Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Fracture, Carpal Bones


Related Terms

  • Broken Wrist
  • Fractured Wrist
  • Wrist Fracture

Differential Diagnosis

Specialists

  • Hand Surgeon
  • Hand Therapist
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Plastic Surgeon
  • Sports Medicine Physician

Comorbid Conditions

Factors Influencing Duration

The severity of the fracture, any complications, and whether the dominant or nondominant hand was injured influence the length of disability.

Duration also depends on job requirements and the bone involved. Disability is longer when job duties require use of both hands for heavy work. If single-handed work is available for sedentary and light work, individuals may be able to return to work sooner. Return to medium to very heavy work requires that the fracture is healed on x-ray and the extremity is rehabilitated.

Medical Codes

ICD-9-CM:
814.00 - Closed Fracture of Carpal Bone, Unspecified; Closed Fracture of Wrist, NOS
814.01 - Closed Fracture of Navicular (Scaphoid) Bone of Wrist
814.02 - Closed Fracture of Lunate (Semilunar) Bone of Wrist
814.03 - Closed Fracture of Triquetral (Cuneiform) Bone of Wrist
814.04 - Closed Fracture of Pisiform Bone of Wrist
814.05 - Closed Fracture of Trapezium Bone (Larger Multangular)
814.06 - Closed Fracture of Trapezoid Bone (Smaller Multangular)
814.07 - Closed Fracture of Capitate Bone (Os Magnum)
814.08 - Closed Fracture of Hamate (Unciform) Bone
814.09 - Closed Fracture of Carpal Bone(s), Other
814.10 - Open Fracture of Carpal Bone, Unspecified; Open Fracture of Wrist, NOS
814.11 - Open Fracture of Navicular (Scaphoid) of Wrist
814.12 - Open Fracture of Lunate (Semilunar) Bone of Wrist
814.13 - Open Fracture of Triquetral (Cuneiform) Bone of Wrist
814.14 - Open Fracture of Pisiform Bone of Wrist
814.15 - Open Fracture of Trapezium Bone (Larger Multangular) of Wrist
814.16 - Open Fracture of Trapezoid Bone (Smaller Multangular) of Wrist
814.17 - Open Fracture of Capitate Bone (Os Magnum) of Wrist
814.18 - Open Fracture of Hamate (Unciform) Bone of Wrist
814.19 - Open Fracture of Carpal Bone(s) of Wrist, Other

Overview

© Reed Group
A carpal fracture is a structural break or disruption in the continuity of one of the eight small bones of the wrist (carpus). These bones are the scaphoid, lunate, capitate, triquetrum, hamate, pisiform, trapezium, and trapezoid.

Fractures of a carpal bone usually do not involve a break in the skin (closed fracture). The mechanism of injury and the force involved will determine if the fracture is closed or open. Carpal fractures may be either stable or unstable. The bone fragments can be out of the normal positioning (displaced) or in normal alignment (nondisplaced). Carpal fractures can occur with or without joint dislocation. Minimally displaced fractures are the most common, except for scaphoid fractures.

The usual cause of a carpal fracture is a fall onto the outstretched hand. Other causes include a motor vehicle collision (when the individual straightens the arm for protection before an impact), collisions between sports participants, or a sudden blow to the palm by a baseball bat or golf club. Carpal fractures are fairly common injuries in athletes. Stress fractures of the carpal bones can occur in individuals experiencing repetitive trauma such as those who use a jackhammer, or a catcher on a baseball team.

The specific carpal bone that is fractured depends on the position of the hand at impact and the exact forces exerted on the hand. For example, when golf clubs, baseball bats, or sports racquets mistakenly strike a stationary object with great force, the hooked portion of the hamate bone can fracture.

The scaphoid is the most frequently fractured carpal bone. Scaphoid fractures are the most disabling, require more prolonged treatment (surgery is common), and are more prone to complications than fractures of the other carpal bones.

The triquetrum is the second most commonly fractured carpal bone. The triquetrum is usually fractured due to a fall on the outstretched hand with the wrist in ulnar deviation.

