However, if you have fractured several metatarsals at the same time and your foot is deformed or unstable, you may need surgery. Adjuvant imaging techniques to analyze fracture geometry and plan implant placement, will be discussed in detail. The reduced fracture is splinted with buddy taping. Foot phalanges. Copyright 2023 Lineage Medical, Inc. All rights reserved. When this happens, surgery is often required. Examination of the metatarsals should include palpation of the metatarsal base, shaft, and head, as well as examination of the proximal tarsometatarsal and distal metatarsophalangeal joints. If the bone is out of place, your toe will appear deformed. . Healing rates also vary considerably depending on the age of the patient and comorbidities. If the wound communicates with the fracture site, the patient should be referred. A fracture, or break, in any of these bones can be painful and impact how your foot functions. The patient notes worsening pain at the toe-off phase of gait. What is the optimal treatment for the proximal phalanx fracture shown in Figure A? Patients should limit icing to 20 minutes per hour so that soft tissues will not be injured. The proximal phalanx is the phalanx (toe bone) closest to the leg. The proximal fragment flexes due to interossei, and the distal phalanx extends due to the central slip. Copyright 2023 Lineage Medical, Inc. All rights reserved. Stress fractures are small cracks in the surface of the bone that may extend and become larger over time. The distal phalanx and proximal phalanx connect via the interphalangeal (IP) joint, which allows you to bend the tip of your thumb. While many Phalangeal fractures can be treated non-operatively, some do require surgery. X-rays. Recent studies have demonstrated that musculoskeletal ultrasonography and traditional radiography have comparable accuracy, sensitivity, and specificity in the diagnosis of foot and ankle fractures9,10 (Figure 1). In most cases, a fracture will heal with rest and a change in activities. Open reduction and placement of two 0.045-inch K-wires placed longitudinally through the metacarpal head, Application of a 1.5-mm straight plate applied dorsally through and extensor tendon splitting approach, Open reduction and lag screw fixation with 1.3mm screws through a radial approach, Placement of a 1.5-mm condylar blade plate through a radial approach, Open reduction and retrograde passage of two 0.045-inch K-wires retrograde trough the PIP joint. 2 ). MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. Patients typically present with varying signs and symptoms, the most common being pain and trouble with ambulation. Patients with these fractures should be referred to an orthopedist.2,3,6, The fifth metatarsal has the least cortical thickness of all the metatarsals.13 There are multiple strong ligamentous and capsular attachments surrounding the proximal fifth metatarsal; these allow stresses to be directed through this portion of the bone.13 Classically, fractures of the proximal fifth metatarsal can be classified based on anatomic location into one or more of three zones (Figure 7).3. Epidemiology Incidence See permissionsforcopyrightquestions and/or permission requests. Radiographic evaluation is dependent on the toe affected; a complete foot series is not always necessary unless the patient has diffuse pain and tenderness. Your video is converting and might take a while Feel free to come back later to check on it. Mounts, J., et al., Most frequently missed fractures in the emergency department. Fractures can affect: Causes of lesser toe (phalangeal) fractures Trauma (generally something heavy landing on the toe or kicking an immovable object) Treatment of lesser toe (phalangeal) fractures Non-displaced fractures Epidemiology Incidence These rules have been validated in adults and children.16 If radiography is indicated, a standard foot series with anteroposterior, lateral, and oblique views is sufficient to make the diagnosis. A 19-year-old cross country runner complains of 3 months of foot pain with running. (OBQ05.226) Note that the volar plate (VP) attachment is involved in the . The middle phalanx (P2) is dislocated or subluxated dorsally, and the volar lip is fractured at its base. Based on the radiographs shown in Figure A, what is the most appropriate next step in treatment? Referral is indicated for patients with first metatarsal fractures with any displacement or angulation. For several days, it may be painful to bear weight on your injured toe. