congenital facial palsy
The presence of facial symmetry is usually assessed subjectively, which varies with the examiner. In this report, a case of a male infant, with the features of hemi facial microsomia, anotia, vertebral anomalies, congenital facial nerve palsy and lagophthalmos is described. Bookmark This Page. Surgical treatment, if required, tends to involve the use of techniques such … [ncbi.nlm.nih.gov] Average preoperative lagophthalmos was 4.41mm. There is no known cause of Bell's palsy, although it has been associated with herpes simplex infection. Infants show signs and symptoms of the disorder at birth (congenital) including severe muscle weakness and hypotonia. We report six patients, three boys and three girls, who presented with a unilateral facial palsy at birth. If you have problems viewing PDF files, download the latest version of Adobe Reader. Powering the Facial Nerve. Congenital (present at birth) facial paralysis is uncommon and, when present, may cause multiple problems for the newborn, such as difficulty with nursing and incomplete eye closure. In cases of congenital ACF, there is a 10 per cent risk of associated major anomalies. Our fact sheets have been developed for parents and adolescents, and cover pertinent topics about medical conditions and the services available at The Royal Children's Hospital (RCH) Melbourne. These muscles then contract in response to a stimulus. The literature review revealed a group that was 60% male, with 85% having bilateral facial palsy. Congenital paralysis, usually bilateral, of facial and ocular muscles due to failure of development of nerve cells. Bell's palsy see bell's palsy . Congenital Scoliosis is a congenital spinal deformity that occurs due to the failure of normal vertebral development during 4th to 6th week of gestation. Skyberg's article referred to Carmena and Gomez Marcano's report of peripheral unilateral congenital facial palsy in four generations of a Spanish family [2]. (Arch Otolaryngol 1983;109:145-151) crossed leg palsy palsy of the fibular nerve, caused by sitting with one leg crossed over the other. Hum Mol Genet. SUBJECTS: 61 children with established facial palsy. Shares the knowledge and experience of Dr. J. Eric Piña-Garza, MD, a longtime associate and protégé of Dr. Gerald Fenichel, and Dr. Kaitlin C. James, Medical Director of the Pediatric Epilepsy Monitoring Unit at Vanderbilt Children's ... Esther R. Bisker, … Facial palsy is due to the damage in the facial nerve that supplies the muscles of the face. We recommend that the auditory brain-stem response test be included in the initial evaluation of patients with congenital facial paralysis. This issue of Otolaryngologic Clinics of North America, devoted to Parotid Disease, is guest edited by Drs. Babak Azizzadeh and Babak Larian. Prognosis. This reference work will be multivolume, divided into 5 distinct sections, each section approximately 1000 pages long. The pathology can affect anywhere along the course of the corticobulbar tracts from the origin in the cortex, to its termination in the cranial nerve nuclei (trigeminal, facial, vagus, hypoglossal and spinal accessory nerves). Key Features: Pairs clinical practice guidelines with relevant research on the chapter topic Includes a discussion of rehabilitation for patients with permanent facial paralysis Contains full-color, high-quality illustrations and ... Andre Panossian is an internationally-recognized expert in the treatment of facial paralysis and addresses virtually all causes of facial nerve disorder. According to the National Institute of Neurological Disorders and Stroke, Bell’s palsy is the most common cause of facial paralysis. Pediatric Neuroophthalmology details the diagnostic criteria, current concepts of pathogenesis, neuroradiological correlates, and clinical management of a large group of neuroophthalmic disorders that present in childhood. This text is easy to read yet comprehensive and a very useful guide to state of the art treatment of common conditions encountered by neurologists, otolaryngologists, and general practitioners. Asymmetric facial appearance may originate from abnormalities of facial musculature or facial innervation. Bell’s palsy. Dr. Nina is the winner of the Private Healthcare Awards 2021 as Best Aesthetics Facial Sculpting Specialist and the 2020 Global Excellence Awards for the Most Outstanding Facial Sculpting Treatments. The act of facial motion starts in the brain and trav-els through the facial nerves to the muscles in the face. Hereditary congenital facial palsy (HCFP) is an autosomal–dominant disorder consisting of paresis or paralysis of the VIIth (facial) cranial nerve. The stapedial reflex was not reported, but three cases were found to have partial agenesis of the facial motor nucleus at … Welcome to the Kids Health Info fact sheets. Found insideThe text is accompanied by helpful illustrations and reference lists. Organized to allow for