Androgen Insensitivity Syndrome: A Case Report

Background: Androgen insensitivity syndrome refers to an inability of the body to respond properly to male sex hormones (androgens) produced during pregnancy. This occurs because of a change (mutation) in a gene involved in the production of the protein inside cells that receives the androgen hormone and instructs the cells in how to use it. This is a genetic disorder that makes XY foetuses insensitive (unresponsive) to androgens, they are born looking externally like normal girls and Internally, there is a short blind pouch vagina and no uterus, fallopian tube or ovaries. There are testes in the abdomen or in the inguinal canal. The CAIS is usually detected at puberty when a girl should but does not begin to menstruate. They are at high risk of osteoporosis so should take oestrogen replacement therapy. Case Report: PAIS results in micropenis with hypospadias and gynaecomastia. We report this rare case of 18yr old female patient with primary amenorrhea. Subsequent investigation including karyotyping revealed that the patient is phenotypically female but genotypically male with testes. Gonadectomy was done with proper counselling and patient was put on hormonal replacement replacement therapy.

The Study On Correlation Of Dermatoglyphics And Schizophrenia

Background: Dermatoglyphics is the study of quantitative and qualitative patterns of ridges in palms and soles.It is being investigated in diseases having genetic basis. The recent evidence from adoption studies has provideda basis for the genetic contributions in schizophrenia. The present conducted to study the finger and palmardermatoglyphic patterns in schizophrenics and to compare dermatoglyphic configurations of schizophrenicswith the normal population.Materials and Methods: The ink and pad method was followed to take finger and the palm prints. The palmarprints of 50 schizophrenic patients and 50 normal individuals of both the sexes were collected for the study.Results: There is statistically significant decrease in frequency of arches in schizophrenics when compared tocontrols, whereas frequency distribution of radial loops, ulnar loops and whorls are not significant. Increase inI4 interdigital pattern is statistically significant in schizophrenics when compared to controls. There is increasein the mean values of total finger ridge count in male, female and combined series of male and femaleschizophrenics and decrease in absolute finger ridge count in male and combined series of male and femaleschizophrenics, while there is decrease in female schizophrenics, when compared to controls. Atd angle isdecreased in both the hands of male schizophrenics and right hand of female schizophrenics as compared tocontrols, whereas it is equal in the left hand of schizophrenics and controls. There is increase in the mean ridgecount in III, IV and V digits in the right hand of male schizophrenics.Conclusion: There are significant differences in the schizophrenics in various dermatoglyphic features, whencompared to controls. Hence it is possible to identify the ‘at risk’ population with the help of dermatoglyphics.

Morphological Study on Shapes of Pterion.

Background: Pterion is defined as an H-shaped small circular area formed by the junction of four bones: frontal, parietal, temporal and sphenoid on norma lateralis of the skull, Pterion junction has been used as a common extra-cranial landmark for surgeons in microsurgical and surgical approaches towards important pathologies of this region. Pterion is an important landmark for anterior branch of middle meningeal artery, Broca’s motor speech area to the left, insula, the lateral cerebral fissure, for the pathologies of optic nerve, orbit, sphenoidal ridge and for the anterior circulation aneurysm and tumors, because of its clinical importance we focused our present study on morphology of shape of pterion. Materials and Methods: A total of 500 pterions were examined from 250 adult dry skulls. The present study was undertaken in adult south Indian skulls from different regions of south India, from different medical colleges. We have observed different shapes of pterion like sphenoparietal frontotemporal, stellate and epipteric. Results: The sutural morphology of the pterion and asterion is important in surgical approaches to the cranial fossae. 250 human skulls of known gender (148 male, 102 female) were examined on both sides. Four types of pterion were observed – sphenoparietal 72.8%, frontotemporal 16.4%, stellate 8.8% and epipteric 2%. Conclusion: The pterion is points of sutural confluence seen in the norma lateralis of the skull. The patterns of formation exhibit population based variations. The sutural morphology of the pterion is important in surgical approaches to the cranial fossae. These findings may helpful in surgical approaches and interventions via the pterion.

Study on Variations of Inferior Segmental Branch of Renal Artery.