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS Find an Orthopaedist program on this website. Great toe fractures are generally treated with a short leg walking cast with a toe plate (Figure 1311 ) that extends past the great toe or with a short leg walking boot for two to three weeks.6 After this time, and in the absence of significant symptoms, the patient can progress to buddy taping and use of a rigid-sole shoe for three to four weeks.6,23,24 Range-of-motion exercises can generally be initiated at four weeks. Even if the fragments remain nondisplaced, significant degenerative joint disease may develop.4. There is evidence that transitioning to a walking boot and then to a rigid-sole shoe (Figure 6) at four to six weeks, with progressive weight bearing as tolerated, results in improved functional outcomes compared with cast immobilization, with no differences in healing time or pain scores.12, Follow-up visits should occur every two to four weeks, with repeat radiography at four to six weeks to document healing.3,6 At six weeks, callus formation on radiography and lack of point tenderness generally signify adequate healing, after which immobilization can be discontinued.2,3,6. Ulnar side of hand. If an acute subungual hematoma is present (less than 24 hours old), decompression may relieve pain substantially. Treatment for a toe or forefoot fracture depends on: Even though toes are small, injuries to the toes can often be quite painful. abductor, interosseous and adductor linked with proximal phalanx may aggravate fracture of the toe bones if these muscles get sudden pull. Fractures can result from a direct blow to the foot such as accidentally kicking something hard or dropping a heavy object on your toes. Stress fractures have a more insidious onset and may not be visible on radiographs for the first two to four weeks after the injury. A fracture may also result if you accidentally hit the side of your foot on a piece of furniture on the ground and your toes are twisted or pulled sideways or in an awkward direction. Immobilization of the distal interphalangeal joint is required for 2 weeks post-operatively, High rates of post-operative infection are common, Open reduction via an approach through the nail bed leads to significant post-operative nail deformity, Range of motion of the DIP joint in the affected finger is usually less than 10 degrees post-operatively, Type in at least one full word to see suggestions list, Management of Proximal Phalanx Fractures & Their Complications, Middle Finger, Proximal Phalangeal Head - Bicondylar Fracture - Fixation, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, PIP Fracture & Dislocation: Case of the Week - Shaan Patel, MD, Ring Finger Proximal Phalanx Fracture in 16M, Fracture of the base of proximal phalanx of 5th finger. Objective Evidence Joint hyperextension, a less common mechanism, may cause spiral or avulsion fractures. If a fracture is present, it will typically be one of two types: a tuberosity avulsion fracture or a Jones fracture (i.e., proximal fifth metatarsal metadiaphyseal fracture). Ulnar gutter splint/cast. Treatment Most broken toes can be treated without surgery. A 26-year-old professional ballet dancer presents with insidious onset of right midfoot pain which began 6 months ago. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx ( Figure 2). (OBQ05.209) Data Sources: We searched the Cochrane database, Essential Evidence Plus, and PubMed from 1900 to the present, human studies only, using the key words foot fractures, metatarsal, toe, and phalanges fractures. most common injuries to the skeletal system, distal phalanx > middle phalanx > proximal phalanx, 40-69 years old - machinery is most common, assess for numbness indicating digital nerve injury, assess for digital artery injury via doppler, proximal fragment pulled into flexion by interossei, distal fragment pulled into extension by central slip, apex volar angulation if distal to FDS insertion, apex dorsal angulation if proximal to FDS insertion, diagnosis confirmed by history, physical exam, and radiographs, type III - unstable bicondylar or comminuted, proximal fragment in flexion (due to interossei), distal fragment in extension (due to central slip), extraarticular fractures with < 10 angulation or < 2mm shortening and no rotational deformity, 3 weeks of immobilization followed by aggressive motion, extraarticular fractures with > 10 angulation or > 2mm shortening or rotational deformity, Unstable patterns include spiral, oblique, fracture with severe comminution, Eaton-Belsky pinning through metacarpal head, minifragment fixation with plate and/or lag screws, lag screws alone indicated in presence of long oblique fracture, proximal fragment in flexion (due to FDS), distal fragment in extension (due to terminal tendon), due to inherent stability provided by an intact and prolonged FDS insertion, proximal fragment in extension (due to central slip), results from hyperextension injury or axial loading, unstable if > 40% articular surface involved, represents avulsion of collateral ligaments, usually stable due to nail plate