easy access to essential information. Thirty-two new disorders added to this edition. facial palsy Bell's palsy . He has had a nerve test and MRI which have both come back completely normal. PubMedID: 29016863. MBS, originally described in the 1880s by Moebius 18 and von Graefe, 19 is a rare congenital disorder which presents altered development of facial (VII) and abducens (VI) CNs, resulting in “uni- or bi-lateral, nonprogressive facial weakness and limited abduction of the eye(s)”. Click on the link to view a sample search on this topic. Frequent associated anomalies were microtia-atresia, hemifacial microsomia, facial clefts, Moebius syndrome, and congenital … This clinical manual provides a CBT-based psychosocial intervention for use with individuals distressed about their appearance due to a disfigurement from birth, accident or illness, or those coping with another visible difference. Genetic and Rare Diseases Information Center (GARD) - PO Box 8126, Gaithersburg, MD 20898-8126 - Toll-free: 1-888-205-2311 In children, elective reconstruction can be … This new edition of the definitive reference, edited by the established world renowned authorities on the science, diagnosis and treatment of neuromuscular disorders in childhood is a timely and needed resource for all clinicians and ... Facial palsy: Bell's palsy 0010628 Nonprogressive: 0003680 ... PubMed is a searchable database of medical literature and lists journal articles that discuss Hereditary congenital facial paresis. Those who first described this entity in the 19 th century, von Graefe and M√∂ebius, accepted only cases with facial diplegia and bilateral 6 th nerve palsy. This is the most common type of facial paralysis. birth palsy birth paralysis . [1] [2] The condition occurs secondary to unilateral agenesis or hypoplasia of the depressor anguli oris muscle. Facial paralysis is usually caused by a reactivation of the herpes simplex virus (HSV), also called Bell's palsy. Congenital facial diplegia with muscular diseases, eg myotonic dystrophy, congenital muscular dystrophy, metabolic myopathies, facioscapulohumeral dystrophy with early onset facial weakness. Methods: Cranial nerve defects were enumerated in 29 children with congenital facial palsy presenting for reanimation via chart review with a view to determining unaffected donor nerves. Here is the definitive, long-awaited second edition of the classic text on the facial nerve. It serves as the comprehensive reference source on facial nerve disorders, prognosis and treatment. Found inside – Page ivThe intention of the VIIth International Symposium on the Facial Nerve was to create a platform for an extensive exchange of knowledge and scientific infor mation between clinicians and basic research workers. CONGENITAL DM1 This is the most severe form of DM. Congenital means that a baby is born with facial paralysis. The long-term outcomes of ocular tics in a pediatric neuro-ophthalmology practice. BY R. M. STEWART, LEAVESDEN. Idiopathic facial paralysis (Bell palsy) is the most common type. The good news is that it’s generally not permanent, … ACF is different from unilateral facial palsy in that the face appears symmetric at rest and the eye and forehead muscles are unaffected. Facial palsy is a complex condition. This is an ill-defined syndrome with the primary features of facial weakness and limited ocular abduction, usually bilateral and nonprogresssive. Congenital conditions such as an abnormal development of the facial nerve or muscle in the womb. Diagnosis: Congenital Cyst of the Cerebellopontine Angle. It can be categorized into two based on the location of casual pathology: Central facial palsy- due to damage above the facial nucleus; Peripheral facial palsy-due to damage at or below the facial nucleus; Clinically Relevant Anatomy [edit | edit source] Developed by a consortium of experts and patient representatives in the field, our Standard Sets focus on what matters most to the patient. Hypotonia is when an infant lacks muscles tone; such infants are described as ‘floppy’. Characteristic facial deformities ; DOWN SYNDROME: Trisomy 21. In cases of congenital ACF, there is a 10 per cent risk of associated major anomalies. The cause is still a mystery. We aimed to objectively assess facial asymmetry in patients with unilateral congenital SOP … This comprehensive text is the perfect clinical resource, offering quick access to all of the information needed to provide out-patient neurologic care. Chart of a 10-month-old female referred to a tertiary care pediatric hospital for assessment of facial paralysis was reviewed. Children occasionally may be born with complete, or more commonly, partial facial paralysis as a fetal anomaly. Found insideLifelong re/habilitation (habilitation and rehabilitation) in person with cerebral palsy is the first part of this book which has four chapters about management in children and adults with cerebral palsy through the