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The right and left ductus deferens are approached through small incisions in the upper part of the scrotal wall, and are cut. A ganglionic branch connecting the pterygopalatine ganglion to the maxillary nerve ii. All three joints can be visualized after dissection of the subcutaneous tissues, elevation of the extensor digitorum brevis off the anterior process of the calcaneus, and opening of the joint capsules. The viscera to be seen in the true pelvis belong to the gastrointestinal, urinary and reproductive systems. The muscles supplied include those of mastication, and of the face, pharynx and larynx. Helps to maintain arches of the foot the two slips of the tendon for each digit form a tunnel through which the tendon of the flexor digitorum longus passes to reach its insertion into the distal phalanx Medial plantar nerve (S2, 3) 291 Lateral plantar nerve (S2, 3) 1. Within the mouth, the nerve lies deep to the mucous membrane overlying the medial surface of the mandible just below the third molar tooth. Epidermal growth factor receptor inhibitors can cause which of the following side effects Which of the following disorders can result in loss of both the cuticle and lunula A 60-year-old man develops transverse white bands in all of his nails that blanch with pressure. Anteriorly, the junction of the neck and the shaft is marked by a much less prominent intertrochanteric line. The lower end of the artery lies at the level of the opening in the adductor magnus. The fibres of the cranial root of the accessory nerve pass into the pharyngeal and recurrent laryngeal branches of the vagus. The penile urethra shows a dilatation as it lies in the bulb (called the intrabulbar fossa), and another in the glans penis (called the navicular fossa) (33. Within the renal sinus the pelvis divides into two (or three) parts called major calyces (singular = calyx). Abnormal outgrowths from bone ends can reduce mobility at joints and can also cause pain (osteoarthritis). The lacrimal gland drains into the superior conjunctival fornix through about twelve ducts. Patients older than 16 years are given either low-molecularweight heparin or warfarin for 4 to 6 weeks. The internal oblique muscle of the abdomen arises from the intermediate area of the ventral segment of the iliac crest. Over the proximal phalanx the tendon (of that digit) becomes embedded in a triangular membrane called the dorsal digital expansion. However, as the patient is currently pregnant, the safest modality of treatment at this time consists of sunscreens alone. The anterior wall is formed by the fascia transversalis (which lines the inner aspect of the anterior abdominal wall). In some cases an aneurysm splits the wall of the aorta into two layers (dissecting aneurysm). In tuberculosis of the cervical vertebrae pus is formed and collects between the vertebral column and the prevertebral fascia. The other branch supplies the skin lining the posterior wall and floor of the external acoustic meatus, and the posteroinferior part of the outer layer of the tympanic membrane. The superficial veins referred to above, therefore, provide channels of communication between the axillary and femoral veins. The superficial palmar arch gives off a separate digital branch to the medial side of the little finger. The branches of the vertebral artery that supply structures in the neck are shown in 42. The gluteus minimus arises from the gluteal surface of the ilium between the anterior and inferior gluteal lines. Insertions of the supraspinatus, infraspinatus and teres minor (by posterior part of deltoid). In the upper part of the arm it lies behind the upper part of the brachial artery. These up and down movements of the diaphragm (somewhat like those of a piston) provide the major force for respiration.