Background: The segmental arteries of the kidney supply the organ in such away that, each renal pole receives its own arterywhile, the anterior portion between the poles is supplied by an upper and lower segmental vessel. These two arteries also include in their territory the lateral edge of the kidney and adjacent to the strip of parenchyma on the dorsal or posterior aspect of the organ. The knowledge of inferior segmental branch of renal artery is very important for surgeries in its distribution area in kidney. Materials and Methods: 100 kidneys (Fifty pairs) intact with abdominal aorta were collected from department of Forensic medicine, JSS Medical College and Mysore Medical College. For study of segmental variation Corrosion cast technique method was used. The variations of inferior segmental branch of renal artery were observed and recorded. Results: In present study type I inferior segmental branch of renal artery were found in - 59% cases, type II in - 6% cases, type III in - 28% cases, type IV in - 2% cases. Conclusion: The inferior segmental artery from the anterior division of the renal artery is the commonest event –arising in 59%. This is Type I, the normal type. It arises from the renal artery (28%) or from the posterior division (6%) or from the aorta (2%). The knowledge of inferior segmental branch of renal artery helpful in kidney transplantation and renal surgery because these type of surgeries success mainly depends on arterial ligations.

Study on Accessory Renal Artery.

Background: Knowledge of the variations of renal vascular anatomy has importance in exploration and treatment of renal trauma, renal transplantation, renovascular hypertension, renal artery embolization, angioplasty. The anomalies of accessory renal artery may be important from the clinical point of view. The importance of being familiar with the renal artery and segmental artery variability, which has become indispensable to urological surgery, has increased as a result of the large number of renal transplants and vascular reconstructions. Materials and Methods: 100 kidneys (Fifty pairs) intact with abdominal aorta were collected from department of Forensic department, JSS Medical College and Mysore Medical College. For study of segmental variation Corrosion cast technique method was used. The variations of posterior division were observed and recorded. Results: Accessory renal arteries were found in two specimens originating directly from aorta out of 100 specimens, it is recorded as 2%. Conclusion: In present study we observed 2% of cases as accessory renal artery. The recent days the increasing demand for kidney transplantation, grafts from living donor is major source for that, with this concept the knowledge of accessory renal artery very essential for kidney transplantation.

Study on Variations of Posterior Division of Renal Artery.

Background: Kidney transplantation is the treatment of choice for the vast majority of patients with end stage renal disease. Many of the current challenges with the donor grafts are the results of anatomic variants, such as multiple renal arteries, multiple. The previous studies have shown that use of vessel grafts is associated with a higher incidence of vascular and urologic complications. With this back ground the knowledge of variations in vascular pattern is very helpful for renal transplantation and renal surgeries. Materials and Methods: 100 kidneys (Fifty pairs) intact with abdominal aorta were collected from department of Forensic department, JSS Medical College and Mysore Medical College. For study of segmental variation Corrosion cast technique method was used. The variations of posterior division were observed and recorded. Results: In present study type I posterior division of renal artery were found in - 27% cases, type II in - 42% cases, type III in - 25% cases. Conclusion: In present studywe found three types of posterior division of renal artery this knowledge helpful in treatment of renal trauma, renal transplantation, renovascular hypertension, renal artery embolization, vascular reconstruction.

Study on Variations of Anterior Inferior Segmental Branch of Renal Artery.

Background: The kidneys are paired solid organs that lie in the retro peritoneum along the borders of psoas muscle. Each kidney is positioned obliquely and awareness of the relationship of the kidneys to the surrounding organs is paramount. Each kidney is supplied by a renal artery, which is a branch of the abdominal aorta, the branching pattern of renal artery shows very much variations , the knowledge of individual segmental artery variation are very helpful for clinical practices of renal surgeries. Materials andMethods: Fifty pairs of kidneys with intact abdominal aorta and renal artery were collected from the dead bodies obtained from themortuary of Forensic department, JSSMedical College andMysore Medical College and studied in JSS Medical College. For study of segmental variation Corrosion cast technique method was used. Results: In present study type I anterior inferior segmental artery were found in 47%, type II in 16%, type III in 24%, type IV 10%, type V in 0% o and type VI 1% of cases. Conclusion: The variation of the anterior inferior segmental artery has not been given importance in previous works and they have been typed (6 types) in the present work. The knowledge of anterior inferior segmental artery variations are helpful in renal surgeries in particular with anterior inferior segmental artery distribution area.

Study of Variations In Superior Segmental Branch of Renal Artery.

