness, skin changes or deformity noted.

On palpation, there is midline tenderness along the spinous process of L1 until L5 with some degree of paraspinal muscle spasm. However, there is no scar
tenderness, gluteal tenderness, increase in temperature, step deformity, swelling or gibbus noted.
Lumbar spine excursion test, range of motion and gait cannot be established as the patient is unable to stand.
Impression: Tenderness along the spinous process of L1 until L5 with spasm of paraspinal muscle indicative pathology at the vertebra and intervertebral disc.
Neurological examination of the lower limb
Inspection: He was lying supine, flat on the bed. There was normal attitude of the lower limb. There were no abnormal movements such as tremors, chorea
and fasciculation. The muscle bulk was equal bilaterally and no muscle wasting.
Special test: Straight leg raising test was negative and sciatic stretch test too.
Tone: Normal tone for both lower limbs.
Power:
Power
Hip flexor (L1)

Right
Grade
5
Hip
extension Grade
(L3)
5
Knee flexion (L2) Grade
5
Knee extension Grade
(L4)
5
Ankle dorsiflexion Grade
(L3)
5
Ankle
Grade
plantarflexion
5
(L5)
Big toe flexion Grade
(L5)
5
Big toe extension Grade
(S1)
5

Reflex:

Left
Grade
5
Grade
5
Grade
5
Grade
5
Grade
5
Grade
5
Grade
5
Grade
5

Reflex
Knee (L3, L4)
Ankle (S1)
Babinski

Right
Normal
Normal
Downgoin
g

Left
Normal
Normal
Downgoin
g

Sensation:
(Chest sensation as the control)
Sensation
Right Left
Groin (L1)
Equal Equal
Anterior thigh (L2)
Equal Equal
Anterior knee (L3)
Equal Equal
Medial aspect of leg Equal Equal
(L4)
Lateral aspect of leg Equal Equal
(L5)
Lateral aspect of Equal Equal
foot (S1)
Posterior aspect of Equal Equal
foot (S2)
Per rectal examination:
There is no swelling or skin changes noted on inspection of the anal region. deep and superficial anal sensation intact
anal tone intact
BCR present
BCR intact
Impression: normal, no neurology.
Neurological examination of upper limb
As he is unable to sit, examination was done while he lying supine.
Inspection: There is normal attitude of both upper limbs with equal muscle bulk. No muscle wasting, skin changes or swelling noted.
Tone: Normal tone of both upper limbs.

Power:
Power
Right
Elbow
flexion Grade
(C5)
5
Wrist extension Grade
(C6)
5
Elbow extension Grade
(C7)
5
Finger
flexion Grade
(C8)
5
Finger abduction Grade
(T1)
5
Reflex:
Reflex
Biceps (C5)
Brachioradialis
(C6)
Tricpes (C7)

Right
Prese
nt
Prese
nt
Prese
nt

Left
Grade
5
Grade
5
Grade
5
Grade
5
Grade
5

Left
Presen
t
Presen
t
Presen
t

Sensation:
Chest sensation as the control
Sensation
Right
Lateral arm (C5)
Equal
Lateral forearm (C6) Equal
Middle finger (C7)
Equal
Medial forearm (C8) Equal
Medial elbow (T1)
Equal

Left
Equal
Equal
Equal
Equal
Equal

Impression: No abnormal findings

ASIA E 324/324

Other systemic examinations

All the respiratory, cardiovascular, abdominal and central nervous system examinations were unremarkable.

SUMMARY
In summary, Mr Yanashekaran, a 57 year-old Indian gentleman who is a pensioner, hx of hypertension, presented with a moderate to severe lower back pain
which is dull aching after an alleged fall from 10 feet height without any neurological symptoms.
DIFFERENTIAL DIAGNOSES
- Burst / compression fracture of lumbar vertebra
- Pelvic fracture avulsion fracture of ischial tuberosity, sacral fracture-rare (no pain over the buttock)
- Sacroiliac injury (but no pain over the buttock)
- Paraspinal muscle spasm but if spasm je, no need referral to tertiary centre. Must be something wrong in the XR
INVESTIGATIONS
RBS/FBC/RP/LFT/CE/Ca/PO4
Laboratory
Chem Path
(Cardiac Enzymes (CK, AST &
LDH))- Aspartate Transaminase
13/12/2011
06:22
69 U/L
(Cardiac Enzymes (CK, AST &
LDH))- Lactate Dehydrogenase
13/12/2011
06:22