dorsally and pulp volarly, often associated with laceration of nail matrix or pulp, shearing due to axial load, leading to fracture involving > 20% of articular surface, avulsion due tensile force of terminal tendon or FDP, leading to small avulsion fracture, terminal tendon attaches to proximal epiphyseal fragment, nail matrix may be incarcerated in fracture and block reduction, distal phalanx fractures with nailbed injury, dorsal base fractures with > 25% articular involvement, displaced volar base fractures with large fragment and involvement of FDP, predisposing factors include prolonged immobilization, associated joint injury, and extensive surgical dissection, treat with rehab and surgical release as a last resort, Apex volar angulation effectively shortens extensor tendon and limits extension of PIPJ, surgery indicated when associated with functional impairment, corrective osteotomy at malunion site (preferred), metacarpal osteotomy (limited degree of correction), most are atrophic and associated with bone loss or neurovascular compromise, Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease). There is typically swelling, ecchymosis, and point tenderness to palpation at the fracture site. and S. Hacking, Evaluation and management of toe fractures. Surgical fixation involves Kirchner wires or very small screws. A 34-year-old male sustains the closed finger injury shown in Figure A one week ago. 118(2): p. e273-8. A stress fracture, however, may start as a tiny crack in the bone and may not be visible on a first X-ray. Examination reveals a well-aligned foot with ecchymosis and swelling on the plantar aspect of the 1st MTP joint. Physical examination reveals marked tenderness to palpation. Toe fractures most frequently are caused by a crushing injury or axial force such as stubbing a toe. Hallux fractures. A common complication of toe fractures is persistent pain and a decreased tolerance for activity. Taping your broken toe to an adjacent toe can also sometimes help relieve pain. Proximal fifth metatarsal fractures have different treatments depending on the location of the fracture. Tang, Pediatric foot fractures: evaluation and treatment. Indications for referral of patients with first metatarsal fractures are different because the first metatarsal has a vital role in weight bearing and arch support. See permissionsforcopyrightquestions and/or permission requests. MB BULLETS Step 1 For 1st and 2nd Year Med Students. Fractures of the lesser toes are four times as common as fractures of the first toe.3 Most toe fractures are nondisplaced or minimally displaced. While celebrating the historic victory, he noticed his finger was deformed and painful. Other symptoms may include: If you think you have a fracture, it is important to see your doctor as soon as possible. Common presenting symptoms include bruising, swelling, and throbbing pain that worsens with a dependent position, although this type of pain also may occur with an isolated subungual hematoma. Proximal articular. They most often involve the metatarsals and toes. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. Patients with displaced fractures of the first toe often require referral for stabilization of the reduction. If the reduction is unstable (i.e., the position is not maintained after traction is released), splinting should not be used to hold the reduction, and referral is indicated. Although tendon injuries may accompany a toe fracture, they are uncommon. Rotator Cuff and Shoulder Conditioning Program. Patients should be instructed to apply ice, elevate the foot above heart level, and use analgesics as needed. laceration bone talks, extensor tendon injuries hand orthobullets, flexor and extensor tendon injuries phoenix az arizona, tendon lacerations twin boro physical therapy, repair and rehabilitation of extensor hallucis longus and, extensor mechanism injury hip amp knee book, A standard foot series with anteroposterior, lateral, and oblique views is sufficient to diagnose most metatarsal shaft fractures, although diagnostic accuracy depends on fracture subtlety and location.7,8 However, musculoskeletal ultrasonography can provide a quick bedside assessment without radiation exposure that accurately assesses overt and subtle nondisplaced fractures. Physical examination should include assessment of capillary refill; delayed capillary refill may indicate circulatory compromise. If stable, the patient can be transitioned to a short leg walking cast or boot3,6 (Figures 411 and 5). Lightly wrap your foot in a soft compressive dressing. Bicondylar proximal phalanx fractures usually are treated with plate fixation. 