The lunate is the third most common carpal bone fractured (Hoynak). Fracture of the lunate can lead to avascular necrosis of the lunate. This is different than Kienböck's disease, which has a similar end appearance (lunate osteonecrosis or avascular necrosis where the bone becomes soft, granular, and fragmented) but often occurs without a history of trauma. This may occur in part because of the relatively limited blood supply to the lunate, a condition thought to be present in approximately 20% of individuals (Wright).

Incidence and Prevalence: Carpal bone fractures account for 18% of hand fractures (Schenck). The bones of the proximal carpal row are the most frequently fractured.

The scaphoid accounts for up to 71% of all carpal fractures (Boles; Hoynak; Schenck); this type of fracture occurs at a high incidence in football players, at 1 per 100 players per year (Steinberg). About 345,000 scaphoid fractures occur annually in the US; these fractures occur most often in individuals between the ages of 15 to 60 years (Boles). Scaphoid fractures account for 10% of all hand fractures (Schenck).

The incidence of fracture of each of the remaining carpal bones is low—between 0.2% and 5% (Schenck).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals at risk for sustaining a carpal fracture include athletes, laborers, and those whose activity places them at risk for high impact repetitive hand or wrist trauma (e.g., use of a jackhammer, participation in gymnastics).

Source: Medical Disability Advisor



Diagnosis

History: The individual reports a trauma, most commonly a fall onto the hand, that is immediately followed by wrist pain. The individual may experience decreased grip strength or pain while moving the wrist.

Physical exam: Swelling (edema), bruising (ecchymosis), and localized tenderness may be evident at the site of injury. The wrist may appear visibly deformed. The injured hand is compared closely with the uninjured (contralateral) one. The arm and elbow are examined for any signs of associated injury. Pain caused by pinching the thumb or pressing the triangular depression at the lateral side of the wrist (anatomical snuff box) is characteristic of a fractured scaphoid bone. Range of motion in the wrist is limited, with pain at the extremes of motion. Instability of the wrist can be demonstrated by several stress tests. Numbness and weakness may occur in the distribution of the median nerve on the palm side of the thumb and the index and long fingers.

Tests: Plain x-rays can diagnose most carpal fractures. Special views may be required for some of the carpal bones, but despite careful attention, a carpal fracture can easily be missed or belatedly diagnosed. A repeat plain x-ray taken 1 to 2 weeks after injury may detect a subtle scaphoid fracture not visible on x-rays taken on the day of injury. Stress x-rays can demonstrate an unstable fracture.

Occasionally other tests such as a computed tomography (CT) scan, magnetic resonance imaging (MRI), or a bone scan may be needed if pain persists and plain x-rays remain normal.

Source: Medical Disability Advisor



Treatment

Treatment of nondisplaced fractures usually consists of immobilization of the wrist in a cast extending from the proximal forearm to the distal palmar crease. This allows for full motion of the finger knuckles (metacarpophalangeal joints, [MCP joints]) and the thumb. However, if the scaphoid bone is involved, the cast often extends above the elbow for the first 6 weeks, and also incorporates the thumb. Follow-up x-rays are needed to monitor healing and detect any displacement of the fracture (loss of the reduction). If the fracture requires immobilization for up to 3 to 4 months, open reduction and internal fixation (ORIF) is more commonly provided.

Fractures where the bones have moved out of alignment (displaced fractures) and / or do not stay aligned (unstable fractures) often require surgery (open reduction) to re-align the bones, ensure proper healing, and restore function. This surgery is usually an open procedure (arthrotomy, i.e. open surgery of the wrist joint), but some surgeons prefer to reduce wrist fractures arthroscopically, using minimally invasive incisions and a pencil-sized camera and lens (arthroscope). Surgery may involve external or internal fixation with pins, wires, screws, or plates, especially if there is also a fracture of the lateral forearm bone (distal radius) extending into the wrist joint. The hardware may need to be removed later.

A bone graft may be done when the bone is broken into many pieces (comminuted fracture) with bone loss, especially if the joint with the thumb is involved. When fracture healing is delayed (delayed union) or has failed (nonunion), electromagnetic bone stimulation may be used. Bone grafting also may be done for nonunion. Other late surgery for post-traumatic arthritis or avascular necrosis may involve fusion (arthrodesis) or removal of several wrist bones (proximal row carpectomy).
Percutaneous screw fixation of nondisplaced or reducible scaphoid fractures has become more popular as techniques and implants have improved (Zlotolow; Merrell).