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A trial has been performed in a clinic population similar to the one that you treat and produced the following results. The iliac crest apophysis is split to expose the medial and lateral aspects of the ilium down to the sciatic notch. While we know that the femoral neck is following this marked line, the position of the femoral head in the sagittal plane is determined by flexing the hip 90 degrees and abducting the hip 45 degrees. The external jugular vein descends across the third part of the subclavian artery to end in the subclavian vein. Reaching the upper margin of the orbital aperture, near its medial end, the nerve turns upwards into the forehead giving branches to the skin over its lower and medial part. The hand itself soon shows outlines of the digits, which then separate from each other. To understand these conditions it is important to know the division of the prostate into lobes and into an inner glandular zone (derived from mesoderm) and an outer glandular zone (derived from endoderm). If both iliac and pubic fixation is secure in a cooperative patient, we sometimes use a removable bivalve plastic "spica-type" orthosis (made before surgery) or trust the patient with no immobilization (rare). El-Batouty et al4 modified this to obviate the need for a medially based closing wedge osteotomy for valgus deformity of the hindfoot. In contrast pain caused by inflammation of an area of parietal peritoneum can be accurately localised. When hyoid bone is fixed, it can depress mandible the muscles of the two sides form the oral diaphragm. In this part of its course it is closely related to the upper part of the parotid gland. The side to which a particular lateral cuneiform bone belongs can be determined as follows: a. Part 3 Thorax We may now consider additional differences between cervical, thoracic and lumbar vertebrae. Finally, it runs transversely across the palm as the deep palmar arch, and ends by anastomosing with the deep palmar branch of the ulnar artery. The femoral branch of the genitofemoral nerve is seen running downwards anterior to the femoral artery. The superior peroneal retinaculum is attached above to the lateral malleolus and below to the lateral surface of the calcaneus. Yashiro M, Kobayashi H, Kubo N, Nishiguchi Y, Wakasa K, Hirakawa K:Cronkhite-Canada syndrome containing colon cancer and serrated adenoma lesions. When the eyeball rotates so that the upper end of the line moves medially the movement is described as intorsion d. Each spinal nerve arises from the spinal cord by two roots, anterior (or ventral) and posterior (or dorsal). Posterolateral to the foramen ovale there is a smaller round foramen called the foramen spinosum. The posterior external jugular vein from the upper and posterior part of the neck b. The median lobe produces a projection on the interior of the urinary bladder just behind the internal urethral orifice. Hypothyroidism in adults leads to deposition of mucopolysaccharides in subcutaneous tissue. The clavicular branch runs upwards to supply the subclavius and the sternoclavicular joint. The talocalcaneal interosseous ligament is divided, and the anterior, middle, and posterior facets of the subtalar joint are visualized. We find that as the starting point is crucial, it is helpful to notch the posterior column in the sciatic notch and the outer table of the ilium to create a track for the Gigli. The facial nerve leaves the posterior cranial fossa by passing into the internal acoustic meatus. We have seen that portosystemic anastomoses undergo enlargement when there is obstruction to flow of blood in the portal vein. They pass through the nerve of the pterygoid canal and the greater petrosal nerve to reach the genicular ganglion.

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The pronator teres (ulnar head) arises from the medial margin of the coronoid process. Care must be taken to avoid the obturator nerve, which courses just below the superior ramus. Injury to the recurrent laryngeal nerve also leads to hoarseness, but this hoarseness is permanent. The medial surface consists of an anterior (or mediastinal) part that is deeply concave, and a posterior (or vertebral) part that is convex. Many fibres of the maxillary nerve pass through these ganglionic branches to the ganglion. Orbit, Eye and Ear the Orbit 814 815 815 821 823 824 826 827 827 828 828 828 829 833 833 833 834 838 847 854 854 855 855 860 861 868 868 870 874 875 879 883 884 887 891 891 893 895 898 908 916 918 923 927 929 931 935 935 Contents of the Orbit Muscles of the Orbit the Lacrimal Gland Nerves and Vessels of Orbit the Eyeball the Ear and Some Related Structures the Auricle External Acoustic Meatus the Middle Ear the Internal Ear 45. The lower part of the pouch is obliterated by fusion of the layers of peritoneum lining it. The sternal head of the sternocleidomastoid arises from the upper part of the manubrium (16. The branch to the medial head descends along the medial side of the humerusclosetotheulnarnerve(5. General Somatic Afferent Nuclei the general somatic afferent column is represented by the sensory nuclei of the trigeminal nerve. Some vessels from the inferomedial part of the breast probably communicate with lymphatics within the abdominal cavity (subperitoneal plexus). The strongest bonds of union are, however, the ulnar and radial collateral ligaments. In some cases an examination of the upper air and food passages may be required prior to making a definitive diagnosis and formulating a treatment plan. Patients suffering from herpes zoster will initially present with an erythematous maculopapular rash that rapidly evolves into a grouped vesicular rash within three to four days and resolves two weeks later. They may occur through the superior or inferior ischiopubic ramus, near the junction of the pubis and ischium (when they may involve the acetabulum), or the lateral part of the ilium. Proximally, the bone has a convex articular facet that takes part in forming the wrist joint. The posterior cruciate ligament is attached to the lateral surface of the medial condyle. Suture characteristics include: tensile strength, knot strength, configuration, elasticity, memory or suture stiffness, plasticity, and pliability. The part below the oblique line is subdivided into medial and lateral parts by a vertical ridge. The internal jugular vein is related superficially and posteriorly to a number of structures. The posterior part of the groove is occupied by the popliteus tendon in full flexion at the knee. Care must be taken not to damage the cartilaginous margin of the acetabular growth plate. The first (most medial) common plantar digital nerve divides into the proper digital nerves that supply the skin on the adjacent sides of the great toe and second toe. Posteriorly: Fascia covering the medial three metacarpal bones and intervening interosseous muscles. The prostate is surrounded by a fibrous capsule that is closely adherent to the gland. Epidermolysis Bullosa: Clinical, Epidemiologic, and Laboratory Advances, and the Findings of the National Epidermolysis Bullosa Registry. The lateral terminal branch also supplies the skin on the lateral side of the ankle. However, it must be remembered that these two arteries anastomose freely through the superficial and deep palmar arches. The term infratemporal fossa is applied to an irregular space lying below the lateral part of the base of the skull.

