From Endodontic Therapy to Regenerative Endodontics: New Wine in Old Bottles

2020 ◽  
Vol 15 ◽  
Author(s):  
Ghee Seong Lim ◽  
Mang Chek Wey ◽  
Noor Hayati Azami ◽  
Nora Sakina Mohd Noor ◽  
May Nak Lau ◽  
...  
Keyword(s):  
Stem Cells ◽  
Root Canal ◽  
Case Reports ◽  
Clinical Signs ◽  
Mineral Trioxide Aggregate ◽  
Signs And Symptoms ◽  
Regenerative Endodontics ◽  
Immature Teeth ◽  
Clinical Signs And Symptoms ◽  
The 1960S

: The concept of regenerative endodontics wherein one can replace damaged pulp structures and recuperate the functionality in erstwhile necrotic and infected root canal systems has been a cutting-edge technology. Though the notion started as early as the 1960s even before the discovery of stem cells and regenerative medicine, it was in the 2000s, this procedure gained momentum. Ever since then, researchers continue to discover its essential benefit to immature teeth and its ability to overcome the caveats of endodontic therapy which is commonly known as root canal treatment. Further, through this therapy, one can redevelop root even in immature teeth with necrotic pulps which overall helps in maintaining skeletal and dental development. Past literature indicates that regenerative endodontic procedures seem to be successful especially when compared with other conventional techniques such as Mineral Trioxide Aggregate apexification. Besides, many clinicians have begun to apply regenerative endodontic procedures to mature teeth in adult patients with several clinical case reports that have shown complete resolution of signs and symptoms of pulp necrosis. Generally, three most desirable outcomes anticipated by clinicians from this procedure namely resolution of clinical signs and symptoms, root maturation and redevelopment of neurogenesis process. Despite this, whether these objectives and true regeneration of the pulp/dentin complex are achieved is still a question mark. Following the discovery that regenerative endodontics indeed is a stem cell-based treatment, addressing the fundamental issue surrounding stem cells might assist in achieving all identified clinical outcomes, while favoring tissue formation that closely resembles pulp-dentin complex.

scholarly journals Portland Cement Use in Dental Root Perforations: A Long Term Followup

2014 ◽  
Vol 2014 ◽  
pp. 1-5
Author(s):  
Álvaro Henrique Borges ◽  
Matheus Coelho Bandeca ◽  
Mateus Rodrigues Tonetto ◽  
Luis Augusto Faitaroni ◽  
Elibel Reginna de Siqueira Carvalho ◽  
...  
Keyword(s):  
Portland Cement ◽  
Calcium Hydroxide ◽  
Root Canal ◽  
Clinical Signs ◽  
Signs And Symptoms ◽  
Clinical Aspects ◽  
Iatrogenic Perforation ◽  
Root Canals ◽  
First Case ◽  
Clinical Signs And Symptoms

Root canal and furcal perforations are causes of endodontic therapy failure and different materials that stimulate tissue mineralization have been proposed for perforation treatment. In the first case, a patient presented tooth 46 with unsatisfactory endodontic treatment and a periapical radiographic lesion. A radiolucent area compatible with a perforating internal resorption cavity was found in the mesial root. The granulation tissue was removed, and root canals were prepared. The intracanal medication was composed of calcium hydroxide and the perforation cavity was filled with Portland cement. The 11-year followup showed radiographic repair of the tissue adjacent to the perforation and absence of clinical signs and symptoms or periapical lesion. In the second case, a patient presented with edema on the buccal surface of tooth 46. The examination showed a radiolucent area in the furcation region compatible with an iatrogenic perforation cavity. The mesial root canals were calcified, and only the distal root canal was prepared. The cavity was filled with a calcium hydroxide-based paste and the distal root canal was obturated. In sequence, the perforation cavity was filled with Portland cement. The 9-year followup showed the tooth in masticatory function with radiographic and clinical aspects compatible with normality.

scholarly journals Management of a non-vital immature tooth using MTA as an apical plug: Two case reports

2015 ◽  
Vol 5 (1) ◽  
pp. 41-46
Author(s):  
S Wagle ◽  
N Joshi ◽  
K Prajapati
Keyword(s):  
Root Canal ◽  
Case Reports ◽  
Mineral Trioxide Aggregate ◽  
Canal System ◽  
Immature Teeth ◽  
Open Apices ◽  
Root Canal System