323 U/L
(Cardiac Enzymes (CK, AST &
LDH))- Creatine Kinase
13/12/2011
06:22
793 U/L
C-Reactive Protein (CRP)
13/12/2011
06:22
1.90 mg/dL
Glucose, Fasting
13/12/2011
06:22
5.5 mmol/L
Magnesium

13/12/2011
06:22
0.62
mmol/L
Phosphate Inorganic
13/12/2011
06:22

1.02
mmol/L
(Renal Profiles)- Urea
13/12/2011
06:22

2.3 mmol/L
(Renal Profiles)- Sodium
13/12/2011
06:22

131
mmol/L
(Renal Profiles)- Potassium

13/12/2011
06:22
3.10
mmol/L
(Renal Profiles)- Chloride
13/12/2011 98.0
06:22
mmol/L
(Renal Profiles)- Creatinine
13/12/2011 52.0
06:22
umol/L
(Liver Function Tests
Protein, Total
13/12/2011 77.0 g/L
06:22
(Liver Function Tests
Globulin
13/12/2011
43 g/L
06:22
(Liver Function Tests
Albumin/Globulin Ratio
13/12/2011
0.79
06:22
(Liver Function Tests
Bilirubin, Total
13/12/2011
06:22

(LFT))-

(LFT))-

(LFT))-

(LFT))-

26.0
umol/L
(Liver Function Tests (LFT))Alanine Transaminase (SGPT)
13/12/2011
06:22

43 U/L
Function Tests

(Liver
(LFT))Albumin
13/12/2011 34 g/L
06:22
(Liver Function Tests (LFT))Alkaline Phosphatase
13/12/2011 112 U/L
06:22
Calcium
13/12/2011 2.16
06:22
mmol/L
Test method :
13/12/2011
06:22
Haematology
Erythrocyte Sedimentation Rate
13/12/2011 25 mm/hr
06:22
(Full Blood Count (FBC))- White
Blood Cell
13/12/2011 7.98
06:22
x10^9/L
(Full Blood Count (FBC))- Red
Blood Cell
13/12/2011 5.37
06:22
x10^12/L
(Full
Blood
Count
(FBC))Haemoglobin
13/12/2011

06:22
13.2 g/dL
(Full
Blood
Count
Haematocrit

(FBC))-

13/12/2011
06:22
40.9 %
(Full Blood Count (FBC))- Mean
Cell Volume
13/12/2011
06:22
76.2 fl
(Full Blood Count (FBC))- Mean
Cell Haemoglobin
13/12/2011
06:22
24.6 pg
(Full Blood Count (FBC))- Mean
Cell Haemoglobin Concentration
13/12/2011
06:22
32.3 g/dL
(Full Blood Count (FBC))- Red Cell
Distribution Width
13/12/2011
06:22
18.7 %
(Full Blood Count (FBC))- Platelet
13/12/2011 143
06:22
x10^9/L

(Full
Blood
Count
Percentage Of Neutrophil

(FBC))-

13/12/2011
06:22
72.9 %
(Full
Blood
Count
(FBC))Percentage of Lymphocyte
13/12/2011
06:22
13.9 %
(Full
Blood
Count
Percentage Of Monocyte

(FBC))-

13/12/2011
06:22
8.8 %
(Full
Blood
Count
Percentage Of Eosinophil

(FBC))-

13/12/2011
06:22
3.3 %
(Full
Blood
Count
Percentage of Basophil

(FBC))-

13/12/2011
06:22
1.1 %
(Full Blood Count (FBC))- Absolute
Neutrophil
13/12/2011

5.82
x10^9/L
(Full Blood Count (FBC))- Absolute
Lymphocyte
06:22

13/12/2011
06:22
1.11
x10^9/L
(Full Blood Count (FBC))- Absolute
Monocyte
0.70
13/12/2011
06:22
x10^9/L
(Full Blood Count (FBC))- Absolute
Eosinophil
13/12/2011 0.26
06:22
x10^9/L
(Full Blood Count (FBC))- Absolute
Basophil
13/12/2011 0.09
06:22
x10^9/L
(Full Blood Count (FBC))- Mean
Platelet Volume
13/12/2011 9 fL
06:22
Microbiology
(Hepatitis B surface Ag (HBs Ag))Hepatits B s Ag (Comment)
13/12/2011
06:36
Negative