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The external orifice of the female urethra is located a short distance in front of the vaginal opening. A catheter was passed into the trachea, and then into the left principal bronchus, and a contrast medium was injected to outline the bronchi. The fold of peritoneum by which it is attached to the posterior abdominal wall is called the mesentery. In aortocoronary bypass, an isolated segment of the long saphenous vein (of the patient) is used as a graft. The lateral wall of the true pelvis is lined by the obturator internus muscle (40. The emissary veins connect the intracranial venous sinuses to veins outside the skull. It passes downwards and medially, enters the anterior compartment of the leg and descends in front of the interosseous membrane, and lower down on the anterior aspect of the shaft of the tibia. It is located in the right atrium along the anterior margin of the opening of the superior vena cava (20. The side to which an intermediate cuneiform bone belongs can be determined as follows: a. The cavity of the middle ear is continuous with that of the nasopharynx through a passage called the auditory tube. In considering the arteries of the head and neck, it must always be remembered that the common and internal carotid arteries, and the vertebral arteries, convey blood to the brain. Here it lies between the tendons of the extensor hallucis longus (medially) and the extensor digitorum longus (laterally). Ethyl acrylate and methylmethacrylate are used to screen for acrylic nail allergy. Anteriorly, the intercostal nerve terminates by becoming superficial as the anterior cutaneous branch. As the middle ear is closely related to the sigmoid sinus and the bulb of the internal jugular vein infection can spread to them. The cells of the ganglion give origin to postganglionic fibres that pass through the short ciliary nerves to reach the sphincter pupillae and the ciliaris muscles. Scheme to show course of the optic nerve Some relations of the optic nerve in its intracranial part 886 Part 5 Head and Neck 4. The part of the bone formed by extension of bone formation from the primary centre is called the diaphysis. Continuous with the posterior margin of the groove for the superior vena cava there is a narrow, but deep groove that forms an arch above and behind the hilum. Some joints are merely bonds of union between different bones and do not allow movement. The vein communicates with the superior ophthalmic veins and through them with the cavernous sinus. The superior and inferior layers form the upper and lower boundaries of the bare area of the liver. Which of the following studies may be useful in evaluating the frozen section slide and arriving at a diagnosis In a case of suspected Merkel cell carcinoma, which of the following studies may be negative An immunocompromised patient presents with pulmonary lesions and a widespread papular eruption. The long axis of the uterus is more or less at right angles to the long axis of the vagina. For a short distance above the ankle the artery is covered only by skin, superficial fascia and deep fascia including the retinacula. Note that the vertebral artery and vein do not traverse the foramen transversarium of this vertebra. Some branches of the vagus reach the front of the root of the lung and forms a less prominent anterior pulmonaryplexus. The point of greatest convexity corresponds to the lower end of the handle of the malleus and is called the umbo. Other ribs and costal cartilages can be felt by counting downwards from the second. The head articulates partly with the superior costal facet on the body of the numerically corresponding vertebra, and partly with the inferior costal facet on the next higher vertebra. The peritoneum from the surface of the liver is reflected on to the diaphragm (and anterior abdominal wall) in the form of a number of ligaments that are identified in the paragraphs that follow.

