• Title/Summary/Keyword: orthopedic

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Reducing error rates in general nuclear medicine imaging to increase patient satisfaction (핵의학 일반영상 검사업무 오류개선 활동에 따른 환자 만족도)

  • Kim, Ho-Sung;Im, In-Chul;Park, Cheol-Woo;Lim, Jong-Duek;Kim, Sun-Geun;Lee, Jae-Seung
    • Journal of the Korean Society of Radiology
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    • v.5 no.5
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    • pp.295-302
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    • 2011
  • To n the field of nuclear medicine, with regard to checking regular patients, from the moment they register up to the doctor's diagnosis, the person in charge of the checks can find errors in the diagnosis, reexamine, reanalyze the results or save images to PACS. Through this process, the results obtained from the readings are delayed due to checks and additional tests which occur in hospitals, causing patient satisfaction and affected reliability. Accordingly, the purpose is to include visual inspection of the results to minimize error, improve efficiency and increase patient satisfaction. Nuclear medicine and imaging tests from examines at Asan Medical Center, Seoul, from March 2008 to December 2008, were analyzed for errors. The first stage, from January 2009 to December 2009, established procedures and know-how. The second stage from January 2010 until June 2010 conducted Pre-and Post-filtering assessment, and the third stage from July 2010 until October 2010 consisted of cross-checks and attaching stickers and comparing error cases. Of 92 errors, the 1st, 2nd and 3rd stage had 32 cases, and there were 46 cases after the 4th stage, with the overall errors reduced by 74.3% from 94.6%. In the field of general nuclear medicine, where various kinds of checks are performed according to the patient's needs, analysis, image composition, differing images in PACS, etc, all have the potential for mistakes to be made. In order to decrease error rates, the image can continuously Cross-Check and Confirm diagnosis.

Effects of Horseshoe Expander (Horseshoe Expander의 확장 효과에 관한 연구)

  • Chung, Kyu-Rhim;Park, Young-Guk;Lee, Young-Jun;Kim, Hong-Suk
    • The korean journal of orthodontics
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    • v.30 no.5 s.82
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    • pp.553-563
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    • 2000
  • Horseshoe Expander is one of Slow Maxillary Expansion(SME) which aims to accommodate the contra- lateral expansion and midpalatal suture expansion or the palate. The appliance consists of skeleton type strew embedded in split Horseshoe appliance. It is the objectives of the presentation to manifest the changes in dental & craniofacial components subsequent to the application of Horseshoe Expander. The subjects for this study consisted of 32 patients (mean age : 12.7). frontal, lateral cephalometric headfilm were taken and study casts were fabricated before and after expansion. 24 items were measured, compared preexpansion with postexpansion. Especially, palatal volume was measured by means of 'Hydro-measurement method'. Tooth axis measurement on the dental casts were made with Universal bevel protractor, and Horseshoe Expander group were compared with RME group. This study of changes to maxillary expansion with Horseshoe Expander revealed the following significant results. 1. Triangular-shaped expansion pattern appeared in frontal cephalometric headfilm. 2. Palatal plane, occlusal plane, mandibular plane and upper incisor to FH increased in lateral cephalometrir headfilm. 3. Palatal volume increased significantly. A slight bite opening, reduction of occlusal contact points showed in dental casts. 4. A 2.2:1 ratio of the amount of intermolar width in maxilla(orthodontic movement) to maxillary width (orthopedic movement) was determined. 5. Horseshoe Expander group has less buccal tipping tendency than RME group, by taking high correlation coefficients in the upper second premolar and first molar. It was suggested that Horseshoe Expander showed less orthodontic changes, less buccal tipping tendency. In addition, it was effective in maxillary expansion.

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PSYCHOLOGICAL CHARACTERISTICS IN CHILDREN WITH CHRONIC PHYSICAL ILLNESS AND HANDICAPPED:SELF-CONCEPT AND STRESS COPING STRATEGY (만성적인 신체 질환 및 장애를 지닌 아동의 심리적 특성 : 자기개념 및 스트레스에 대한 대처 양상 비교)

  • Choi, Seung-Mi;Chung, Chin-Youb;Kim, Zoung-Soul;Shin, Min-Sub
    • Journal of the Korean Academy of Child and Adolescent Psychiatry
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    • v.11 no.2
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    • pp.252-261
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    • 2000
  • Objectivity:This study was conducted to examine the depression, self-concept, perception of stress & coping strategy in children with chronic physical illness. Methods:Two groups of participants were recruited for this study, 13 children with chronic illness in outpatient or inpatient treatment at Seoul National University Children's Hospital, and 13 nonpatient children. They were assessed using Korean form of the Piers-Harris Self-Concept Scale (PHSCS), Kovacs' Children's Depression Inventory(CDI) and three subscaleds('color how you feel' 'color how others make you feel' 'A children in the rain' of Children's Self-Report and Projective Inventory(CSRPI). Result:There were significant differences between the chronic ill children and the healthy children in scores of depression and self-concept. The chronicity ill children were more depressive and had very negative self-concept, and obtained significantly lower scores than the healthy children in the subscales of PHSCS, 'intellectual/school status' and 'popularity' Among three scales of CSRPI, there was no difference in 'color how you feel' and 'color how others make you feel' But there were significant differences in all items of 'A child in the rain'(quantity of raining, duration of raining, tool, and effectiveness). 'Duration of raining' correlated most negatively with PHSCS scores, and correlated positively with CDI scores. Conclusion:The children with chronic illness are more depressive and have very negative selfconcept. And they feel that the stresses are more permanent, but have no appropriate coping strategy. The results suggest that the chronic illness strongly affects the psychological and emotional adjustment of children(i.e. depression, peer relation, stress coping strategy).

