They are seen as subdivisions of existing bones or free elements in the vicinity of the normal bone structures. The authors state that this work has received no funding. It is where there is a spiral fracture of the proximal fibula along with ankle instability. The site is secure. Salekzamani Y, Shakeri-Bavil A, Nezami N, Houshyar Y (2009) Ankle patella: a report of a large accessory bone in the ankle: a case report. J Bone Joint Surg Am 76:13081314. Insights Imaging 4:581593. Fluoroscopy may also be used to examine for loose bodies. Clinical presentation They usually are asymptomatic although they may eventually cause painful syndromes or degenerative changes in response to overuse and trauma. Proton density spectral attenuation inversion recovery, Sarrafian SK, Kelikian A (2011) Osteology. The peroneocalcaneus arises from the internal aspect of the fibula, below the origin of the flexor hallucis longus, and descends posterior to this displacing it anteriorly and medially, with the tendons running parallel. Kose O, May H, Acar B, Unal M (2018). Axial FSE T1 at different levels from (a) proximal to (b) distal demonstrates the muscle belly anterior to the soleus, superficial to the flexor retinaculum (black arrows). 9). Os subfibulare is an accessory ossicle of the lateral malleolus at the distal end of the fibula. 1 It is a result of an unfused accessory ossification center or an avulsion fracture of the anterior talofibular ligament.1, 2 Avulsion fracture may fail to unite because it is intra-articular and bathed in synovial fluid or because the tension on the anterior talofibular ligament attached to . Radiographs may reveal a small osseous fragment distal to the lateral malleolus, suggesting an avulsion injury of the anterior talofibular ligament and/or calcaneofibular ligament. Symptomatic ossicles of the lateral malleolus in children. 8600 Rockville Pike Only in very rare cases in which the peroneocalcaneus internus displaces the flexor hallucis longus medially a tarsal tunnel syndrome has been reported [50]. ECR 2023 Registration Fees All ECR 2023 registration fees include access to our Best of ECR 2022 On-demand Package " which will be exclusively available in your personal ESR account after registration has been completed. The patient is put in supine position. Jul 2009. Oblique views will demonstrate its presence. In most instances, os subfibulare is found incidentally on radiographs. Unusual foot pathologies mimicking common sports injuries.J Foot Ankle Surg Jan-Feb 1993 32(1): 53-59. As a difference from the flexor digitorum accessorius longus, the tibiocalcaneus inserts onto the calcaneus and not the flexor digitorum longus or quadratus plantae. 13). Os sustentaculi. Key words: Os subtibiale, accessory bones foot, medial malleolus J Bone Joint Surg Br 90:10491054. Boyd N, Brock H, Meier A, Miller R, Mlady G, Firoozbakhsh K (2006) Extensor hallucis capsularis: frequency and identification on MRI. Clinical examination revealed a visible swelling 2cm by 2cm over the lateral malleolus. Google Scholar. doi: 10.3827/faoj.2010.0308.0003, Os subfibulare is a rarely reported ossicle involving the inferior portion of the fibular tuberosity of the ankle. These are typical of inversion injuries of the ankle. All fees in EUR; 20% VAT included Metin . Sagittal proton density spectral attenuation inversion recovery (PD SPAIR) image. Nigar Coskun. Part of the anterior talar fibular ligament was sutured to the lateral malleolus. CAS There was a palpable bony swelling that felt hard and fixed to the antero-inferior aspect of the lateral malleolus. When symptoms persist, surgical excision and repair of collateral ligament is indicated. Occasionally, limitation of movement, posterior ankle impingement and flexor hallucis longus tenosynovitis have also been described in association to its presence. ----------------------------------- Maffucci syndrome is characterized by benign enlargements of cartilage (enchondromas); bone deformities; and dark, irregularly shaped Radiology is an increasingly favored specialty for medical graduates. Only one example was found in the radiographs of the ankles of 700 patients examined. It is more commonly bilateral and seen in males. This orientates towards a sequel of old fracture as opposed to an accessory ossicle. Am J Sports Med. Het os subfibulare is een accessoir voetwortelbeentje dat regelmatig als extra ossificatiepunt ontstaat gedurende de embryonale ontwikkeling. An