Source: Medical Disability Advisor



ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
 
Kienböck Disease
Scaphoid Fracture
 
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines



Prognosis

About 90% of nondisplaced low energy scaphoid fractures heal in 8 to 12 weeks when treated in a timely fashion (Boles), but malalignment can occur, even with surgery, and some wrist stiffness is common. This has led to the early percutaneous screw fixation of nondisplaced or reducible scaphoid fractures as referenced above. Nondisplaced lunate fractures are rare but usually heal. Displaced lunate fractures often progress to osteonecrosis or avascular necrosis as discussed above. Fractures of the other carpal bones generally have a satisfactory outcome if nondisplaced and if not associated with other injuries or conditions (such as fracture-dislocation or open with soft tissue loss). Surgical treatment of carpal fractures has a favorable outcome if there are no associated co-injuries. Nonunion, avascular necrosis, or post-traumatic arthritis of a carpal fracture may lead to permanent disability.

Source: Medical Disability Advisor



Rehabilitation

The duration and type of rehabilitation for a carpal fracture is related to the location, type, and severity of the fracture. Protocols for rehabilitation of fractured carpal bones must be based upon stability of the fracture and fracture management (operative, nonoperative). As with all fractures, resumption of pre-injury status is the goal with consideration of any residual deficit. Hand dominance and the involved extremity will greatly influence the individual's degree of disability. Rehabilitation may be administered by a physical therapist, occupational therapist, or hand therapist (Bucholz; Cooney; Dell; Koval).

The goal of rehabilitation is to decrease pain and to return the individual to full function with a painless wrist. Local cold application may be beneficial for controlling pain. As blood supply to the bone may be compromised due to the trauma associated with the fracture, immobilization may be required for at least six weeks. Rehabilitation primarily emphasizes restoring full range of motion and strength while maintaining independence in as many of the activities of daily living as is possible. Range of motion exercises of the adjacent joints may be beneficial unless contraindicated based on fracture stability. When indicated, range of motion and strengthening exercises should be started at the wrist and hand. Initially, active range of motion exercise within pain tolerance is considered the most beneficial form of physical therapy. After 1 to 2 weeks, passive range of motion therapy may be allowed but should be done cautiously (Jaworski). Massage, ice, taping, splints, and gloves may also be used (Atkinson). Tendon gliding exercises should be included to reduce the chance of scarring around nearby tendons that may cause loss of motion (Hardy; Meals). Exercise intensity and difficulty should progress until full function is achieved. Strengthening exercises may include the use of putty, activities to improve grip strength, and careful progressive weight bearing through the hand (Wright; Jaworski). Rehabilitation must emphasize functional use of the hand, which includes the therapist's assessment of the individual's ability to perform activities of daily living (Dell). Return to activities of daily living and work as tolerated is encouraged as part of therapy (Wright).

If the carpal fracture is operatively managed, the rehabilitation protocol will be guided by the treating physician.

Bone healing may occur within 6 to 18 weeks; however the bone strength and the ability of the bone to sustain a heavy load may take up to several years (Chapman). Once healing has occurred, the individual may resume full activities of daily living. It is important to instruct the individual not to overload the fracture site until the bone has regained its full strength. The resumption of heavy work and sports should be guided by the treating physician.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistFracture, Carpal Bones
Occupational / Hand / Physical TherapistUp to 8 visits within 10 weeks
Surgical
SpecialistFracture, Carpal Bones
Occupational / Hand / Physical TherapistUp to 16 visits within 12 weeks
Note on Nonsurgical Guidelines: Rehabilitation may not begin until tissue healing, about 6 to 8 weeks after the fracture.
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Incorrect alignment (malunion), nonunion (especially the scaphoid), delayed union, and collapse of the bone (avascular necrosis) can occur. For example, the scaphoid has a 10% to 15% rate of nonunion, as well as frequent malunion (Boles). A scaphoid fracture is difficult to detect on x-ray and may not show x-ray (radiographic) changes until much later, when it is more difficult to treat.

Joint pain, stiffness, limitation in wrist movement, and weakness of grip can persist. There can be wrist instability and post-traumatic arthritis, especially if there is also an associated fracture of the radius. As a late complication, post-traumatic arthritis can damage the tendons to the fingers with the possibility of tendon rupture.