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The Hospital Life of the Patient with Femoral Neck Fracture (대퇴경부 골절 환자의 입원 생활)

  • Kim, Kyung-Ja;Chi, Sung-Ai
    • Journal of Korean Academy of Nursing Administration
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    • v.2 no.1
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    • pp.35-56
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    • 1996
  • Nowerdays, the increase of traffic accidents and old age population make the Femoral Neck Fracture(FNF) patients increase. By the improvement of education and standard of living the patients demand better medical service than before. This study is designed to give practical help for the FNF patients by observing their hospital life and establish practical nursing strategies for the FNF patients. For these purposes the Ethnographic Participant Observation was adopted. By this study is focused on the hospital life patient's view. For this end, the field study adopted orthopedic ward in the C University Hospital with 400 beds in Seoul. The object patients of the study were twelve patients. The patients experienced five stages : Embarrassment, Conflict, Stability, Independent, and Extension Stage. The findings and prepared nursing strategies are stated as follows. First, in the Embarrassment Stage they suffered embarrassment, anxiety, pain, they could not do ordinary things. The patients who accidental fractures had anxiety from unfamiliar tests and from hospitalization itself. They lamented that they could not ordinary things, and do nothing but obeying the hospital, and endure the pain. They recognized the changed environment and resigned themselves to life in the ward. In this stage, full openness by the nurses is needed. Second, the attribute of the Conflict Stage were conflict, fear, curiosity, belief, reflection. When they sign the consentment form, they experience conflicts about the possibility of complication, fear of recovery from anesthesia, curiosity about the operation procedure, post - operation state, reflection on their past life, and promise to care for their family members after discharge and keep their religious life faithfully. And they accepted the operation depending on God, believing in modern medicine, and the surgeon. Asking for their changed informations, they expected positive results from the operation. In this stage, an empathic attitude by the nurses is needed. Third, the attribute of the Stability Stage were relief, gratitude, difficulty with excretion, and pain. When they awoke from anesthesia, they felt relief because of a the end of the operation, but they experienced extreme pain, difficulty of excretion in bed. They accepted the changed environment and expected recovery. In this stage, support by the nurses is needed. Fourth, the attributes of the Independence Stage were freedom, exercise, nurturing, anxiety, and discomfort. When they ambulated and exercised, they experienced freedom. They showed exhibited weakness of the digestive organs and discomfort hospital's space, structure, and facilities, the delay of medical certificate issue the lack of prompt response by the medical agents. They ate nurturious food and felt anxiety on the end of hospital life and returning to their ordinary life. They showed the independence of overcoming their environment by increasing exercise and expected their discharges. In this stage, respect by the nurses is needed for the patients to, overcome their environment and prepare for their independence. Fifth, the attributes of the Extension Stage were pessimism, isolation, dissatisfaction, and pain. Accompanied injury and old age made their ward life extend to over seven weeks. They exhibited weariness, melancholy, skeptisis, general pessimistic feeling, and desperation caused by their isolated life. They experienced the digestive discomfort caused by the prolonged medication and psycological pain caused by long-time hospitalization. As a, result, their dissatisfaction on the human, physical, and systematic environments had been increased. They acquired critical power and sought for something to do spending their time. They expected vaguely about the returning of their ordinary life. In this stage, counseling is needed by the nurse to overcome positively their psychological, social, and physical problems. The process of the FNF patient's ward life starts from the dependent state, when they are hospitalized, and gradually progresses to self-fulfillment in order to keep independent life. As a result, the FNF patients showed "Response in Challenge" or "Adaptation in Conflict" through their experiences of social, physical, and psychological difficulties.

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The Characteristics and Medical Utilization of Migrant Workers (외국인 노동자의 특성과 의료이용 실태)