2012 Oct; 43 ( 10 ): 1626-32. doi: 10.1016/j.injury.2012.03.010. RESULTS: Stable fractures can be successfully treated nonoperatively, whereas unstable injuries benefit from surgery. Because it is the longest of the toe bones, it is the most likely to fracture. (OBQ12.89) Am Fam Physician, 2003. All Rights Reserved. The next bone is called the proximal phalanx. Open fractures, Infection, Compartment syndrome 3; References, Classification, Courses 3; Distal articular. protected weightbearing with crutches, with slow return to running. Your foot may become swollen and discolored after a fracture. This procedure is most often done in the doctor's office. Jones fractures are located in a watershed area for blood supply (zones 2 and 3) and have high rates of delayed union and nonunion17 (Figure 10). Foot Ankle Int, 2015. We help you diagnose your Hand Proximal phalanx case and provide detailed descriptions of how to manage this and hundreds of other pathologies. He states he has a 30-year-old lumberjack who earlier today was playing softball in the county championship when he slid into home plate in the bottom of the 9th inning. This webinar will address key principles in the assessment and management of phalangeal fractures. angel academy current affairs pdf . Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. The proximal phalanx is the toe bone that is closest to the metatarsals. This content is owned by the AAFP. 5th metatarsal most commonly fractured in adults, 1st metatarsal most commonly fractured in children less than 4 years old, 3rd metatarsal fractures rarely occur in isolation, 68% associated with fracture of 2nd or 4th metatarsal, peak incidence between 2nd and 5th decade of life, may have significant associated soft tissue injury, occurs with forefoot fixed and hindfoot or leg rotating, Lisfranc equivalent injuries seen with multiple proximal metatarsal fractures, consider metabolic evaluation for fragility fracture, shape and function similar to metacarpals of the hand, first metatarsal has plantar crista that articulates with sesamoids, muscular balance between extrinsic and intrinsic muscles, Metatarsals have dense proximal and distal ligamentous attachments, 2nd-5th metatarsal have distal intermetatarsal ligaments that maintain length and alignment with isolated fractures, implicated in formation of interdigital (Morton's) neuromas, multiple metatarsal fractures lose the stability of intermetatarsal ligaments leading to increased displacement, Classification of metatarsal fractures is descriptive and should include, look for antecedent pain when suspicious for stress fracture, foot alignment (neutral, cavovarus, planovalgus), focal areas or diffuse areas of tenderness, careful soft tissue evaluation with crush or high-energy injuries, evaluate for overlapping or malrotation with motion, semmes weinstein monofilament testing if suspicious for peripheral neuropathy, AP, lateral and oblique views of the foot, may be of use in periarticular injuries or to rule out Lisfranc injury, useful in detection of occult or stress fractures, second through fourth (central) metatarsals, non-displaced or minimally displaced fractures, evaluate for cavovarus foot with recurrent stress fractures, sagittal plane deformity more than 10 degrees, restore alignment to allow for normal force transmission across metatarsal heads, lag screws or mini fragment plates in length unstable fracture patterns, maintain proper length to minimize risk of transfer metatarsalgia, limited information available in literature, may lead to transfer metatarsalgia or plantar keratosis, treat with osteotomy to correct deformity, Majority of isolated metatarsal fractures heal with conservative management, Malunion may lead to transfer metatarsalgia, Posterior Tibial Tendon Insufficiency (PTTI). hand fractures orthoinfo aaos metatarsal fractures foot ankle orthobullets phalanx fractures hand orthobullets fractures of the fifth metatarsal physio co uk 5th metatarsal . Radiographs often are required to distinguish these injuries from toe fractures. There is typically focal tenderness, swelling, and ecchymosis at the base of the fifth metatarsal. Examination should consist of a neurovascular evaluation and palpation of the foot and ankle. Radiographs are shown in Figure A. However, return to work and sport can generally take six to eight weeks depending on activity level; some high-level athletes may require more time.6, Initial management of lesser toe fractures (Figure 14) includes buddy taping to an adjacent toe, use of a rigid-sole shoe, and ambulation as tolerated. Your doctor will tell you when it is safe to resume activities and return to sports. Salter-Harris type II fractures of the proximal phalanx are the most common type of finger fracture. Bony deformity is often subtle or absent. Posterior splint; nonweight bearing; follow-up in three to five days, Short leg walking cast with toe plate or boot for six weeks; follow-up every two to four weeks; healing