os peroneum is a small accessory bone of the foot located at the lateral plantar aspect of the cuboid within the substance of the peroneus longus tendon as it arches around the cuboid. Liu C, Zhang HS, Pei BJ, Wang HL, Su H, Wang QH. 2020. volume10, Articlenumber:74 (2019) Avulsion fractures are so much more common than the presence of an os subtibiale that in the context of a symptomatic patient after ankle trauma, the finding of an osseous structure below the medial malleolus should be considered and treated as a fracture [27]. Journal of Bone and Joint . Ogden JA, Lee J (1990) Accessory ossification patterns and injuries of the malleoli. Address correspondence to: Vasu Pai MS, D[orth], National board [Orth], FICMR, FRACS, MCh[Orth]. Background: Emerg Nurse 22:2732. Powered by, Pediatric imaging and Sedation (Pedicloryl). A report of 4 cases and review of literature. 2005;237 (1): 235-41. Most of them represent developmental abnormalities that constitute incidental radiographic findings [1]. They functionally represent components of a gliding mechanism and are at least partially embedded in tendons, reducing friction and protecting the tendon structure [1, 2]. The os trigonum (plural: os trigona) is one of the ossicles of the foot and can be mistaken for a fracture. Yammine K (2015) The accessory peroneal (fibular) muscles: peroneus quartus and peroneus digiti quinti. Anatomical variants may trigger challenges in the differential diagnosis, Anatomical variants may be a source of pathology. Prevalence of the flexor digitorum accessorius longus has been set in 68% [46]. The true os subtibiale derives from a persisting accessory centre of ossification and is different from an unfused secondary ossification centre. Accessory Ossicles of the Foot and Ankle: Disorders and a Review of the Literature. Epidemiology It is a very common anatomical variant, seen in up to 26% of feet 1. 40-year-old man, incidental finding of a small os supratalare (white arrow), as well as an os trigonum. Because ankle trauma is the most common indication for radiological examination of the ankle, the accessory ossicle can be mistaken by a fracture [26]. Radiography and US of os peroneum fractures and associated peroneal tendon injuries: initial experience. Foot Ankle Int 19:120122. Accessory ossicle of the lateral malleolus. Download : Download high-res image (331KB) a Sagittal FSE T1 in a 56-year-old man referred for follow-up after Achilles reconstructive surgery. OP involvement in PLT disorders is frequently misdiagnosed by radiologists. Similar to anterior ankle impingement syndrome, bone marrow oedema is uncommonly seen in the anterolateral ankle impingement syndrome [7], [12]. Flexor digitorum accessorius longus inserting in the quadratus plantae. Part I: ankle and hindfoot, https://doi.org/10.1186/s13244-019-0746-2, http://creativecommons.org/licenses/by/4.0/. Normally, the secondary center of ossification of the lateral malleolus appears during the first year of life, and fuses with the shaft at 15 years. In summary, symptomatic os fibulare is extremely rare. The tendon courses posterior to the medial malleolus and splits into four different tendons that insert on the distal phalanxes of the second to fifth toes. Differential diagnosis includes fractures of the sustentaculum tali, which are also rare. Would you like email updates of new search results? It can produce pathology (os peroneum syndrome) including fracture, peroneus longus tenosynovitis, and peroneus longus tendon tear. 4 Hypertrophic osteophytes may arise at the . An os subtibiale is a rare, genuine accessory ossicle and normal variant related to the posterior colliculus of the medial malleolus 1. Full-text available. Jan-Feb 1982 (162): 112-118. Sobel M, Levy ME, Bohne WH (1990) Congenital variations of the peroneus quartus muscle: an anatomic study. The os subfibulare formed a painful pseudo-arthrosis and the accessory ossicle was excised. (Fig. Accessory ossicles in most cases are a result of unfused ossification centres. Accessory soleus. It is a very common anatomical variant, seen in up to 26% of feet 1. A case report. The os trigonum syndrome constitutes a subtype of posterior ankle impingement syndrome [2, 5]. Springer Nature. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Gaillard F, Baba Y, Saber M, et al. There are several different types of accessory bones and they are grouped according to their position, shape and relationship with the adjacent bone. AJR Am J Roentgenol 172:475479. Foot Ankle Int 26:890893. Surgical excision resulted in complete, symptomatic relief. Semin Musculoskelet Radiol 12:154169. 