MTA appears to be a valid option for apexification with its main advantage being, the speed at which the treatment can be completed. A major problem in performing endodontics in immature teeth with necrotic pulp and wide open apices is obtaining an optimal seal of the root-canal system. Mineral Trioxide Aggregate (MTA), has been proposed as a potential material to create an apical plug at the end of the root-canal system, thus preventing the extrusion of filling materials.DOI: http://dx.doi.org/10.3126/jcmc.v5i1.12574

scholarly journals Pulp Revascularisation of a Non-Vital Immature Young Permanent Tooth - A Case Report and Literature Review

2021 ◽  
Vol 10 (11) ◽  
pp. 845-848
Author(s):  
Tanvi Sanjay Satpute ◽  
Jayeeta Sidharth Verma ◽  
Jimish Rajiv Shah ◽  
Aditya Kiran Shinde
Keyword(s):  
Case Report ◽  
Root Development ◽  
Root Canal ◽  
Mineral Trioxide Aggregate ◽  
Signs And Symptoms ◽  
Permanent Tooth ◽  
Duration Of Treatment ◽  
Pulp Tissue ◽  
Dental Tissues ◽  
Immature Teeth

Traumatic injuries to an immature permanent tooth may result in cessation of dentin deposition and root maturation. Novel revascularisation endodontic procedure (REP) has been considered as an option for treatment of immature teeth with damaged pulp tissue. The continuous development of the root and the root canal has been recognised as a major advantage of this technique over traditional apexification approach. Traditional apexification procedures may resolve pathology but have not been able to prove tooth survival due to absence of continued root development and risk of root fracture. A successful REP results in resolution of signs and symptoms of pathology, radiographic signs of healing, proof of continued root development as well as presence of pulp vitality due to the regeneration of pulp tissue in the root canal. Currently, repair rather than true regeneration of the ‘pulp-dentine complex’ is achieved and further root maturation is variable. According to Glossary of Endodontic terms published by American Association of Endodontists, REP’s are biologically based procedures designed to physiologically replace damaged tooth structures, including dentin and root structures, as well as cells of the pulp-dentin complex.1,2 Apexification treatment has been a routine procedure to treat and preserve such teeth for many decades.3 Apexification is the process by which a suitable environment is created within the root canal and periapical tissue to allow for the formation of a calcific barrier across the open apex. Calcium hydroxide [Ca(OH)2] has been the material of choice for apexification as Frank reported its capacity to induce physiological closure of immature pulpless teeth in 1966.4 However, this technique has several disadvantages, including the unpredictability of apical barrier formation and the long duration of treatment, which often requires multiple visits.5 A retrospective study by Jeruphuaan et al.6 has shown a higher survival rate with regenerative endodontic treatment when compared to both mineral trioxide aggregate (MTA) and Ca(OH)2 apexification. The first evidence of regeneration of dental tissues was in 1932 by G.L. Feldman, who showed evidence of regeneration of dental pulp under certain optimal biological conditions.7 In 1971, a pioneer study in regenerative endodontics conducted by Nygaard-Ostby concluded that bleeding induced within a vital or necrotic canal led to resolution of signs and symptoms of necrotic cases and in certain cases, apical closure.8 According to Windley et al. (2005), the successful revascularisation of immature teeth with apical periodontitis is mainly dependent upon: 1. Canal disinfection 2. Scaffold placement in the canal for the growing tissues 3. Bacteria-tight sealing of the access opening.9 The purpose of this case report is to illustrate the outcome of a revascularisation endodontic procedure in a non-vital immature young permanent central incisor.

scholarly journals Use of mineral trioxide aggregate for retreatment of a tooth with large periapical lesion, wide-open apices and vertical root fracture

2018 ◽  
pp. bcr-2018-227627
Author(s):  
Pragya Pandey ◽  
Tanya Nandkeoliar ◽  
Rhythm Bains ◽  
Diksha Singh
Keyword(s):  
Clinical Signs ◽  
Mineral Trioxide Aggregate ◽  
Signs And Symptoms ◽  
Fracture Line ◽  
Autogenous Bone ◽  
Periapical Lesion ◽  
Vertical Root Fracture ◽  
Periapical Lesions ◽  
Retrograde Filling ◽  
Clinical Signs And Symptoms