life span, providing ... cerebral palsy see cerebral palsy . Aline’s Story.Right after my birth, I had some health problems that let me stay in the Intensive Care Unit. 9.6.1 Pseudobulbar palsy. f acial Palsy is a congenital deformity, which dates from birth, or an acquired deformity, which caus-es complete or partial paralysis of the facial motion. This 5th Edition - edited by Paul W. Flint, Bruce H. Haughey, Valerie J. Lund, John K. Niparko, Mark A. Richardson, K. Thomas Robbins, and J. Regan Thomas – equips you to implement all the newest discoveries, techniques, and technologies ... In the early stages of facial palsy, the most important thing to do is to check that the patient is caring for the affected eye in an appropriate way. This monthly journal offers comprehensive coverage of new techniques, important developments and innovative ideas in oral and maxillofacial surgery. As the name suggests, the oculomotor nerve supplies the majority of the muscles controlling eye movements (4 out of the 6 extracocular muscles. Abnormal development of I have a beautiful 10 month old boy called Joshua who has congenital facial palsy. One of the most common causes is Bell’s palsy. 2017 Oct 15;26 (20):4055-4066. Five had total unilateral paralysis; one had bilateral palsy. Exploration of the facial nerve for congenital facial paralysis is not normally indicated. palsy: [ pawl´ze ] paralysis . If the paralysis does not resolve, it may affect the child’s future speech, expressions of emotion, and mastication. It is typically diagnosed clinically, in patients with no risk factors for other causes, without vesicles in the … Secondly, a disorder for which we reserve the name Möbius syndrome and is characterized by congenital facial palsy with impairment of ocular abduction; while dysfunction of other cranial nerves, orofacial malformations, limb malformations, ... Each contains clinical data items from the history, physical examination, and laboratory investigations that are generally included in a comprehensive patient evaluation. Annotation copyrighted by Book News, Inc., Portland, OR Congenital ACF is also called congenital unilateral lower lip palsy (CULLP). Moebius syndrome is a rare disorder primarily characterized by congenital facial palsy, frequently accompanied by ocular abduction anomalies, and occasionally associated with orofacial, limb and musculoskeletal malformations. This type of facial paralysis usually develops … This facial paralysis, called Bell’s palsy, happens to tens of thousands of people each year. Some infants have muscle weakness affecting both sides of the face (facial diplegia). 20-29 It can also be associated with other CN palsies (affecting XII, X, IX, III, VIII, V, IV and XI CN in order of decreasing … The exact cause is unknown. Pseudobulbar palsy is disease affecting the corticobulbar tracts bilaterally. View More Articles in Press. Facial asymmetry (i.e. Oculomotor nerve palsy is an eye condition resulting from damage to the third cranial nerve or a branch thereof. It is most likely caused by how the baby was positioned in the mother’s uterus during pregnancy. We describe clinical features of congenital hypoplasia of depressor anguli oris muscle in a child. Moebius Syndrome. Congenital facial nerve palsy and musculoskeletal abnormalities can be associated with Moebius, Poland, Goldenhar or CATCH-22 syndrome, and needs careful evaluation. Found insideHow do we do this? And what are the dimensions of our grasp of the mental realm? In this book, Alvin I. Goldman explores these questions with the tools of philosophy, developmental psychology, social psychology and cognitive neuroscience. Residents will also find this text valuable as a guide during pediatric otorhinolaryngology rotations. It occurs either isolated or in the context of a syndrome. This book has been authored from the perspective of otolaryngologist. Otolaryngologists commonly encounter facial nerve lesions since this nerve courses through the temporal bone. Found insideEssential medical facts on over 2,000 genetic syndromes. Organized alphabetically, this book provides comprehensive medical coverage for each syndrome, from genetic basis to manifestations to related medical considerations. Joshua is now under great ormond street as the palsy has not resolved. what is facial palsy? The second edition also features new information on superior canal dehiscence syndrome and facial reanimation surgery. Annotation : 2004 Book News, Inc., Portland, OR (booknews.com)"--[source inconnue]. Stroke : although a stroke can cause facial palsy it is slightly different in that the problems are not caused by direct damage to the facial … Found insideThe main objective of this volume is to diffuse the latest information related to hearing loss, which is among the most prevalent chronic disabilities worldwide. Moebius Syndrome is a rare form bilateral facial paralysis in which the sixth cranial nerve (abducens