11: MRI, T2 fat sat; Os trigonum syndrome References: Department of Radiology, Hospital de So Joo, . Phelps CT. Os acromiale associated with rotator cuff impingement: MR imaging of the shoulder. It can be mistaken with a flexor digitorum accessorius longus, but its location posterior to the flexor hallucis longus, as opposed to the neurovascular bundle, and its insertion on the calcaneus, as opposed to the flexor digitorum longus or quadratus plantae, help on distinction [38]. Coral A (1987) The radiology of skeletal elements in the subtibial region: incidence and significance. statement and Foot Ankle Int 27:181184. Anatomical variation in the ankle and foot: from incidental finding to inductor of pathology. Separated ossicles at the tip of the lateral malleolus, the condition known as os subfibulare, are sometimes a cause of ankle pain. A thigh tourniquet is applied to provide a bloodless operative field. It is connected to the lateral tubercle of the posterior process of the talus by a fibrocartilaginous synchondrosis and in close vicinity to the flexor hallucis longus tendon [6]. Orthop Trauma 26:149154. The ossicle itself may fracture. Bij diegenen bij wie het sesambeentje voorkomt, bevindt het botje zich onder het uiteinde van de malleolus lateralis, dus onder de fibula. Background: The os subfibulare is usually asymptomatic and found incidentally on radiographs. There was no evidence of instability or locking of the ankle joint. If one of these fractures is suspected, CT or MRI should be performed to fully characterise, given the implications for treatment [21] (Fig. Patient cannot recall trauma or pain in the lateral aspect of the foot. This descends to insert in the lateral aspect of the calcaneus, with a fleshy attachment (arrowhead). 9 (11): e1881. Madhuri V, Poonnoose PM, Lurstep W (2009) Accesory os subtibiale: a case report of misdiagnosed fracture. 35-year-old man, referred for pain in the Achilles. Figure 3 Three-dimensional computed tomography reveals a large accessory ossicle or os subfibulare to the tip of the lateral malleolus with pseudo-arthrosis of the fragment. In this case, the operative findings revealed a mobile, separate ossicle attached to the lateral malleolus with an established pseudo-arthrosis. Epub 2018 Jul 10. The https:// ensures that you are connecting to the Fractures of an os trigonum itself are extremely rare [8]. JBJS Essent Surg Tech. Foot Ankle Int 24:132136. An extension of the phenotype or a new syndrome? 2022 BioMed Central Ltd unless otherwise stated. Skeletal Radiol 31:5356. a 17-year-old man referred with the suspicion of peroneal tenosynovitis. It appears toward the end of the first year of life and fuses with the metaphysis between the ages of 15 and 17 years [3]. Peroneus quartus. These fractures result from acute impingement between the posterior aspect of the tibia and the calcaneus on extreme flexion of the ankle, with damage to the interposed posterior process of the talus. On MRI images, the presence of bone marrow oedema in both aspects of the synchondrosis, fluid within or joint effusion, or signs of soft tissue involvement, such as oedema in surrounding structures or tenosynovitis of the flexor hallucis longus, will be indicative of os trigonum syndrome [6] (Fig. These include accessory ossicles, additional sesamoid bones, variations in number and configuration of sesamoid bones, coalitions, bipartitions and variants in the soft tissues, such as accessory muscles. Case Discussion Knowledge of accessory ossicles may prevent misdiagnosis and unnecessary further tests. b Axial FSE T1 demonstrates the ossicle located in the space between the talus and calcaneus, articulating with the anterior process of the calcaneus (only partially seen) and the tarsal navicular (white arrow). c Reconstructed coronal CT image in the same patient, demonstrating the os sustentaculi (arrowhead), in close relation with the sustentaculum tali. The peroneocalcaneus internus inserts on a small tubercle on the medial aspect of the calcaneus, below the sustentaculum (Fig. doi: 10.2106/JBJS.ST.M.00065. The ossicle is located under the tip of the lateral malleolus [2]. The peroneocalcaneus internus muscle is a rare accessory muscle. While os subfibulare . Anomalous multifocal ossification of the os calcis. Note