time of six weeks, Repeat radiography at one week and again at four to six weeks, Open fractures; fracture-dislocations; intra-articular fractures; fractures with displacement or angulation, Short leg walking boot or cast for six weeks; follow-up every two to four weeks; healing time of six weeks, Repeat radiography at one week and again at four to eight weeks, Open fractures; fracture-dislocations; multiple metatarsal fractures; displacement > 3 to 4 mm in the dorsoplantar plane; angulation > 10 in the dorsoplantar plane, Three-view foot series with attention to the oblique view, Compressive dressing; ambulate as tolerated; follow-up in four to seven days, Short leg walking boot for two weeks, with progressive mobility and range of motion as tolerated; follow-up every two to four weeks; healing time of four to eight weeks, Repeat radiography at six to eight weeks to document healing, Displacement > 3 mm; step-off > 1 to 2 mm on the cuboid articular surface; fracture fragment that includes > 60% of the metatarsal-cuboid joint surface, Short leg nonweight-bearing cast for six to eight weeks; cast removal and gradual weight bearing and activity if radiography shows healing at six to eight weeks, or continue immobilization for four more weeks if no evidence of healing; healing time of six to 12 weeks, Repeat radiography at one week for stability and at the six- to eight-week follow-up; if no healing at six to eight weeks, repeat radiography at the 10- to 12-week follow-up, Displacement > 2 mm; 12 weeks of conservative therapy ineffective with nonunion revealed on radiography; athletes or persons with high activity level, Three-view foot series or dedicated phalanx series, Short leg walking boot; ambulate as tolerated; follow-up in seven days, Short leg walking boot or cast with toe plate for two to three weeks, then may progress to rigid-sole shoe for additional three to four weeks; follow-up every two to four weeks; healing time of four to six weeks, Repeat radiography at one week if fracture is intra-articular or required reduction, Fracture-dislocations; displaced intra-articular fractures; nondisplaced intra-articular fractures involving > 25% of the joint; physis (growth plate) fractures, Buddy taping and rigid-sole shoe; ambulate as tolerated; follow-up in one to two weeks, Buddy taping and rigid-sole shoe for four to six weeks; follow-up every two to four weeks; healing time of four to six weeks, Displaced intra-articular fractures; angulation > 20 in dorsoplantar plane; angulation > 10 in the mediolateral plane; rotational deformity > 20; nondisplaced intra-articular fractures involving > 25% of the joint; physis fractures. In an analysis of 339 toe fractures, 95% involved less than 2 mm of displacement and all fractures were managed conservatively with good outcomes.25, The most common mechanisms of injury are axial loading (stubbing) or crush injury. Toe fractures of this type are rare unless there is an open injury or a high-force crushing or shearing injury. toe phalanx fracture orthobulletsdaniel casey ellie casey. If this maneuver produces sharp pain in a more proximal phalanx, it suggests a fracture in that phalanx. This usually occurs from an injury where the foot and ankle are twisted downward and inward. Non-narcotic analgesics usually provide adequate pain relief. This content is owned by the AAFP. Narcotic analgesics may be necessary in patients with first-toe fractures, multiple fractures, or fractures requiring reduction. Following reduction, the nail bed of the fractured toe should lie in the same plane as the nail bed of the corresponding toe on the opposite foot. Continue to learn and join meaningful clinical discussions . Diagnosis is made with plain radiographs of the foot. (Right) The bones in the angled toe have been manipulated (reduced) back into place. If no healing has occurred at six to eight weeks, avoidance of weight-bearing activity should continue for another four weeks.2,6,20 Typical length of immobilization is six to 10 weeks, and healing time is typically up to 12 weeks. Primary care physicians are often the first clinicians patients see for foot injuries, and fractures are among the most common foot injuries they evaluate.1 This article will highlight some common foot fractures that can be managed by primary care physicians. The first toe has only two phalanges; the second through the fifth toes generally have three, but the fifth toe sometimes can have only two (Figure 1). This joint sits between the proximal phalanx and a bone in the hand . Toe fractures are one of the most common fractures diagnosed by primary care physicians. At the conclusion of treatment, radiographs should be repeated to document healing. A fracture that is not treated can lead to chronic foot pain and arthritis and affect your ability to walk. It ossifies from one center that appears during the sixth month of intrauterine life. Physicians should consider referring patients with fractures of the great toe that have any degree of displacement, angulation, or rotational deformity 6,24 (Figure 12). 