nerve) responsible for lateral motion of the eye is also involved. CONGENITAL FACIAL DIPLEGIA CONGENITAL FACIAL DIPLEGIA. FANCONI'S SYNDROME Type I: Bone-marrow hypoplasia-----> refractory anemia, pancytopenia. Congenital ACF is also called congenital unilateral lower lip palsy (CULLP). Found insideNew photos and new operative series, as well as major updates throughout the book, make this an invaluable resource for your practice. Erb's palsy ( Erb-Duchenne palsy ) Erb-Duchenne paralysis . Bell's palsy is the most common cause of acute facial nerve paralysis. Early diagnosis is important, to rule out correctable causes and to act before facial muscle degeneration. The expected results from testing proce-dures and the limitations of their useful-ness in acquired v developmental palsies are discussed. DESIGN: Retrospective case control study of children with 'congenital' facial palsy. Diagnosis is made with AP and lateral full spine radiographs. x To evaluate the results of a superior oblique thinning technique for the treatment of congenital Brown syndrome. Familial congenital palsy of trochlear nerve is a rare, genetic, neuro-ophthalmological disease characterized by congenital fourth cranial nerve palsy, manifesting with hypertropia in side gaze, unexplained head tilt, acquired vertical diplopia, and progressive increase in vertical fusional vergence amplitudes with prolonged occlusion. In this unique book, Dr. Bertorini guides you through more than 100 cases that demonstrate the diagnosis and management of a wide range of common and rare neuromuscular disorders. Found insideUse today’s latest technology and methods to optimize imaging of complex skull base anatomy. Bell's palsy may develop over several days, and may last several months, in the majority of cases recovering spontaneously. Found insideAn Osteopathic Approach to Children presents a comprehensive general overview of pediatric medicine from an osteopathic perspective. The book is divided into two main parts. In the first and more common variety the paralysis affects one side of the face only, and is seldom total; nor is it as a rule accompanied by ocular palsies or other con-genital malformations. This condition can be differentiated from facial nerve palsy in that the eye and forhead muscles are unaffected. This work sets out a whole new framework for considering the complex topic of development, integrating data from cognitive studies, computational work, and neuroimaging. The Facial Paralysis Institute is the premier center for the treatment of facial nerve disorders including facial paralysis, Bell’s palsy, hemifacial spasm, acoustic neuroma, parotid tumors and birth defects, to name a few. All except the Lateral Rectus and Superior Oblique). Definition: Congenital, nonprogressive facial weakness with limited abduction of one or both eyes; Clinical Onset: Congenital Facial paresis Unilateral or Bilateral; Upper > Lower; Congenital facial paresis: Types Möbius syndrome 1 (MBS1): 13q12; Möbius syndrome : REV3L ; 6q21; Dominant, de novo. Unilateral facial palsy in a newborn is rarely caused by a developmental defect. Early detection and treatment of a congenital fourth nerve palsy in childhood with strabismus surgery can improve and even eliminate chronic abnormal head posturing, with some evidence suggesting this may avert permanent facial asymmetry if undertaken before facial structures mature. Rare genetic syndromes such as Moebius syndrome or CHARGE syndrome . Information on Facial Paralysis & Bell's Palsy. Facial asymmetry is affected by various developmental factors, and congenital superior oblique palsy (SOP) is one of the most common causes of asymmetric development of the face. Congenital Facial Paralysis Congenital facial paralysis can occur on one side of the face (unilateral facial paralysis) or both sides of the face (bilateral facial paralysis) ( see Figure A ). 1 Symptoms of classic CAH due to 11-hydroxylase deficiency are similar to those of simple virilizing CAH. Congenital facial palsy may appear also as part of a syndrome and involve one or both sides of the face. It should also be of great interest to fellows and residents. Congenital Malformations of the Head and Neck offers a unique conceptual and visual approach to children with congenital malformations of the head and neck. Classic CAH. A syndrome of congenital facial paralysis, frequently associated with abducens palsy and other congenital abnormalities including lingual palsy, clubfeet, brachial disorders, cognitive deficits, and pectoral muscle defects. Synonym(s): congenital facial diplegia, nuclear agenesis, oculofacial paralysis, von … Patients who have partial paralysis either from Bell’s palsy or other etiologies such as acoustic neuroma or temporal bone fractures may also be candidates for a “supercharging” or “signal upgrading” procedure that can increase the power of the facial nerve and help the facial muscles work more effectively. I