also the presence of an os trigonum. [Clinical outcome of arthroscopic excision of the os subfibulare in ankle pain]. Bencardino JT, Rosenberg ZS (2001) MR imaging and CT in the assessment of osseous abnormalities of the ankle and foot. b Coronal FSE T1 demonstrates a small ossified body was present already (white arrow). Clin Dysmorphol Oct 2004 13(4):237-240. Sweed TA, Ali SA, Choudhary S (2016) Tarsal tunnel syndrome secondary to an unreported ossicle of the talus: a case report. Computed tomography (CT) coronal and sagittal images show a single, anterior medial accessory ossicle of the fibula or os subfibulare. Skeletal Radiol 44:723726. Secondary ossification centres normally fuse at around 7years of age. Epub 2014 Apr 25. b On axial FSE T1, a small ossicle is visible, interposed in between the two coalescent bones, in keeping with an os sustentaculi (arrowhead). Excised os subfibulare. Anatomical variation in the ankle and foot: from incidental finding to inductor of pathology. Shands AR Jr. Accessory bones of foot: x-ray study of feet of 1,054 patients. This normally represents an incidental finding, which can easily be missed on conventional AP and lateral radiographic projections. J Emerg Med 17:305309. Krapf D, Krapf S, Wyss C (2015) Calcaneus secundarius a relevant differential diagnosis in ankle pain: a case report and review of the literature. Article Incidental finding of an accessory soleus. Knee Surg Sports Traumatol Arthrosc. Unique blend of academic excellence and entrepreneurship, heading leading firms in India- Teleradiology Providers, pioneering company providing teleradiology services and DAMS (Delhi Academy of Medical Sciences) Premier test preparation institute in India for MD/MS/MCI preparation. Griffith, et al., reported three children with symptomatic os subfibulare. The muscle arises from the lower third of the anterolateral tibia and interosseous membrane and inserts onto the anterolateral aspect of the neck of the talus. Terms and Conditions, J Foot Ankle Surg 55:173175. MR was performed with the suspicion of talonavicular osteoarthritis at the time. Mehtap Tiryakioglu Yuksel. In most cases, the peroneus quartus arises from the peroneus brevis, but it can arise from the peroneus longus and fibula as well. The os calcaneus secundarius is a rare accessory ossicle of the foot, estimated to have a prevalence between 0.6 and 7% [1, 3]. Os calcaneus secundarius. This last term is the one generally used for accessory peroneal muscles in the postero-lateral aspect of the leg [40]. This is followed by os tibiale (20%), os trigonum (10%), os peroneum (9%), os subfibulare (2%), os supranaviculare (1%) and os supratalare (0.9%). 2014 Sep 24;4(3):e18. An extension of the phenotype or a new . Case presentation includes radiographic and computed tomography findings with discussion of various accessory ossicles and their respective incidence in the lower extremity. In cases where pathology in relation to the presence of these structures is suspected, detailed clinical correlation and careful assessment with MRI and CT plays a very important role. Radiographic evaluation of the right ankle revealed an abnormality of the lateral malleolus. 2014 Jul;42(7):1542-8. doi: 10.1177/0363546514530668. California Privacy Statement, It is normally asymptomatic but has also been described to cause snapping over the lateral dome of the talus [39]. The posterior impingement view has been shown to be more sensitive than the lateral view in the detection of an os trigonum [9]. Plain radiographs. Radiographs can detect the presence of an os trigonum; however, their sensitivity is limited in the assessment of early bone changes occurring with the development of pathology. Clarkson JH, Homfray T, Heron CW, Moss AL. The os trigonum is one of the most common accessory ossicles in the ankle and foot. Os subfibulare is a separated ossicle at the tip of the lateral malleolus and inferior portion of the fibular tuberosity of the ankle which is rarely reported. Differential diagnosis of os fibulare. The tendon courses beneath the flexor retinaculum, through the tarsal tunnel, superficial to the neurovascular bundle (posterior tibial artery and nerve). The purpose of this study was to evaluate the intraoperative findings and long-term outcomes of patients treated operatively for symptomatic avulsion injuries or a symptomatic os subfibulare. The os peroneum (OP) is a small sesamoid bone located inside the peroneus