50(3): p. 183-6. Most fractures can be seen on a routine X-ray. Patients with intra-articular fractures are more likely to develop long-term complications. A fractured toe may become swollen, tender, and discolored. All Rights Reserved. They typically involve the medial base of the proximal phalanx and usually occur in athletes. Therefore, phalanges and digits adjacent to the fracture must be examined carefully; joint surfaces also must be examined for intra-articular fractures (Figure 3). Referral also should be considered for patients with other displaced first-toe fractures, unless the physician is comfortable with their management. The Ottawa Ankle and Foot Rules should be used to help determine whether radiography is needed when evaluating patients with suspected fractures of the proximal fifth metatarsal. An AP radiograph is shown in FIgure A. High-impact activities like running can lead to stress fractures in the metatarsals. Proximal interphalangeal joint (PIPJ) dislocation is one of the most common hand injuries. Although referral rarely is required for patients with fractures of the lesser toes, referral is recommended for patients with open fractures, fracture-dislocations (Figure 5), displaced intra-articular fractures, and fractures that are difficult to reduce. 21(1): p. 31-4. Most broken toes can be treated without surgery. Your next step in management should consist of: Percutaneous biopsy and referral to an orthopaedic oncologist, Walker boot application and evaluation for metabolic bone disease, Referral to an orthopaedic oncologist for limb salvage procedure, Internal fixation of the fracture and evaluation for metabolic bone disease, Metatarsal-cuneiform fusion of the Lisfranc joint. Follow-up visits should be scheduled every two weeks, and healing time varies from four to eight weeks.3,6 Follow-up radiography is typically required only at six to eight weeks to document healing, or earlier if the patient has persistent localized pain or continued painful ambulation at four weeks.2,3,6. The most common symptoms of a fracture are pain and swelling. 24(7): p. 466-7. Pediatr Emerg Care, 2008. Referral should be strongly considered for patients with nondisplaced intra-articular fractures involving more than 25 percent of the joint surface (Figure 4).4 These fractures may lose their position during follow-up. Smith, Epidemiology of lawn-mower-related injuries to children in the United States, 1990-2004. The distal phalanx is the most common location for a non-physeal injury which typically involves a crushing mechanism, and the most common location for physeal injury is the proximal phalanx. Toe and forefoot fractures often result from trauma or direct injury to the bone. Nail bed injury and neurovascular status should also be assessed. Referral is recommended for children with fractures involving the physis, except nondisplaced Salter-Harris type I and type II fractures (Figure 6).4. To control pain and swelling, patients should apply ice and elevate the affected foot for the first few days after the injury. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. FPnotebook.com is a rapid access, point-of-care medical reference for primary care and emergency clinicians. Healing time is typically four to six weeks. 2017 Oct 01;:1558944717735947. rest, NSAIDs, taping, stiff-sole shoe, or walking boot in the majority of cases. Differential Diagnosis The same mechanisms that produce toe fractures. Distal metaphyseal. Spiral fractures often lead to rotation or shortening, and transverse fractures lead to angulation.6. Follow-up radiographs may be taken three to six weeks after the injury, but they generally do not influence treatment and probably are not necessary in nondisplaced toe fractures. To minimize the possibility of future disability, the position of the bone fragments after reduction should be as close to anatomic as possible. Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. She is active in ballet and her pain is exacerbated with push-off and en pointe maneuvers. Copyright 2023 Lineage Medical, Inc. All rights reserved. Follow-up should occur within three to five days to allow for reduction of soft tissue swelling. Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. If you experience any pain, however, you should stop your activity and notify your doctor. He undergoes closed reduction and pinning shown in Figure B to correct alignment. Bite The Bullet, He Needs Long Term Function: Be The Hated Person - Robert Anderson, MD.

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