Background: Based on vascular divisions the renal tissue divided into five segments that are apical, anterior superior, anterior inferior, inferior and posterior. The apical segment occupies the antero medial region of the superior pole. The superior segment includes the rest of the superior pole and the central antero-superior region. The segmental arteries of the kidney supply the organ in such a way that, each renal pole receives its own artery while, the anterior portion between the poles is supplied by an upper and lower segmental vessel. The present study concentrated on variation of superior segmental artery which is help in nephrology clinical practice. Materials andMethods: Fifty pairs of kidneys with intact abdominal aorta and renal artery were collected from the dead bodies obtained from themortuary of Forensic department, JSSMedical College andMysore Medical College and studied in JSS Medical College. For study of segmental variation Corrosion cast technique method was used. Results: In present study type I superior segmental artery were found in 28%, type II in 12%, type III in 14%, type IV 20%, type V in 1% o and type VI 23% of cases. Conclusions:We observed variations in superior segmental branch of renal artery in 100 kidneys and observed 6 types of variation. These knowledge of vascular segments of kidney helpful for the clinician to do renal transplantation interventional radiological procedures.

Study on Variations of Anterior Division of Renal Artery.

Back ground: Urinary System is one of most important system among many systems in our body the most common variations in case of circulatory system usually occur in form of origin, number, length, and diameter. Based on divisions of renal artery, the renal parenchyma is divided into five segments: apical, anterior superior, anterior inferior, inferior and posterior. The main renal artery divides initially into an anterior and posterior branch. The anterior branch almost always supplies the upper, middle and lower segments of the kidney. Materials andMethods: Fifty pairs of kidneys with intact abdominal aorta and renal artery were collected from the dead bodies obtained from themortuary of Forensic department, JSSMedical College andMysore Medical College and studied in JSS Medical College. For study of segmental variation corrosion cast technique method was used. Results: In present study type I anterior division of renal artery were found in 31%, type II in 19%, type III in 8%, type IV 20% and type V in 16% of cases. Conclusion: We observed variations in anterior division of renal artery in 100 kidneys and observed 5 types of variation. These variations are helpful for the surgeon performing major surgeries like kidney transplant and partial nephrectomy.

Morphometric and Morphological Study on Foramen Ovale.

Background: Foramen ovalee is an important foramen of the middle cranial fossa. Foramen ovalee is situated in the greater wing of the sphenoid bone, posterior to the foramen rotundum and lateral to the lingula and posterior end of the carotid groove. Through the foramen ovale the mandibular nerve, accessory meningeal artery and lesser petrossal nerve are passing through it. The shape of foramen ovale is ovale in shape as compare to other foramina of the skull, its shape and size is quite variable. Meterials and Methods: A total 250 skulls were used for this study. The skulls were collected with I MBBS student from different medical colleges in south India. Skulls in poor conditions or skulls with partly damaged surroundings of the foramen ovalee were not considered. Maximum length and width of foramen ovalee was measured. Variation in right and left side and sex difference in length and width were calculated, the variations in shape also recorded. Results: The mean value of length of left foramen ovale is 8.5+1.32mm and right was 8.9+1.67mm. In female it was 8.7+1.67mmandmalewas 8.4+1.71mm. Themean value ofwidth of left foramen ovale is 3.7+1.03mmand right was 3.9+0.98mm. In female it was 3.8+0.92mm andmale was 3.7+1.02mm.The shape of foramen ovalewas ovale in 69% of skulls, almond in 29% of skulls and round was 2% of skulls. Conclusion: The present study conclude that there is significant difference between sizes of right and left side foramen ovale and found that between male and female foramen ovale sizes also not shown any significance difference. Foramen ovale has practical significance to both neurosurgical and functional cranial neuroanatomy as it provides transcutaneous approaches to the skull base especially in cases of trigeminal neuralgia, as the Gasserion ganglion can be approached through it.

Study on Neck Shaft Angle And Femoral Length of South Indian Femurs.