A median nerve injury can result from excessive flexion of the wrist in a cast or by direct injury, stretching, or compression from bleeding. Carpal tunnel syndrome can occur. Pressure on the local blood vessels from swelling while wearing a cast can result in compartment syndrome that if untreated can cause permanent muscle and nerve damage and persistent clawing of the fingers. Shoulder stiffness and pain can develop if the arm stays immobile in a sling after the injury (shoulder-hand syndrome). Complex regional pain syndrome (CRPS), or reflex sympathetic dystrophy (RSD), is a serious complication with potential long-term disability.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Immobilization in a cast strictly limits use of the injured arm. The individual is temporarily unable to lift and carry heavy or bulky objects and operate some equipment. Ability to drive a motor vehicle is dependent on multiple factors (Goodwin). Some individuals may find ergonomically adjusted or pneumatic tools useful during the healing period. If the dominant hand is affected, the individual may be unable to write legibly or type well. In some cases, alternatives to a standard keyboard, such as speech recognition software or one-handed keyboards, may be appropriate accommodations. Likewise, carpal fracture in the dominant hand affects fine motor skills such as those needed to work in a laboratory or on an assembly line. Therefore, individuals whose dominant hand is affected may require a temporary or permanent reassignment of duties. After the cast or splint is removed, work may have to be temporarily modified to allow for stiffness, weakness, and lack of endurance in the hand and shoulder.

Risk: Risk is dependent on the diagnosis (which carpal bone was fractured) and mechanism of injury (amount of force) that caused the fracture. If the fracture is stable and can be supported by casting, early return to work with low risk is possible. If the fracture is unstable and ORIF provides limited support, risk for re-injury may be high.

Capacity: Capacity will vary depending on the diagnosis, mechanism of injury, and the associated soft tissue injuries. For example, an open fracture-dislocation of the scaphoid that can be treated with ORIF and is stable may allow for early return to light work like a receptionist. However return to work as a jackhammer operator with be difficult.

Tolerance: Tolerance for fracture pain is a frequent reason individuals choose to perform or avoid specific activities, considering the rewards (salary, enjoyment) versus the cost (pain). Casting may limit the ability to hold onto items, preventing, for example, climbing a ladder. Both risk and capacity will impact the tolerance.

Accommodations: Accommodations are the key to one’s ability to return to activities after carpal fracture. Most individuals can perform noninjured hand activities, using the injured hand only as an assist. The limiting factor then becomes the employer’s ability to provide that work activity.

Source: Medical Disability Advisor



Maximum Medical Improvement

56 to 168 days.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Did individual present with a sudden onset of pain in the wrist?
  • Was swelling present? Bruising? Localized tenderness?
  • Was the wrist visibly deformed?
  • Was individual's wrist range of motion impaired?
  • Was individual tender to pinching the thumb? Pressure at the anatomical snuff box?
  • Did individual have numbness or weakness along the median nerve distribution?
  • Has diagnosis of carpal fracture been confirmed through plain x-rays?
  • If fracture was not visible on plain x-ray films, were repeat films taken 1 to 2 weeks later? Were at least four different views obtained? Stress x-rays?
  • If plain x-rays were negative for carpal fracture even though the symptoms strongly suggested a fracture, were MRI, CT, or bone scans conducted?

Regarding treatment:

  • Was fracture nondisplaced? If so, were closed reduction and immobilization indicated?
  • Has fracture failed to heal even after 3 to 4 months of immobilization in a cast?
  • Were follow-up x-rays done to monitor healing?
  • Was electromagnetic bone stimulator used?
  • Has individual experienced any complications related to fracture or treatment of fracture (malunion, nonunion, avascular necrosis, nerve injury, etc)? If so, have complications been addressed in the treatment plan?
  • Did surgery involve external or internal fixation with pins, wire, screws, or plates? Percutaneous screw fixation?
  • Will hardware need to be removed later?
  • Was bone graft required?
  • If needed, has individual received physical or occupational therapy?