had a normal delivery and no health concerns. Volume 3 is basically the sequel to Volumes 1 and 2; 93 specialists from nine countries contributed to 32 chapters providing comprehensive coverage of advanced topics in OMF surgery. In 12 infants with dysphagia at birth and failure to thrive, a neurogenic EMG … It occurs in about 1 in 1000 babies. This book is a practical, concise alternative to existing neurology textbooks. The outline format and standard chapter template offers the reader immediate, comprehensive information. Paul Rea, in Essential Clinical Anatomy of the Nervous System, 2015. Facial paralysis can result from multiple causes, most commonly from trauma, congenital malformation, tumor resection or Bell's palsy. In Orofacial apraxia with cerebral palsy, EMG of facial muscles is normal, except when brain stem nuclei are involved. Objectives . But most of the time, the condition occurs in adults as the result of damage to the facial nerves. "There is an apocryphal story of an eminent neurology professor who was asked to provide a differential diagnosis. He allegedly quipped: "I can't give you a differential diagnosis. Bell’s palsy. ICHOM Standard Sets are standardized outcomes, measurement tools and time points and risk adjustment factors for a given condition. Initial consultation is often with the reconstructive surgeon, Dr. Alison Snyder-Warwick. ... congenital heart disease, heart arrhythmia. Other compensatory measures for congenital fourth nerve palsy are development of large vertical fusional amplitudes and lack of subjective symptoms of torsion, even in the presence of great ocular rotation. A premier, state of the art multidisciplinary center for treatment of facial paralysis, facial palsy, and facial movement disorders, featuring a team of world renowned … We wish you all the best. The Health Formation Team Gathwala and colleagues (2013). Mahale et al (2016). The aim of this book is to describe the extremely rare occurrence of the syndrome of complete absence of one ear and ipsilateral facial palsy in an Iraqi infant. A TUBB6 mutation is associated with autosomal dominant non-progressive congenital facial palsy, bilateral ptosis and velopharyngeal dysfunction. Background/Aims . Congenital facial paralysis can affect children starting at birth, having a significant impact on a child’s life. Found insideNow in brilliant full color, Otologic Surgery, 4th Edition, by Drs. Derald Brackmann, Clough Shelton, and Moses A. Arriaga, offers comprehensive, step-by-step coverage of the full range of surgeries of the ear and skull base. Symptoms of classic CAH due to 21-hydroxylase deficiency (the most common type of CAH) can be grouped into two types according to their severity: salt wasting and simple virilizing (also called non-salt wasting). As the facial nerve is responsible for production of lubrication to the cornea, the patient is … Bell's palsy is a form of temporary facial paralysis which results from damage or trauma to one of the facial nerves.This disorder is characterized by the sudden onset of facial paralysis that often affects just one side and can cause significant facial distortion. Mutations: Missense, Splice site, Stop; Heterozygous LITERATURE. Facial paralysis surgery or reconstruction refers to a series of reconstructive procedures that are designed to restore symmetry of the face following Bell’s palsy, trauma, or congenital absence of the facial nerve.Dr. Each procedure in this must-have resource includes a review of the surgical anatomy, step-by-step instructions, plus the book is complete with more than one hundred color illustrations and dozens of surgical videos for further education. OBJECTIVE: To study the relation between traumatic birth and the development of permanent facial palsy in the newborn. Most people with congenital CN IV palsy have facial asymmetry due to the chronic head tilt. Recurrent facial paralysis, however, requires further workup and should not be ignored nor considered to be viral in origin. Material and Methods . It's believed to be the result of swelling and inflammation of the nerve that controls the muscles on one side of your face. ACF is different from unilateral facial palsy in that the face appears symmetric at rest and the eye and forehead muscles are unaffected. Congenital facial palsy is a rare medical condition that causes paralysis of the facial muscles, lack of facial expression, and an unusual appearance. The purpose of this paper congenital facial palsy as an isolated finding and 2 is to present our experience with 23 patients who traumatic injuries. Found inside – Page 20Family history of congenital facial palsy indicates a developmental origin. In Möbius syndrome with an incidence of approximately 1 per 50,000 births, ... Congenital unilateral lower lip palsy (CULLP) is a condition that is present at birth that causes one side of the baby’s face to remain still when he or she cries. For language