Background: Femoral nek anteversion describes the angle subtended by the femoral neck with reference to the transcondylar plane of the distal end of the femur and is usually 15° to 45°. This along with the neck shaft angle, hip axis length, femoral neck width influence the risk of femoral neck fracture. Femoral neck anteversion angle has to be taken into consideration when reduction and fixation is selected as a method of treatment. Objectives: The objectives of present study to find out the measurements of Neck shaft angle, Femoral Length and Neck Length of femur. Materials and Methods: In present study have used 250 femurs from different colleges in south India. The following measurements were conducted Neck shaft angle, Femoral Length and Neck Length of femur. Results: The results of present study are the length of femur was 446.2+26.39mm, right femur was 446.6+26.66mm and left femur was 445.8+26.12mm, the Neck Length femur was 36.3+4.2mm, right femur was 36.1+4.1mm and left femur was 36.4+4.3m. the neck shaft angle of femur was 137.10 , right femur was 137.30 and left femur was 136.90. Conclusion: There is no significance difference between right and left femur measurements. Orthopaedists and Radiologists use the normal range and means of the neck shaft angle in the diagnosis and treatment of the disease of the hip. The angle is increased in congenital subluxation and dislocation of the hip, poliomyelitis, cerebral palsy and idiopathic scoliosis and decreased in the congenital coxavara , post traumatic coxa vara due to malunited femoral neck and inter trochanteric fractures.

Anthropometric Study of Femur In South India.

Background: Anthropometry provides scientific method and technique for taking various measurements in different geographic regions and races. The femur is the weight bearing typical long bone of lower limb which extends from the pelvis to the knee. The anatomical knowledge of different dimensions of femur specially head and neck of the femur is very essential in anthropological and medico-legal practice for sex determination and as well as to radiologists, rheumatologists and orthopaedic surgeons for diagnosis and planning of treatment. Objectives: The objectives of present study to find out the measurements of Platymeric index,Robusticity index and Foraminal index. Materials and Methods: In present study have used 250 femurs from different colleges in south India. The following measurements were conducted Platymeric index, Robusticity index and Foraminal index for both right and left femur. Results: The results of present study are the Physiological length of left femur was 44.15+2.35 and right was 43.98+2.15, the Rubusticity index of left femur was 15.26+1.17 and right was 14.34+1.21the Platymetric index of left femur was 85.70+6.35 and right was 86.32+6.15, the Foraminal index of left femur was between 37-65% and right was 35-62%. Conclusion: The present study shows that there is significance different in between right and left femurs measurements. The anatomical knowledge of different dimensions of femur is very essential in anthropological and medico-legal practice for sex determination and as well as to radiologists, rheumatologists and orthopedic surgeons for diagnosis and planning of treatment.

Study of Lateral Circumflex Artery.

Background: The lower limb arteries are commonly involved with peripheral occlusive arterial diseases and the femoral artery at femoral triangle is widely used for certain clinical procedures like arterial catheterization, as it can be readily accessed. Lateral circumflex femoral artery is a laterally running branch given off near the root of the profunda femoris. It supplies blood to head and neck of femur, greater trochanter, vastus lateralis and knee. It has many implications in clinical practice, it is used in an anterolateral thigh flap, aortopoplitial bypass, coronary artery bypass surgery, extracranial- intracranial bypass surgery. Methods: 50 adult lowerlimbs were procured from embalmed cadavers of J.J.M. Medical College and S.S.I.M.S & R.C, Davangere, Karnataka, India for the study. Dissection of femoral triangle was carried out according to Cunningham’s manual. Site and mode of origin of the branches of femoral artery were studied, configuration of the femoral origin lateral circumflex femoral artery and its prevalence were studied. Results: out of 50 cases Lateral circumflex femoral artery took origin from profunda femoris in 45 specimens and from the femoral artery in 5 specimens. Conclusion: The knowledge of normal origin and variation of lateral circumflex femoral artery is very valuable in preventing iatrogenic injury to these vessels during surgical procedures of femoral triangle. As medial and lateral circumflex femoral arteries supply blood to head and neck of femur, it is important to avoid injuring them during surgery of hip joint to prevent necrosis of femoral head. Lateral circumflex femoral artery has many implication in clinical practice. It is used in an anterolateral thigh flap.

Study of Medial Circumflex Artery.