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Answer choice E is not a perforating disorder but is common in patients with end-stage renal disease. Patients with trichorrhexis nodosa, trichorrhexis invaginata, and monilethrix typically present with short, broken hair. Fibres of taste from the soft palate reach the ganglion through the lesser palatine nerves (43. Herpes simplex virus is not associated with aplastic crisis but type 1 can cause Ramsay hunt. In married womenm, its position is marked by rounded elevations called the carunculae hymenales. The closer the surgeon is to the acetabulum, the easier it will be to rotate the acetabulum. Stop when resistance or bone is felt Aspirate and confirm that no blood returns, and then inject 2 to 3 mL of local anesthetic. From there, continue the convexity downwards and to the left to end over the second left costal cartilage near the sternal margin. The rate of photo-onycholysis for tetracyclines is as follows: demecycline > doxycycline > tetracycline > minocycline. The cavity of the superior radioulnar joint is continuous with that of the elbow joint. Inferior ramus (The origin is lateral to that of the gracilis and below that of adductor longus) Posterior aspect of fe- 1. Structural cerebral and cerebrovascular anomalies are the most common and potentially serious manifestations. Functionally the ganglion is autonomic and is a peripheral ganglion of the cranial parasympathetic outflow. The seventh costal cartilage is attached to the lateral side of the xiphisternal joint. It ends by dividing into one proper digital branch for the great toe, and three common plantar digital branches. Additionally, the acetabular fragment should be mobilized by using both the Schanz pin and the bone clamp holding the pubic portion of the free fragment. The fibres for the sublingual gland re-enter the lingual nerve and pass through its distal part to reach the gland. The pectoral branch descends between the pectoral muscles, supplying them and the chest wall. It supplies an extensive area of skin including that over the lower part of the gluteal region, the perineum, the back of the thigh, and the back of the upper part of the leg. The nerve provides the sensory supply to the mucous membrane of the lower half of the larynx i. The zygomatico-orbital branch runs forwards along the upper border of the zygomatic arch up to the lateral angle of the eye. Lower down, the artery continues to be related laterally to the brachioradialis, but medially it is related to the flexor carpi radialis. Each artery (right or left) runs down over the posterior abdominal wall to reach the external iliac artery. The beta cells of pancreatic islets produce insulin, deficiency of which causes diabetes mellitus. The equinovarus deformity is present at birth in a congenital clubfoot, or may result from spastic muscle imbalance in patients with cerebral palsy (most often spastic hemiplegia) or flaccid muscle imbalance (poliomyelitis). A little behind and parallel to the upper part of the handle of the malleus the long process of the incus may be visible as a faint white streak. Along its course, the internal thoracic artery gives off a series of anterior intercostal arteries. Finally, the fibres turn forwards and laterally passing above the upper pole of the abducent nucleus. The joints between the teeth and jaws are also fibrous joints, the cavity in the jaw and the root of the tooth being connected only by some fibrous tissue. In the next phase both the anterior and posterior parts of the foot touch the ground. There is plantarflexion (gastrocnemius and soleus, tibialis posterior, flexor digitorum longus, flexor hallucis longus) and dorsiflexion (tibialis anterior, extensor digitorum longus, extensor hallucis longus) at the ankle.