Regarding prognosis:

  • Does individual have an underlying condition (i.e., osteoarthritis, rheumatoid arthritis, or associated injuries) that may affect recovery?
  • Did individual have an established nonunion from a previous, undiagnosed injury that was aggravated by a recent injury?
  • Does a nonunion of the carpal fracture persist despite appropriate treatment and adequate time for healing?
  • Has avascular necrosis occurred? Post-traumatic arthritis?
  • Is individual now a candidate for surgical intervention?
  • Has individual experienced any long-term potentially disabling sequelae (nerve injury, regional pain syndrome) from the fracture?

Source: Medical Disability Advisor



References

Cited

Atkinson, Robert. "Section B: Hand. 1. Athletic Injuries of the Adult Hand." DeLee and Drez's Orthopaedic Sports Medicine. Eds. Jesse C. DeLee and David Drez. 2 ed. Saunders Elsevier, 2003.

Boles, Carol A. "Scaphoid Fracture Imaging." eMedicine. Eds. Felix S. Chew, et al. 10 May. 2013. Medscape. 31 May 2014 <http://emedicine.medscape.com/article/397230-overview>.

Bucholz, Robert, and James D. Heckman. Rockwood and Green's Fractures in Adults. 6th ed. Philadelphia: Lippincott, Williams & Wilkins, 2005.

Chapman, Michael W. Chapman's Orthopaedic Surgery. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 2001.

Cooney, W. P. "Scaphoid Fractures: Current Treatments and Techniques." Instructional Course Lectures 52 (2003): 197-208. National Center for Biotechnology Information. National Library of Medicine. 31 May 2014 <PMID 12690849>.

Dell, P. C., and R. B. Dell. "Management of Carpal Fractures and Dislocations." Rehabilitation of the Hand and Upper Extremity. Eds. E. J. Mackin, et al. 5th ed. Philadelphia: Mosby, Inc., 2002. 1171-1184.

Goodwin, D. , et al. "Driving after Orthopedic Surgery." Orthopedics 36 6 (2013): 469-474.

Hardy, M. A., ed. "Principles of Metacarpal and Phalangeal Fracture Management. A Review of Rehabilitation Concepts.." Journal of Orthopadedic Sports Physical Therapy 34 (2004): 78-99.

Hoynak, Bryan. "Wrist Fracture in Emergency Medicine." eMedicine. Eds. Rick Kulkarni, et al. 1 Jun. 2012. Medscape. 31 May 2014 <http://emedicine.medscape.com/article/828746-overview>.

Jaworski, Carrie A., Michelle Krause, and Jennifer Brown. "Rehabilitation of the Wrist and Hand Following Sports Injury." Clinics in Sports Medicine 29 1 (2010): 61-80. PubMed. 17 Jun. 2014 <http://www.ncbi.nlm.nih.gov/pubmed/19945587>.

Koval, K. J., and Joseph Zuckerman. Handbook of Fractures. 2nd ed. Philadelphia: Lippincott, Williams & Wilkins, 2002.

Meals, Roy A., and G. Neil, eds. "Extraarticular Hand Fractures in Adults: A Review of New Developments." Clinical Orthopaedics and Related Research 455 133-145.

Merrell, G. , and J. Slade. "Technique For Percutaneous Fixation of Displaced and Nondisplaced Acute Scaphoid Fractures and Select Nonunions." Journal of Hand Surgery 33 6 (2008): 966-973.

Schenck, Robert R. "Carpal Fractures." eMedicine. Ed. Harris Gellman. 29 Oct. 2013. Medscape. 31 May 2014 <http://emedicine.medscape.com/article/1238278-overview>.

Steinberg, R. B. "Acute Wrist Injuries in the Athlete." Orthopedic Clinics of North America 33 3 (2002): 535-545. National Center for Biotechnology Information. 1 Jun. 2002. National Library of Medicine. 4 Feb. 2009 <PMID: 12483949>.

Wright, Phillip E. "Chapter 73 - Carpal Tunnel, Ulna Tunnel and Stenosing Tenosynovitis." Campbell's Operative Orthopaedics. Eds. S. Terry Canale and James H. Beaty. 11th ed. Philadelphia: Mosby Elsevier, 2008.

Zlotolow, D. A. , E. Knutsen, and J. Yao. "Optimization of Volar Percutaneous Screw Fixation For Scaphoid Waist Fractures Using Traction, Positioning, Imaging, and an Angiocatheter Guide." Journal of Hand Surgery 36 5 (2011): 916-921.

Source: Medical Disability Advisor






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