(Hepatitis B surface Ag (HBs Ag))Test Method :

13/12/2011
06:36
(Human
Immunodeficiency
Virus(HIV))- HIV Ab (Comment)

13/12/2011
06:36

Non
Reactive
(Human
Immunodeficiency
Virus(HIV))- Test Method :
13/12/2011
06:36
(Hepatitis C Virus Ab (HCV Ab))Anti HCV (Comment)

13/12/2011
06:36

Non
Reactive
(Hepatitis C Virus Ab (HCV Ab))Test Method :
13/12/2011
06:36

infective screening -ve

121211
XR from HTK 2pm
AP view of pelvic,

AP and lateral view of thoracolumbar,

XR lumbosacral - increased interpedicular distance L1, compression fracture >50% loss of vertebral height involving anterior & middle columns. Slight
spondylolisthesis of L5/S1. Slight retropulsion of L1
IMP: Burst fracture L1, with no neurological deficit

6pm XR chest clear

XR thoracolumbar AP & lateral

131211 - CT - Axial
cuts are helpful in
examining the integrity
of the middle column,
which
helps
distinguish
compression fractures
from burst fractures,
as well as assess for
canal
compromise

due to bony fragments. These cuts also show excellent detail of the posterior elements, which may reveal injuries such as laminar fractures, facet fractures, or
dislocations. Sagittal and coronal reconstructions may allow for evaluation of alignment in greater detail than that provided by plain radiographs

There is a burst compression fracture seen at the body of L1 involving the right lamina and the spinal canal.
Retropulsed segment is noted within the spinal canal causing 55% stenosis of the canal.
Fracture also seen involving the spinous process of T12.
Impression:
Burst fracture of L1 is likely resulted from hyperflexion injury of the lumbar spine. There is associated spinal canal stenosis.
Suggest MRI for futher evaluation of the cord and nerve

141211 0 MRI - Trauma

to the spinal cord or conus medullaris can be identified by edema, represented by areas of increased signal intensity on T2-weighted images. MRI can also
show injuries to spinal ligaments, such as the posterior
ligamentous complex.

Burst compression fracture of L1 (anterior and posterior elements) with retropulsed fragment causing spinal canal stenosis. Narrowest AP
diameter of the canal measures 5.9mm. Compression of the conus medullaris and crowding of the cauda equina nerve roots are seen, with
presence of oedema seen as evidenced by T2 hyperintensity within. There are obliteration of the lateral recesses, right more than left by the
retropulsed fragment resulting in compression onto the L2 traversing nerve root (R>L). The exit neuroforamina are still preserved at this
level.

Fracture
of
spinous
process
of T12.
Burst

compression fracture of L1 (anterior and posterior elements) with retropulsed fragment causing spinal canal stenosis. Narrowest AP
diameter of the canal measures 5.9mm. Compression of the conus medullaris and crowding of the cauda equina nerve roots are seen, with