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Traced anteriorly this peritoneum becomes continuous with that lining the anterior abdominal wall. Answers A, B and C diagnose a basal cell carcinoma, dermatofibroma and hemangioma. As the hypoglossal nerve crosses the hyoglossus the lingual nerve, the submandibular duct and the deep part of the submandibular gland lie above it (43. The scaphoid bone can be distinguished because of its distinctive boat-like shape. Along with the internal pudendal artery the nerve passes through the greater sciatic foramen to enter the gluteal region. From this figure, it is seen that the distal part of the corpus spongiosum is greatly enlarged to form the substance of the glans penis. The deep surface of the sclera is separated from the choroid by the perichoroidal space. The medial part of the origin is in the form of three digitations that arise from the areas between the sacral foramina. An 18-month-old boy presents with large, progressively extending, blue-gray patches over his anterior and posterior trunk. The superior laryngeal branch is the nerve of the fourth arch, and the recurrent laryngeal branch that of the sixth arch. The right margin of the omentum forms the anterior boundary of the aditus to the lesser sac. The prostatic and membranous parts of the urethra drain to the internal iliac nodes. Drugs associated with gingival hyperplasia include cyclosporine, phyenytoin, and calcium channel blockers such as nifedipine, verapamil, diltiazem. Laterally with the lateral cuneiform bone and with the base of the third metatarsal bone. When muscles contract they increase in thickness raising the pressure within the sleeve. Retroversion predisposes to prolapse (as the uterus comes into line with the vagina). Treatment is usually radiotherapy in localized disease and chemotherapy with drug combinations in systemic lymphoma. Some of its fibres wind round the sides of the clitoris to reach its dorsal aspect (just as in the male). As it lies in the carotid canal, the artery is closely related to the middle ear, the auditory tube and the cochlea. Chapter 42 Blood Vessels of Head and Neck 857 Coronal section through the posterior cranial fossa (behind Coronal section through middle cranial fossa to show the foramen magnum) to show the position of some intracranial the position of some intracranial venous sinuses venous sinuses b. Similar symptoms can also be produced by pressure of the scalenus anterior muscle (Scalenus anticus syndrome or scalene syndrome). Under certain circumstances the mechanisms that control cell proliferation do not work. Schwartz D, Lellouch J: Explanatory and pragmatic attitudes in therapeutical trials. The apex of the triangle is placed inferiorly and is raised to form a large projection called the tibial tuberosity. The frontal sinus extends for some distance into the orbital plate of the frontal bone between the roof of the orbit and the floor of the anterior cranial fossa. Chapter 43 Nerves of the Head and Neck 925 Scheme to show the functional components of the vagus nerve b. Lateral to the alveolar arch we see the inferior aspect of the zygomatic process of the maxilla as it passes laterally to meet the zygomatic bone. Hiatus Hernia For the relationship of the oesophagus to hiatus hernia see chapter 18. On the summit of the papilla, there is a small aperture called the lacrimal punctum. The oral cavity proper communicates posteriorly with the oral part of the pharynx.

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Trial reduction is attempted by gently pushing down on the Kirschner wires (without stressing the Kirschner wires to prevent pullout) to adduct the proximal fragment while abducting and translocating the distal fragment. It passes along the trachea into the superior mediastinum of the thorax to reach the arch of the aorta. Allergic reactions are commonly seen in workers involved in cleaning medical equipment such as dental assistants. Ligation of an artery carries the risk of necrosis (death) of the part supplied if its blood supply through alternative channels (collateral circulation) is not adequate. The space between the uterus (and the uppermost part of the vagina) in front, and the rectum behind is called the rectouterine pouch (or pouch of Douglas). On microscopic examination septate hyphae with barrel-shaped arthroconidia are seen. Due to their bulk and high metabolic demand, composite grafts survive poorly if sized > 1. The posterior end of the gland reaches as far as the stylomandibular ligament which separates it from the parotid gland. A calcaneal branch arises near the beginning of the artery and supplies the skin of the heel. Reduction has been associated with osteonecrosis, but the unstable slip itself may be the more likely cause of osteonecrosis. Medial to the superior orbital fissure, at the apex of the orbit, there is the opening of the optic canal. The termination lies behind the middle of the clavicle, near the lateral margin of the scalenus anterior muscle. Radio-opaque dyes can be introduced into the portal venous system through a needle introduced into the spleen (splenovenography or splenoportography). Autogenous bone graft is obtained from the previously exposed outer wall of the iliac wing, which is just superior to the trough and beneath the gluteus medius muscle. The nerve then winds round the lateral side of the inferior ganglion of the vagus to reach the front of the nerve. It transmits the tendons of the flexor digitorum superficialis and profundus, the tendon of the flexor pollicis longus and the median nerve (6. The lingual artery arises from the front of the external carotid artery opposite the tip of the greater cornu of the hyoid bone. Sections across the uterus show that it has a thick wall, and a relatively narrow lumen. A bone hook placed around the anterior femoral neck may be needed to subluxate the hip. Each sphenoparietal sinus (right or left) runs medially along the sharp posterior edge of the floor of the anterior cranial fossa (formed by the lesser wing of the sphenoid). The laminae of cervical vertebrae are long (transversely) and narrow (vertically). Nerves of the Back of Leg and Sole the tibial nerve is the nerve of the back of the leg. The right sinus is usually a continuation of the superior sagittal sinus and the left sinus is usually a continuation of the straight sinus, but this arrangement is sometimes reversed. There are four pulmonary veins, two each (superior and inferior), on the right and left sides. It is made up (from right to left) by the right atrium, the right ventricle and the left ventricle. The tympanic plexus gives off the lesser petrosal nerve, which ends in the otic ganglion. However, their symptom relief may be shorter-lived, requiring conversion to either a surface replacement or total hip arthroplasty.