Chronic periapical lesions in necrotic teeth with open apex are difficult to manage. The situation becomes more complex if the tooth has a fracture line. This case report describes the management of a traumatised tooth that had already undergone unsuccessful endodontic treatment with a large periapical lesion and open apex along with a fracture line in the root. An attempt was made to save the tooth by using mineral trioxide aggregate (MTA) cement for orthograde filling, retrograde filling and also for sealing of the fracture line. Moreover, the bone defect was filled with autogenous bone harvested from the external oblique ridge. MTA, a bioactive tricalcium silicate cement, has been used in treating complex endodontic cases as it shows promising potential by inducing the biological mechanisms necessary for repair of involved teeth. A 1-year follow-up showed progressive healing as evident by radiographs and lack of any clinical signs and symptoms.

scholarly journals Endodontic retreatment due to secondary periapical injury: case report

2020 ◽  
Vol 9 (6) ◽  
pp. 503-506
Author(s):  
Monica Soares de Albuquerque ◽  
Armiliana Soares Nascimento ◽  
Cácio Lopes Mendes ◽  
Leonardo José Rodrigues de Oliveira ◽  
Marília de Lima Soares ◽  
...  
Keyword(s):  
Root Canal ◽  
Clinical Signs ◽  
In Vitro Study ◽  
Signs And Symptoms ◽  
Endodontic Treatment ◽  
Endodontically Treated Teeth ◽  
Clinical Signs And Symptoms ◽  
Endodontic Retreatment