Background: The proper knowledge of the course and ramification of blood vessels of lower limbs is very important for surgeons and interventional radiologist. Medial circumflex femoral artery usually originates from posteromedial aspect of the profunda femoris, but often originates from femoral artery itself. It has an important role in supplying blood to femoral neck and head, fatty tissue in acetabular fossa and used in flaps reconstructive surgery. Methods: 50 adult lowerlimbs were procured from embalmed cadavers of J.J.M. Medical College and S.S.I.M.S & R.C, Davangere, Karnataka, India for the study. Dissection of femoral triangle was carried out according to Cunningham’s manual. Site and mode of origin of the branches of femoral artery were studied, configuration of the femoral origins of medial and lateral circumflex femoral artery and their prevalence were studied. Results: Out of 50 extremities, Medial circumflex femoral artery took origin from profunda femoris in 41 specimens and from femoral artery in 9 specimens. Conclusion: The knowledge of normal origin and variation of medial circumflex femoral artery is very valuable in preventing iatrogenic injury to these vessels during surgical procedures of femoral triangle.

Study of Posterior Division of Internal Iliac Artery.

Background: The internal iliac artery originates from the common iliac artery at the level of sacroiliac joint. The internal iliac artery descends posterior to the greater sciatic foramen thereby dividing into anterior and posterior divisions. The posterior division of the internal iliac artery is known to give rise to three main branches i.e. iliolumbar artery, lateral sacral artery. Accidental haemorrhage is common during erroneous interpretation of anomalous blood vessels. The knowledge of the normal and the abnormal anatomy of the branches of the internal iliac artery is essential for obstetric surgeons. Methods: 50 adult human pelvic halves were procured from embalmed cadavers of J.J.M. Medical College and S.S.I.M.S & R.C, Davangere, Karnataka, India for the study. Results: Out of 50 specimens, ilio-lumbar artery took origin from posterior division, directly in 22 specimens (44%), with obturator artery in 5 specimens (10%) and with superior gluteal artery in 2 specimens (4%). From anterior division, with obturator artery in 6 specimens (12%) and with inferior gluteal artery in 1 specimen (2%). From common trunk, as direct branch in 10 specimens (20%), with lateral sacral artery in 1 specimen (2%), with vertebral branch in 1 specimen (2%), with superior gluteal artery in 1 specimen (2%) and was found to be absent in 1 specimen (2%). Posterior division of internal iliac artery given origin directly to superior gluteal artery in 44 specimens (88%), with ilio-lumbar artery in 1 specimen (2%), with obturator artery in 2 specimens (4%). Lateral sacral artery from posterior division was observed in 38 specimens (76%) and unpaired origin was observed in 7 specimens (14%). Conclusion: Internal iliac artery supplies the pelvic viscera and musculature the knowledge of its branches helpful in pelvis surgeries.

Study of Variations In Anterior Division of Internal Iliac Artery.

Background: The internal iliac artery is the chief pelvic artery. It supplies to the all pelvic viscera, musculoskeletal part of the pelvis. The branches of the anterior trunk of the internal iliac artery are the superior and inferior vesical, middle rectal, vaginal, obturator, uterine, internal pudendal and inferior gluteal. Knowledge of internal iliac artery is very helpful in pelvic surgery practice. Methods: 50 adult human pelvic halves were procured from embalmed cadavers of J.J.M. Medical College and S.S.I.M.S & R.C, Davangere, Karnataka, India for the study. Results: Middle rectal artery took origin from anterior division in 42 specimens (84%), most frequently with internal pudendal artery in 32 specimens (64%) and was found to be absent in 8 specimens (16%). The obturator artery took origin most frequently from the anterior division of Internal iliac artery in 36 specimens (72%), from posterior division in 9 specimens (18%), from external iliac artery in 1 specimen (2%) and from inferior epigastric artery in 3 specimens (6%). The superior vesical artery, inferior vesical artery, uterine artery, vaginal artery and superior gluteal artery were found to be constant in their origin and course. Conclusions : The branches anterior division of internal iliac artery shows multiple variations, knowledge about these variation are helpful in pelvic surgeries.

Morphological Study of Internal Iliac Artery.