presence of oedema seen as evidenced by T2 hyperintensity within. There are obliteration of the lateral recesses, right more than left by
the retropulsed fragment resulting in compression onto the L2 traversing nerve root (R>L). The exit neuroforamina are still preserved at
this level.
Mild disc dessication of T12/L1 and L1/2 with paracentral disc buldges not causing canal stenosis.
L1/2 :
Mild paracentral disc buldges with ligamentum flavum and facet joint hypertrophy causing narrowing of the lateral recesses. However, no
nerve root compression and the exit neuroforamina are preserved. AP diameter of canal measures 1.0cm.
L2/3 :
Mild posterolateral disc buldges with ligamentum flavum and facet joint hypertrophy causing narrowing of the lateral recesses and exit
neuroforamina. However, no nerve root compressions. AP diameter of canal measures 9.5mm.
L3/4 :
Diffuse disc buldge with ligamentum flavum and facet joint hypertrophy causing narrowing of the lateral recesses and more of the exit
neuroforamina causing impingement of the L3 exiting nerve roots. The L4 traversing nerve are preserved. AP diameter of canal measures
1.0cm.
L4/5 :
Disc dessication & Diffuse disc protrusion with ligamentum flavum and facet joint hypertrophy, which together causes narrowing of the
lateral recesses and exit neuroforamina causing impingement of the L4 exiting nerve roots and L5 traversing nerves bilaterally. No
crowding of the cauda equina. AP diameter of canal measures 8.0mm.
Impression:
Burst compression fracture of L1 causing spinal canal sternosis resulting in conus&nerve root compressions with oedema.
Other level lumbar degenerative disc changes with variable degree of root compressions as described above
IMP :
FINAL DIAGNOSIS

L1 burst compression fracture with 55% spinal stenosis, but without no neurology*
MANAGEMENT
Primary and secondary survey
T PCM 1g QID
C tramal 50mg TDS
Daily ASIA charting
Complete rest in bed

advice to move limbs minimally to prevent bedsore

meds at home
NBM at 0200 for CT on Day 2 admission
PROGRESS
Issues:
Dr Wan explained to pt regarding need for surgery to stabilize fracture
Cost of implant informed to daughter
If family able to raise funds for implant, pt is willing to go for operative intervention
15th December 2011 Patient was depressed? Refused to lie down.
Afebrile, v/s stable
Plan :
for posterior instrumentaion 2 level and 2 level below
- apply FOC either Korean screw or Johnson screw
aim for op on Wednesday next week

DISCUSSION
Mr Yanashekaran is a 57 year-old Indian gentleman pensioner, with a known hx of hypertension, presented with a CHIEF COMPLAINT OF a moderate to
severe lower back pain which is dull aching and non radiating and aggravated by movement after an alleged fall from 10 feet height without any neurological
symptoms.
Causes of back pain

In this patient, the chief complaint was lower back pain. As illustrated in the diagram above, there are plenty causes of back pain ranging from a life
threatening one like AAA, to a malingering one. However for this patient, who presented with a history of fall from height prior to the onset of lower back pain,
the most likely cause is fractures or muscle strain. But fractures usually present associated with muscle strain. Unlike muscle strain, this can present on its
own. In Mr Y, he fell from a 10 m height which exerted an excessive axial load on the spine.
On PE, there was tenderness at the level of T12/L1 vertebra. Hence, we have to think of lumbosacral fracture until proven otherwise. It was confirmed by the
Xray done in Tanjung Karang Hospital that there was a fracture at the level of L1.
Common site T12/L1 due to transition of mobile lumbar and relatively rigid thorax, between kyphosis thorax and lordosis lumbar. vulnerable to axial load
forces.
Neurologic deficits can result from retropulsed fragments of bone or disc into the spinal. In this patient, PE revealed only positive tenderness at the L1 level.
There was no neurology.
Consideration of the neural elements is also critical. The spinal cord terminates at the conus medullaris at L1 in adults. Below this level, the nerve roots of the
cauda equina have a relatively large canal within which to travel. Moreover, the nerve roots are far more resistant to blunt trauma than the spinal cord. Thus
even a displaced burst fracture with significant canal compromise can demonstrate surprisingly minimal neurological deficits in the lumbar spine. In contrast,
the spinal cord has less space available as it travels through the thoracic spinal canal, and it is much less forgiving to even mild trauma.
There are two types of fracture which can result from an axial load of forces.
Burst vs compression fracture; can be differentiated on XR. AP radiographs
allow for evaluation of coronal and rotation
alignment. Coronal translations and disruption of the
normal interpedicular distance are findings that would
indicate severe trauma. On lateral radiographs, the clinician