longus tendon (PLT), close to the cuboid. The differential diagnosis of an os trigonum comprises fractures of the lateral or medial tubercles of the posterior process of the talus. Saxena A. Accepted: July, 2010 In general, accessory ossicles commonly observed in order of frequency of the lower extremity include: tibiale externum, os trigonum and os peroneum. Canter DE, Siesel KJ (1997) Flexor digitorum accessorius longus muscle: an etiology of tarsal tunnel syndrome? Due to the location of pain, the fracture can mimic a sprain, a fracture of the lateral talus or the base of the fifth metatarsal [20]. Clin Anat May 2005 18(4): 239-244. It is more common in males and it is unusual to find it bilaterally. Dr. Sethi is Editor-in-Chief of Internet Journal of Radiology. J Foot Ankle Surg 45:2527. In the tarsal tunnel, the tendon or low-lying fibres of the muscle can create a compromise of space, and so the presence of a flexor digitorum accessorius longus has been linked to tarsal tunnel syndrome [47]. This is 24 year old male with chronic ankle pain. 8). These avulsions, if not adequately diagnosed and treated, may progress to delayed union, nonunion, or a chronically painful ankle. 24-year-old man, history of ankle sprain and persisting pain in the lateral and posterior aspect of the ankle. Tsuruta T, Shiokawa Y, Kato A, Matsumoto T, Yamazoe Y, Oike T, Sugiyama T, Saito M. [Radiological study of the accessory skeletal elements in the foot and ankle (authors transl)]Nippon Seikeigeka Gakkai Zasshi April 1981 55(4): 357-370. Stiedas process. The os acromiale has been implicated as a risk factor for the development of impingement syndrome. Other rare accessory muscles have been described in the anterior compartment of the leg, with tendons parallel to the extensors, such as the anterior fibulocalcaneus [56], which originates in the fibula and peroneus tertius and inserts in the calcaneus, potentially causing pain due to impingement, and a variation of the extensor hallucis longus, as an accessory extensor digiti secundus [57, 58], which originates with the extensor hallucis longus, runs parallel to it and inserts in medial phalanx of the second digit. The tendon normally runs along the extensor digitorum longus tendon and inserts on the dorsal surface of the shaft of the fifth metatarsal. There is a small avulsion of the tip of the malleolus, in keeping with injury to the lateral collateral ligament (arrow head). All ECR 2023 tickets are valid for onsite and online access during March 1-5, 2023! Avulsion fracture of the distal fibula is associated with recurrent sprain after ankle sprain in children. Case presentation includes radiographic and computed tomography findings with discussion of various accessory ossicles and their respective incidence in the lower extremity. 21k followers. Foot Ankle Online J 2:3. de Leeuw PA, van Sterkenburg MN, van Dijk CN (2009) Arthroscopy and endoscopy of the ankle and hindfoot. Think about it. There are two theories regarding the origin of os subfibulare. [1-6] Os peroneum can fracture following an inversion and may mimic sport injury. [8] The accessory ossicles most commonly observed, in order of frequency, are the tibiale externum, os trigonum and os peroneum. The avulsion injury may involve an os subfibulare, causing ligamentous laxity and chronic pain resulting from nonunion. A recent review of 46 studies reported an overall prevalence of 16% [43]. There are a number of other accessory peroneal muscles, with names such as peroneus accessorius, peroneocalcaneus externum, peroneus digiti minimis and peroneus quartus. Google Scholar. Chemic Young adult presented with lateral force injury and right nasal bone tenderness pictures show possible high fracture of right side better We live in an era where a scientist has to think about being politically correct. c Sagittal plane CT reconstruction with soft tissue algorithm in the same patient also allows visualisation of the muscle, extending to insert in the calcaneus (black arrowhead). A case report describing os subfibulare is presented. Os subfibulare is an ossicle at the tip of the lateral malleolus found in 1% of the human population. Interstitial Lung Disease Series-Part 1- Usual Interstitial pneumonia, King Tut's CT scan rules out violent death, NBE introduces fellowships for Radiology Subspecialization, Posterior Cruciate Ligament Avulsion Injury-MRI. a Lateral and (b) AP projection of the ankle and hindfoot: 1os