Background: The internal iliac artery is the “artery of the pelvis”. It supplies most of the blood to the pelvic viscera, gluteal region, medial thigh region and perineum. A severe and potentially lethal complication in pelvic surgeries is arterial bleeding commonly involving the branches of internal iliac artery. While operating on pelvic organs, the knowledge of internal iliac artery and its variations is important for surgeons. The present study was conducted to study of morphology of internal iliac artery. Methods: 50 adult human pelvic halves were procured from embalmed cadavers of J.J.M. Medical College and S.S.I.M.S & R.C, Davangere, Karnataka, India for the study. Results: The classification of branching pattern of internal iliac artery was based on modified Adachi classification. Out of the 50 specimens studied, Type Ia arrangement was found in 52% of the specimens, Type III in 34%, Type IIa and type V was found in 2% each, Type IV was not found in any of the specimens and 10% of the specimens could not be classified because of the absence of inferior gluteal artery in them. Adachi Type Ia arrangement was the most frequent finding. The obturator artery took origin most frequently from the anterior division of internal iliac artery. Middle rectal artery was not constant. Conclusion: The internal iliac artery morphology shows multiple variation the knowledge is very helpful during pelvic surgeries.

Morphological Study of Obturator Artery.

Background: The obturator artery normally arises from the anterior trunk of internal iliac artery. High frequency of variations in its origin and course has drawn attention of pelvic surgeons, anatomists and radiologists. Normally, artery inclines anteroinferiorly on the lateral pelvic wall to the upper part of obturator foramen. The obturator artery may origin individually or with the iliolumbar or the superior gluteal branch of the posterior division of the internal iliac artery. However, the literature contains many articles that report variable origins. Interesting variations in the origin and course of the principal arteries have long attracted the attention of anatomists and surgeons. Methods: 50 adult human pelvic halves were procured from embalmed cadavers of J.J.M. Medical College and S.S.I.M.S & R.C, Davangere, Karnataka, India for the study. Results: The obturator artery presents considerable variation in its origin. It took origin most frequently from the anterior division of internal iliac artery in 36 specimens (72%). Out of which, directly from anterior division in 20 specimens (40%), with ilio-lumbar artery in 5 specimens (10%), with inferior gluteal artery in 3 specimens (6%), with inferior vesical artery in 2 specimens (4%), with middle rectal artery in 1 specimen (2%), with internal pudendal artery in 4 specimens (8%) and with uterine artery in 1 specimen (2%). The obturator artery took origin from the posterior division of internal iliac artery in 9 specimens (18%), from external iliac artery in 1 specimen (2%), from inferior epigastric artery in 3 specimens (6%) and was found to be absent in 1 specimen (2%).

Prevalence of dental caries in first and second permanent molars.

Background: This study was conducted to assess the First and Second molar permanent molar caries in school children of Nalgonda district, Andhrapradesh, India. Methods: We have taken total 1800 school going children as study population age between 12-15 years, who lived in the same place since birth and consumed drinking water form single source. Results: The mean of caries in first and second were 0.12 ± 0.36 and 0.36 ± 0.70 respectively and total was 0.49 ± 0.92. Conclusion: The prevalence of Second molar teeth was found higher than First molar teeth and these caries were untreated.

A clinical study of management of proximal humeral fractures in adults.

Background: Fractures of the proximal humerus are one of the commonest fractures encountered by an orthopaedician. The incidence of this fracture has significantly increased perhaps due to the increased vehicular traffic and mechanized life. The approach towards the management of these fractures types of fractures has changed during the course of period. Since the appropriate treatment and results associated with each modality of treatment for these fractures is not defined this study was undertaken. Methods: This longitudinal study was done on 150 cases of proximal humerus fractures which were managed by both conservative and surgically. Initial preoperative clinical and radiological assessment was done and appropriate mode of treatment of given depending upon type of fracture according Neer’s classification. Follow up of patient was done both clinically and radiologically at 2nd, 6th and 8th weeks and assessed for any complications. Final assessment was done according to Neer`s shoulder scoring criteria. Results: The 90 cases were treated conservatively and 60 surgically. Maximum follow up was 9 months and minimum 4 month with an average follow- up of 6.67 months. Our series showed excellent result in 70 cases (46.6%), satisfactory in 65 cases (43.3%) and fair in 15 cases (10%). Conclusion: Undisplaced fractures of the proximal humerus can be managed conservatively and non-displaced tuberosity fractures, if managed conservatively, give good results. Displaced two or three part fractures in young patients need anatomical reduction with internal fixation. Conservative treatment of four part fractures, four part fracture dislocation and anatomical neck fractures gives poor results and so primary hemiarthroplasty is indicated. There is direct relationship between displaced proximal humeral fractures between fracture severity i.e. greater displacement, communition, and crushing and the eventual results that is more than the initial insult, worse the prognosis. Rehabilitation is the key to success.