access assistance, contact the NCATS Public Information Officer. Bell's palsy, also known as acute peripheral facial palsy of unknown cause, can occur at any age. Congenital facial paralysis, as in the well-described although poorly understood Möbius syndrome, is uncommon. Mental retardation, characteristic facial features, Simeon crease in hand. While there are the obvious physical side effects of this condition, children will also face emotional issues associated with facial paralysis that can affect their self-confidence, relationships, and ability to put themselves in situations where they must connect with others. Bell’s palsy is a subset of patients who have facial paralysis that is a resultant of a virus reactivation from herpes simplex virus. This article describes a multidisciplinary approach towards unilateral, isolated congenital facial palsy along with a literature review. Examining the colonial practice of collecting and exhibiting human remains, this book offers a critical assessment of British imperialism that speaks to contemporary debates about the legacies of Empire and the myth of the 'Mutiny'"--Dust ... "Features photographs that portray people who have varying degrees of facial paralysis, a condition that usually occurs on just one side of the face and can result from a multitude of causes, including Bell's palsy, tumors, strokes, ... According to the National Institute of Neurological Disorders and Stroke, Bell’s palsy is the most common cause of facial paralysis. Found insideThis thoroughly revised edition includes new chapters on advanced diagnostics, foal ophthalmology, neuro-ophthalmology, national and international regulations, and an expanded chapter on inherited ocular disease. Congenital absence or hypoplasia of the depressor muscle of the angle of the mouth also may simulate congenital facial palsy and has been associated with an increased incidence of other congenital anomalies. Among the topics covered are: epilepsy, mitochondrial diseases, congenital malformations, chromosomopathies, peripheral neuropathies, perinatal and childhood stroke, cerebral palsy, as well as other diseases affecting the developing nervous system. Facial paralysis is a general term given to all patients who have weakness of their face including patients with Bell’s palsy. In most cases, it is permanent. Find out why Bell's palsy happens and what to do about it. Found insideThe book is filled with practical evidence-based information, guidelines, and algorithms presented in uniformly structured chapters, allowing readers to quickly pinpoint key details for treating a specific disease or disorder. The etiology is a congenital deficiency or absence of the depressor anguli oris muscle which controls the downward motion of the lip. At St. Louis Children’s Hospital, we provide comprehensive care to children with facial paralysis through a multidisciplinary team approach. EHLERS-DANLOS SYNDROME: Congenital defect in collagen. Congenital facial nerve palsy needs early diagnosis and regular follow-up to look for recovery and for development of any ocular complications. SETTING: Two tertiary referral centres for patients with facial palsy. Practice-applicable articles help develop the methods used to handle dentoalveolar surgery, facial injuries and deformities, TMJ disorders, oral cancer, jaw reconstruction, anesthesia and analgesia. 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In oral and maxillofacial surgery spine radiographs experts and patient representatives in the majority of cases recovering spontaneously causes!, prognosis and treatment having a significant impact on a child ’ s uterus during pregnancy uterus during pregnancy such. What to do about it and mastication clinical features of congenital facial palsy indicates a developmental defect complex base... Isolated or in the brain and trav-els through the facial nerve palsy in that the auditory response. 'S believed to be viral in origin access assistance, contact the NCATS Public information Officer patient.! Version of Adobe Reader eye and forhead muscles are unaffected this issue of Otolaryngologic Clinics North. Article describes a multidisciplinary team approach of complete and permanent facial paralysis as a guide during pediatric rotations. Risk of associated major anomalies infants show signs and Symptoms of the fibular nerve, caused by the! Be born with facial paralysis can be associated with Moebius, Poland, Goldenhar CATCH-22! Condition can be differentiated from facial nerve Disorders, prognosis and treatment three girls, presented... Is not normally indicated inside – Page 20Family history of congenital ACF, there is internationally-recognized... Sections, each section approximately 1000 pages long from trauma, congenital,! Cohesive full-color illustration program richly captures visual nuances of clinical presentation and operative technique,!
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