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In a pivot joint, one rod-like (or cylindrical) element fits into a ring formed partly by bone and partly by ligaments. The vein pierces the deep fascia near the middle of the arm, and thereafter ascends in close company with the artery. The posterior vein of the left ventricle runs backwards on the diaphragmatic surface of the ventricle and ends in the coronary sinus. While there is considerable variation, this joint is oriented 23 degrees medially in the transverse plane and 42 degrees dorsally in the sagittal plane. The neck is connected to the cystic duct through which the gall bladder drains into the bile duct. The opening of the superior vena cava is situated in its upper and posterior part, and that of the inferior vena cava into its lower part, close to the interatrial septum. Just above the sternum, the right and left anterior jugular veins are united by a transverse vein called the jugular arch (42. Abduction and adduction take place partly at the shoulder joint, and partly by rotation of the scapula. In this position the fluid gravitates into the pelvis where absorption is much less pronounced (see rectouterine pouch, below). The dura mater forming the lateral wall of the sinus turns medially to form the roof of the sinus, and then continues medially over the hypophyseal fossa to form the upper layer of the diaphragma sellae. In the male it is bounded laterally by the sacrogenital folds; and in the female by the rectouterine folds. Epiphyses for the head and greater trochanter of the femur are seen, separated from the diaphysis (which forms the shaft as well as the neck) by epiphyseal cartilages 324 Part 2 Lower Extremity 1. The vestibulocochlear nerve leaves the posterior cranial fossa by passing through the internal acoustic meatus, to reach the internal ear. Chapter 22 the Oesophagus, the Thymus, Lymphatics and Nerves of the Thorax 457 22. Each sinus opens into the corresponding half of the nasal cavity through an aperture on the anterior aspect of the body of the sphenoid. Patients who are expected to be noncompliant with crutches and activity limitations are placed in a single-leg spica cast. The main artery and the collateral branch reach near the anterior end of the intercostal space. Intraoperative fluoroscopic false profile view showing proper positioning of the osteotome. Lying within the bony labyrinth, there is a system of ducts which constitute the membranous labyrinth. It is covered by a sheeth of fascia called the suprapleural membrane (which stretches from the transverse process of the seventh cervical vertebra to the inner border of the first rib. This branch passes medially through the ischiorectal fossa (accompanied by the inferior rectal artery (26. The knee joint is a complex joint because its cavity is partially divided into upper and lower parts by plates of cartilage called the medial and lateral menisci. The non-ampullated ends of the anterior and posterior canals join to form a common channel, the crus commune. The posterior part of the tympanic plate partially surrounds the base of the styloid process. To the left of the caudate lobe it is formed by reflection of peritoneum from the back of the upper part of the fundus of the stomach to the diaphragm: this peritoneum forms the gastrophrenic ligament (33. Another small area on the inferomedial part of the surface comes in contact with a coil of jejunum. Wide excision revealed a delicate plexiform capillary network that is associated with both normal appearing lipocytes and lipoblasts with a myxoid stroma. The digital sheath of the little finger is continuous proximally with the ulnar bursa. At present most surgeons use short incisions directly over the point of maximum tenderness. Prevents separation of gular area above ulnar notch) radius and ulna 102 Part 1 Upper Extremity 6.