can evaluate sagittal alignment and potential

loss of vertebral body height.
And on CT Axial cuts are
helpful in examining the integrity of the middle column,
which helps distinguish compression fractures
from burst fractures, as well as assess for canal compromise
due to bony fragments. These cuts also show
excellent detail of the posterior elements, which may
reveal injuries such as laminar fractures, facet fractures,
or dislocations.
Compression of spinal cord
But first, I need to discuss about the Denis 3 column
In 1983, Denis popularized a classification system involving a three-column model, based on his radiographic review of 412 thoracolumbar injuries. The
anterior column consists of the ALL, anterior annulus fibrosus, and anterior vertebral body. The middle column contains the posterior vertebral body, posterior
annulus fibrosus, and the PLL. The posterior column consists of posterior bony arch, interspinous and supraspinous ligaments, facet capsule, and ligamentum
flavum.

In this patient,
XR:increased interpedicular distance L1, compression fracture >50% loss of vertebral height involving anterior & middle columns. Slight spondylolisthesis of
L5/S1. Slight retropulsion of L1

CT:There is a burst compression fracture seen at the body of L1 involving the right lamina and the spinal canal.
Retropulsed segment is noted within the spinal canal causing 55% stenosis of the canal.
Fracture also seen involving the spinous process of T12.
Impression:
Burst fracture of L1 is likely resulted from hyperflexion injury of the lumbar spine. There is associated spinal canal stenosis.
Suggest MRI for futher evaluation of the cord and nerve
MRI:to the spinal cord or conus medullaris can be identified by edema, represented by areas of increased signal intensity on T2-weighted images. MRI can
also show injuries to spinal ligaments, such as the posterior
ligamentous complex.

Burst compression fracture of L1 (anterior and posterior elements) with retropulsed fragment causing spinal canal stenosis. Narrowest AP

diameter of the canal measures 5.9mm. Compression of the conus medullaris and crowding of the cauda equina nerve roots are seen, with
presence of oedema seen as evidenced by T2 hyperintensity within. There are obliteration of the lateral recesses, right more than left by the
retropulsed fragment resulting in compression onto the L2 traversing nerve root (R>L). The exit neuroforamina are still preserved at this
level.
Canal compromise greater than 50% is frequently cited as an indication for surgical decompression, but little data support this figure as a universal rule.
Primary survey disability immobilization
The patient should be moved without flexion or rotation of the thoracolumbar spine. A scoop stretcher and spinal board are very useful.
Secondary survey check the spine log roll
mechanism of the injury and the
history can be much valuable to clue the surgeon into
looking for occult injury, i.e., falling from a height may
lead to aortic injuries and multiple level injuries.

Neurological assessment ASIA chart is a validated method to reliably classify and monitor the patients level and severity of spinal cord injury. A complete spinal cord injury is one that has total loss of motor
and sensory function caudal to the level of injury. Any residual voluntary motor or sensory function below the injury level would classify the lesion as an incomplete spinal cord injury.

Mc Afee modified Denis classification-Stable injuries that consist of compression fractures and stable burst fractures can be treated nonoperatively. Unstable
injuries, such as unstable burst fractures, flexion-distraction injuries
(including Chance fractures), and fracture-dislocations, typically require surgical stabilization [indications for surgical intervention: greater than 50% loss of
anterior body height, greater than 25 of kyphosis, or interspinous distance widening
Stable burst - treated nonoperatively, with or without bracing, depending on the severity of the fracture. With conservative management, close radiographic
follow-up, including weight-bearing radiographs, is crucial to confirm the
lack of kyphotic progression.
Nonoperative treatment of neurologically intact patients with stable thoracolumbar burst fractures has lower complication rates
Symptomatic nonunion of the anterior and middle columns in a burst fracture can also be an indication for surgical intervention
The treatment of these injuries is dependent on the presence of instability or neural compromise. The generally accepted criteria for operative treatment
include canal compromise greater than 50%, vertebral
body comminution with greater than 30 of kyphosis, greater than 50% loss of vertebral body height, and the presence of neurologic deficits with cord or root
compression.
Surgical management of these injuries can involve anterior, posterior, and combined approaches.

NAME OF STUDENT: Hakimah Khani Binti Suhaimi (2008409718)

DATE: 19th December 2011
COMMENTS:

GRADE:
NAME OF SUPERVISOR: Dr. Yohan A Khirusman