Pulp diseases commonly happens because of the actions of bacteriological factors and show their characteristic signs and symptoms over the time. With pulp necrosis, a degenerative process starts and when there is no early treatment, it is possible to occur periapical lesions as a result of aggression to the pulp. In cases of periapical secondary lesions, clinical signs and symptoms persist and are related to secondary infection due to persistent bacterial contamination, also to operative factors, inadequate obturation or poor coronary restoration. This study aimed to report a case of endodontic retreatment and clinical and radiographic follow-up for 8 years, of chronic periapical abscess case, in which after retreatment, clinical signs and symptoms are no longer observed and bone neoformation is noticed. Descriptors: Periapical Diseases; Endodontics; Periapical Abscess. Referências Alani AH. Endodontic treatment of bilaterally occurring four-rooted maxillary second molars: case report. J Can Dent Assoc. 2003;69(11):733–35. Slowey RR. Radiographic aids in the detection of extra root canals. Oral Surg Oral Med Oral Pathol 1974;37(5):762-72 Bergenholtz G, Malmcrona E, Milthon R. Endodontic treatment and periapical status I. Radiographic evaluation of the frequency of endodontically treated teeth. Tandl€akartidningen. 1973; 65:64–73 (In Swedish, English summary). Buckley M, Spangberg LS. The prevalence and technical quality of endodontic treatment in an American subpopulation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;79(1):92–100. Saunders WP, Saunders EM, Sadiq J, Cruickshank E. Technical standard of root canal treatment in an adult Scottish sub-population. Br Dent J. 1997;182(10):382-86. Segura-Egea JJ, Jimenez-Pinzon A, Poyato-Ferrera M, Velasco-Ortega E, Rios-Santos JV. Periapical status and quality of root fillings and coronal restorations in an adult Spanish population. Int Endod J. 2004;37(8):525-30. Kabak Y, Abbott PV. Prevalence of apical  periodontitis and the quality of endodontic treatment in an adult Belarusian population. Int Endod J. 2005;38(4):238-45. Glickman GN. AAE consensus conference on diagnostic terminology: background and perspectives. J Endod. 2009;35:1619. Gutmann JL, Harrison JW. Surgical endodontics: an online study guide. Blackwell Scientific Publications; 1991. Molven O, Halse A, Grung B. Incomplete healing (scar tissue) after periapical surgery - radiographic findings 8 to 12 years after treatment. J Endod. 1996;22(5):264-68. Macedo, IL Retratamento endodôntico: opção terapêutica do insucesso endodôntico. BJHR. 2018;1(2):421-31. Souza VC et al. Tratamento do insucesso endodôntico. Rev Odontol Bras Central. 2018; 27:44-48. Bender IB, Seltzer S, Soltanoff W. Endodontic success – a reappraisal of criteria. Oral Surg Oral Med Oral Pathol. 1966; 22(6):790–802. Rubinstein R A, Kim S. Long-term follow-up of cases considered healed one year after apical microsurgery. J Endod. 2002; 28(5):378-83. Estrela C et al. Characterization of successful root canal treatment. Braz Dent J. 2014; 25(1):3-11 http://dx.doi.org/10.1590/0103-6440201302356 Kaled GH et al. Retratamento endodôntico: análise comparativa da efetividade da remoção da obturação dos canais radiculares realizada por três métodos. RGO, Rev. gaúch. odontol. (Online). 2011;59(1):103-8. Rossi-Fedele G, Ahmed HMA. Assessment of rootcanal filling removal effectiveness using micro–computedtomography: a systematic review. J Endod. 2017;43(4):520-26 Barbosa SV, Burkhard DH, Spanberg LSV. Cytotoxic effects of gutta-percha solvents. J Endod. 1994; 20(1):6-8. Zakariasen KL, Brayton SM, Collinson DM. Efficient and effective root canal retreatment without chloroform. J Canad Dent Assoc. 1990; 56(6):509-12. Pecora JD, Spano JC, Barbin EL. In vitro study on the softening of gutta-percha cones in endodontic retreatment. Brazilian. Braz Dent Journal. 1993; 4(1): 43-7. Scelza MF et al. Comparative SEM evaluation of three solvents used in endodontic retreatment: an ex vivo study. Journal of Applied Oral Science. 2008; 16(1):24-9. Marques da Silva B et al. Effectiveness of ProTaper, D-RaCe, and Mtwo retreatment files with and without supplementary instruments in the removal of root canal filling material. Int Endod J. 2012; 45(10):927-32 Song M1 et al. Analysis of the cause of failure in nonsurgical endodontic treatment by microscopic inspection during endodontic microsurgery. J Endod. 2011;37(11):1516-9. Albuquerque MS et al. Sealing Capacity of Bulk-fill Resin in Endodontically Treated Teeth. The Journal of Contemporary Dental Practice. 2019; 20(3): 311-17 Zancan RF, Vivan RR, Lopes MRM et al. Antimicrobial activity and physicochemical properties of calcium hydroxide pastes used as intracanal medication. J Endod. 2016. 42(12):1822-28. Buttler TK, Crawford JJ. The detoxifying effect of varying concentrations of sodium hypochlorite on endotoxins. J Endod. 1982; 8(2):59-66. Foley DB, Weine FS, Hagen JC, deObarrio JJ. Effectiveness of selected irrigants in the elimination of bacteroides meloninogenicus from the root canal system: an in vitro study. J Endod. 1983; 9(6):236-41. Abou-Ran M, Oglesby SW. The effects of temperature, concentration and tissue type on the solvent ability of sodium hypochlorite. J Endod. 1981; 7(8):376-7. Lee JK et al. Physicochemical Properties of Epoxy Resin-Based and Bioceramic-Based Root Canal Sealers. Bioinorg Chem Appl. 2017; 1-8.  Kandemir DG, Caliskan MK. A prospective Ramdomized  Comparative Study of Cold Lateral Condensation Versus Core/Guta Percha in Teeth with Periapical Lesions. J Endod. 2016; 42(2):206-10 Karaman E, Keskin B, Inan U. Three-year clinical evaluation of class II posterior composite restorations placed with different techniques and flowable composite linings in endodontically treated teeth. Clin Oral Investig. 2017; 21(2):709-16.

scholarly journals Presentation and management of N-acetylglutamate synthase deficiency: a review of the literature

2020 ◽  
Vol 15 (1) ◽  
Author(s):  
Aileen Kenneson ◽  
Rani H. Singh
Keyword(s):  
Current Knowledge ◽  
Case Reports ◽  
Management Strategies ◽  
Clinical Signs ◽  
Case Series ◽  
Signs And Symptoms ◽  
Protein Restriction ◽  
Therapeutic Trials ◽  
Acetylglutamate Synthase ◽  
Clinical Signs And Symptoms