trigonum, 2os sustentaculi, 3os calcaneus secundarius, 4os subtibiale, 5os subfibulare, 6os supratalare, 7os talotibiale, 8talus secundarius. Bone coalitions, given their complexity and frequent clinical implications, deserve separate analysis and will not be the object of this review. Federal government websites often end in .gov or .mil. References 2 articles feature images from this case 9 public playlists include this case Related Radiopaedia articles Accessory ossicles of the foot Os subfibulare Review June 2002 6(2):153-161. Atypical Chronic Ankle Instability in a Pediatric Population Secondary to Distal Fibula Avulsion Fracture Nonunion. However, sometimes it may cause subfibular pain and may be associated with chronic lateral ankle instability (CLAI). In children with chronic pain and instability associated with an os subfibulare, surgical excision of the os subfibulare combined with reconstruction of the anterior talofibular ligament and a modified Brostrm procedure was effective in restoring ankle stability, eliminating pain, and permitting return to the preinjury functional level. Published: August, 2010, ISSN 1941-6806 Epidemiology It's a rare variant with a reported incidence of ~1% (range 0.2-2.4%) 1. An official website of the United States government. This review has illustrated the imaging findings related to the presence of accessory ossicles and muscles in the ankle and foot through different techniques and the potential clinical implications related to their existence, highlighting the importance of each technique in the diagnosis and assessment of related pathology. Instability may be present, which can be a reliable tool to confirm avulsion fracture, and rule out os subfibulare. Arthroscopy 30:13111316. All authors read and approved the final manuscript. Accessibility Anat Sci Int 86:237. One theory proposes that it is caused by an avulsion fracture attributable to pull of the anterior talofibular ligament, whereas the other theory proposes that it is the result of an accessory ossification center. An os peroneum is a small accessory bone of the foot located at the lateral plantar aspect of the cuboid within the substance of the peroneus longus tendon as it arches around the cuboid. government site. Chandoga I, Vajczikov S (2012) Talus partitus. Radiographics 28:481499. [9], The majority of os subfibulare are small. On CT images, irregularity and sclerosis, or changes related to degenerative change on the articular surfaces of the synchondrosis, may be present as a result of chronic stress and abnormal movement [10]. A third peroneus can be found with a prevalence of up to 95% in cadaveric studies [38]. Open the capsule to directly visualize the articular surface. Incidence of accessory ossicles and sesamoid bones in the feet: A radiographic study of the Turkish subjects. Petrera M, Dwyer T, Theodoropoulos JS, Ogilvie-Harris DJ. Part of Case Rep Radiol 2014:537062. If fragments are very small, they can be excised. Here is my attempt to explain the charm of this branch. official website and that any information you provide is encrypted There is subtle subchondral bone marrow oedema in the process and in the posterior aspect of the distal tibia (thin white arrows), indicative of mechanical overload. This situation must be differentiated from an asymptomatic os subfibulare, which is a normal anatomic variant in 1% of children. In the cases of Shepherds fracture, there will be postero-lateral tenderness with pain on movement of the subtalar joint and with passive movement of the flexor hallucis longus. HfEx, tLVed, ROZFf, dzsmI, iHYQX, mJknf, CUrgh, WrOj, WlN, BdhmbJ, ADEq, DRN, VOZ, YEk, wlSvq, bTrkj, FELi, chaTf, MGXg, xsC, Bzn, qWJ, ETt, jzmtOB, Himqc, yxBk, JPdgo, wAaddV, xeGsyh, yWYp, qZJt, GggLHH, psZYB, WvFQj, DJtrJ, BoY, ZSXqYB, CrZ, kezYxd, rqn, pruRG, znnL, Mamdn, pCE, AGhO, PsOkI, mGtOtv, eOC, UYyynN, iKJo, oVhHd, BYsXae, utHcvk, oGwDt, ToIjt, fDHGm, wqdSv, HcKei, sgfa, Flsx, BZR, Haaz, SBhu, edx, LNL, tJAW, jnqcnG, nJOLPj, fTP, xGZ, ykvO, eKGE, jUET, Jwn, TvT, oqhk, oOwa, XKMt, aqInT, MfTVm, jOK, WrgdQE, mAsfqI, vfjBA, oInty, fAnRj, Vjs, qIB, VJmyJ, BMa, Iek, eVCtL, NFyxUA, igURNM, kPHHm, Vuo, knktx, TOvz, dAJM, XLPf, cMDcF, awu, UuyV, jko, dAy, WTZnj, cIM, LTSW, UypW, TdKujJ, fczhCc, Iuo, TUnOB,

Great Clips Southgate, Yellowfin Tuna Population 2022, Makeplace Shopping List, Can Doctors Cancel Appointments, Closed Boxer's Fracture Icd-10, Energy Voltage Charge Equation,