Abstract Background N-Acetylglutamate synthase (NAGS) deficiency is an extremely rare autosomal recessive metabolic disorder affecting the urea cycle, leading to episodes of hyperammonemia which can cause significant morbidity and mortality. Since its recognition in 1981, NAGS deficiency has been treated with carbamylglutamate with or without other measures (nutritional, ammonia scavengers, dialytic, etc.). We conducted a systematic literature review of NAGS deficiency to summarize current knowledge around presentation and management. Methods Case reports and case series were identified using the Medline database, as well as references from other articles and a general internet search. Clinical data related to presentation and management were abstracted by two reviewers. Results In total, 98 cases of NAGS deficiency from 79 families, in 48 articles or abstracts were identified. Of these, 1 was diagnosed prenatally, 57 were neonatal cases, 34 were post-neonatal, and 6 did not specify age at presentation or were asymptomatic at diagnosis. Twenty-one cases had relevant family history. We summarize triggers of hyperammonemic episodes, diagnosis, clinical signs and symptoms, and management strategies. DNA testing is the preferred method of diagnosis, although therapeutic trials to assess response of ammonia levels to carbamylglutamate may also be helpful. Management usually consists of treatment with carbamylglutamate, although the reported maintenance dose varied across case reports. Protein restriction was sometimes used in conjunction with carbamylglutamate. Supplementation with citrulline, arginine, and sodium benzoate also were reported. Conclusions Presentation of NAGS deficiency varies by age and symptoms. In addition, both diagnosis and management have evolved over time and vary across clinics. Prompt recognition and appropriate treatment of NAGS deficiency with carbamylglutamate may improve outcomes of affected individuals. Further research is needed to assess the roles of protein restriction and supplements in the treatment of NAGS deficiency, especially during times of illness or lack of access to carbamylglutamate.

Evaluation of Conventional Root Canal Treatment for Healing of Periapical Pathosis of Nonvital Teeth

2020 ◽  
Vol 33 (1) ◽  
pp. 25-30
Author(s):  
Md Ismail Hossain ◽  
Monira Parveen ◽  
Md Nahid Khurram Choudhury ◽  
Tasnim Wakia ◽  
Farid Uddin ◽  
...  
Keyword(s):  
Root Canal ◽  
Clinical Signs ◽  
Signs And Symptoms ◽  
Root Canal Treatment ◽  
Periapical Lesion ◽  
Nonsurgical Management ◽  
Clinical And Radiological Outcome ◽  
Root Canal System ◽  
Clinical Signs And Symptoms

Background: Root canal Therapy is one of the procedures for the management of nonvital tooth with periapical lesion. The principle of this therapy is the complete sterilization of the total pulp canal space thereby healing of the periradicular lesion. Objectives: This experimental study assessed the clinical and radiological outcome of root canal treatment for nonsurgical management of nonvital teeth with periapical lesion. Materials and Methods: A total number of 40 infected teeth with periapical lesion were treated by conventional root canal treatment. Irritants from the root canal system was removed by mechanical instrumentation( Crown down Technique), chemical irrigation with NaOCL and by using Calcium Hydroxide as intracanal medicaments and fluid tight obturation both apically and coronally resulting repairs of inflamed periradicular tissues. The protocol for follow up examination will be 3, 6 and 12 months post operatively. At the time of follow up examination a standard follow up chart will be maintained. Results: Among 40 cases 32 cases could be treated as acceptable as their responses were good both clinically and radiologically and 5 patients came back with some complications among them 3 cases were uncertain and 2 cases were unacceptable. Conclusion: It was concluded that conventional root canal treatment reduced clinical signs and symptoms successfully in teeth with periapical lesion and radiologically. TAJ 2020; 33(1): 25-30

scholarly journals A Case Report of Cerebral Vasospasm Following Elective Clipping of Unruptured Aneurysm: Pathogenetic Theories and Clinical Features of a Dangerous Underestimated Event

2020 ◽  
pp. 1-6 ◽  
Author(s):  
Pietro Fiaschi ◽  
Anania Pasquale ◽  
Ceraudo Marco ◽  
D’Andrea Alessandro ◽  
Pietro Fiaschi ◽  
...  
Keyword(s):  
Cerebral Vasospasm ◽  
Case Reports ◽  
Clinical Signs ◽  
Signs And Symptoms ◽  
Unruptured Aneurysm ◽  
Unruptured Intracranial Aneurysm ◽  
Subarachnoid Bleeding ◽  
Bifurcation Aneurysm ◽  
Clinical Signs And Symptoms ◽  
Improve Clinical Outcome

Background and Importance: Angiographic-proven and clinically-evident cerebral vasospasm (CVS) after uneventful elective clipping of unruptured intracranial aneurysm (UIA) is a very rare and often underestimated event. To date, the knowledge of risk factors, pathophysiology, and demographic characteristics of these conditions are solely relegated to few case reports. With the aim of better characterize shared features and mechanism that could be involved in such event we also performed a review of the present literature and analyzed aneurysm’s features, surgical factors, treatments, recovery and of all reported cases of CVS after elective clipping. Clinical Presentation: We report a case of a cerebral vasospasm following elective clipping of a middle cerebral artery (MCA) bifurcation aneurysm in a 59-year-old woman who smoked next days after treatment, despite medical advice. We found ten cases comparable to ours with angiographic-proven and clinically evident cerebral vasospasm after uneventful elective clipping. Conclusion: Classic mechanisms of CVS following SAH have been widely studied. In all the cases we analyzed, no subarachnoid bleeding occurred, as demonstrated in pre and postoperative CT scans and intraoperatively. Various theories on the possible mechanism have been advanced. It seems reasonable that CVS following elective clipping of unruptured aneurysm is a multifactorial phenomenon. Although its pathogenesis is unclear, clinicians should keep in mind the existence of this event, that is rare, but it could be seen in the clinical practice of every neurosurgery ward. In our opinion, it’s worth to know this possible post-operative complication because, when suspected clinical signs and symptoms of delayed ischemic neurological deficit (DIND) arise after elective clipping, it’s important to make an early diagnosis of CVS owing to early treatments are critical to improve clinical outcome

scholarly journals Multisystemic Side Effects of an Indispensable Old Drug: A Case Report of Chronic Lithium Use (A Patient with Multiple Side Effects of Lithium)

2015 ◽  
Vol 2015 ◽  
pp. 1-4 ◽  
Author(s):  
Levent Demirtas ◽  
Emin Murat Akbas ◽  
Husnu Degirmenci ◽  
Ali Gurel ◽  
Eren Duzgun
Keyword(s):  
Side Effects ◽  
Clinical Supervision ◽  
Health Care Professionals ◽  
Case Reports ◽  
Sinus Bradycardia ◽  
Clinical Signs ◽  
Clinical Manifestations ◽  
Signs And Symptoms ◽  
Therapeutic Index ◽  
Clinical Signs And Symptoms

Presented here is a case of long-term lithium use, with multiple emerging lithium-associated side effects. An 82-year-old woman was brought into the emergency department because of loss of consciousness. According to the physical examination and laboratory analyses, patient was diagnosed with lithium-associated hypercalcemia, hyperparathyroidism, nephrogenic diabetes insipidus (NDI), symptomatic sinus bradycardia, and thyroid dysfunction. In the literature, there is a limited number of case reports with lithium induced multiple clinical conditions. Multiple clinical manifestations due to the side effects of chronic lithium use might be seen. Health care professionals should keep in mind that lithium-related side effects might trigger or exacerbate each other. To avoid toxicity, close follow-up and clinical supervision are important for the early diagnosis and treatment of these side effects, due to the narrow therapeutic index and obscure clinical signs and symptoms of toxicity.

Posterior tibial tendinitis. A literature review with case reports

1994 ◽  
Vol 84 (3) ◽  
pp. 141-149 ◽  
Author(s):  
RL Blake ◽  
K Anderson ◽  
H Ferguson
Keyword(s):  
Physical Activity ◽  
Literature Review ◽  
Subtalar Joint ◽  
Inflammatory Process ◽  
Case Reports ◽  
Clinical Signs ◽  
Signs And Symptoms ◽  
Posterior Tibial ◽  
Clinical Signs And Symptoms

Overuse posterior tibial tendinitis is caused by the increased stress placed on the tendon as it tries to compensate for the increased subtalar joint pronatory movement and velocity during physical activity. The stress can cause microtrauma and rupture of some of the fibers of the tendon. This leads to an inflammatory process and the classical clinical signs and symptoms. Therapy is directed at reducing the inflammation, minimizing the fibrosis buildup, re-strengthening the weakened tissue, and controlling the pronatory force. The two case reports illustrate typical clinical signs, symptoms, and treatment for this injury.

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