  • Ju, Sun Me
    • Korean Journal of Occupational Health Nursing
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    • v.7 no.2
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    • pp.164-176
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    • 1998
  • This study deals with the current medical utilization for migrant workers and the characteristics of them. The purpose of this study is to provide the basic information to establish proper medical policy. For the study self-made questionnaire was used, which was answered by 453 migrant workers working in the area of manufacturing and non-technical work in 10 cities like Seoul, Inchon, Namyangju, Sungnam, Kwangju, Pyungchon, Kunpo, Kimpo, Masuk in Kyungki-do and Chunan in Chungchungnam-do. Besides, 303 medical records of those who had visited free medical check-up center were analyzed. The period of accumulating data is 6 months, from November 1st, 1996 to April 30th, 1997. The characteristics of migrant workers and current medical utilization are analyzed by percentage and the relation between characteristics and current medical utilization were analyzed using ${\chi}^2$-test, t-test, ANOVA. The finding of this study was as follows : 1) The number of nationality was 16. The first majority was Philippians as 32.0%. Among 16 nationalities Southeastern and Northern Asians were 48.9%, Southwestern Asian was 46.5%, the rest was 7.3%. Men were 81.0%, those who are aged from 26 to 30 were 39.0%, Graduatee from high school 92.7%, Christians 56.3%, unmarried 55.4% and salary from 600,000 Won to 800,000 Won 53.8% averaging monthly payment 669,810 Won. As for their residence, those who resided over 3 years were 31.9% and the illegal residence reached 77.4%. As for Korean language, those who speak in middle level were 5.6%. 2) As for kind of work and circumstances, manufacturing was 81.1%, 4 off-days per month 72.2% and 9-10 working hours per day 42.1%. As for accommodation, residence in fabric was 62.6% and one or two members as roommate 40.2%. 3) The characteristics of health behavior showed that 89.4% of migrant workers had 3 meals, 70.9% of them did not drink alcohol, 73.5% of them did not smoke. 4) As a characteristic of health status, 71.8% of them perceived of their health. 76.1% thought that they had no illness before coming Korea. Among them who recognized their illness, those who had problem in circulatory system was 35.3%, respiratory system ENT 19.1% and nervous system 19.1%.66.2% of those having illness had already had sickness when coming to Korea. 5) During last one month, 79.2% of them were known as ones having no illness. Among the sick, those who had problem in circulatory system was 31.6%, nervous system 23.7% and respiratory system 21.1%. 60.3% of the sick were not cured at that time. 6) Sorting the symptom of those who visited free medical check up, dental care was 24.2%, orthopedic 14.0% and digestive system 13.8%. Teethache was 34.4%, stomach problem 11.6%, upper respiratory inflammation 10.2% and back pain 5.9%. Averagely they visited free medical check up 1-2 times. According to symptom, epilepsy 25.5 times, heart and vascular disease 9 times, constipation 2.8%, neurosis 2.38 times and stomach problem 2.34 times. 7) The most frequently visited medical service by migrant workers was hospital. The most mentioned reason was good healing as 36.3%. The medical service satisfied migrant workers mostly was hospital as 64.3%. The reason of satisfaction was also good healing as 45.9%. 8) 77.2% of respondents did not spend money for medical check. Average monthly medical cost was 25,100 Won, 3.7% of income. Those who had no medical security was 73.4%. In their case, 67.7% got discount from hospital or support from working place and religious organization. 9) As for the difference of medical utilization according for the characteristics of migrant workers, legal workers and no-Korean speaker used hospital more frequently. 10) Those who were satisfied most of all with the service of hospital were female workers, hinduists and buddhists, legal workers or manufacture workers. 11) Christians, those who have 3 meals or recognize themselves as healthy ones mostly had no illness. As a result, the most of migrant workers in Korea are from Asia. They are good educated but are working in manufacturing and illegal. Their average income is under 700,000 Won which in not enough for medical cost. They have no medical security and medical fee is supported by religious organization or discounted. Considering these facts the medical policy by government is to be established.

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Laminin-1 Expression in Bone Marrow Stromal Cells of Cyclophosphamide-treated Rat (Cyclophosphamide가 흰쥐 골수의 기질세포에서 Laminin-1의 발현에 미치는 영향)

  • Lee, Chang-Hun;Chung, Ho-Sam;Paik, Doo-Jin;Hwang, Se-Jin;Kim, Won-Kyu;Youn, Jee-Hee;Kim, Chong-Kwan
    • Applied Microscopy
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    • v.32 no.4
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    • pp.385-398
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    • 2002
  • The purpose of the present study is to investigate whether stromal cells supporting specific microenvironment for hematopoiesis of bone marrow are affected by toxicants and therapeutic drugs such as antibiotics and anticancer drugs and whether laminin-1 is associated with such effects. SD rats were intraperitoneally injected with 75 mg/kg of cyclophosphamide which is widely used to treat infant's solid tumor, leukemia and myeloma and sacrificed after 3 days, 1 week, 3 weeks or 5 weeks of injection. The bone marrow extracted and paraffin-sectioned was analyzed using immunohistochemical staining. A part of tissues was subjected to electron microscopy following reaction with rabbit anti-laminin antibody, biotinylated goat anti-rabbit IgG conjugated with 12 nm gold particles, and staining with uranyl acetate. 1. The bone marrow tissue at day 3 post injection with cyclophosphamide displayed dilated venous sinus, partial necrotic death, and decreased number of hematopoietic cells. Laminin-1 was intensively stained in the reticular and adipose tissues. 2. Up to 5 weeks post injection, laminin-1 was stained at a low level in the stromal tissue of bone marrow and the number of hematopoietic cell was increased. 3. Deposition of the gold particle which represents laminin-1 expression was observed at the highest level in the stromal cells of bone marrow obtained 3 days after injection, and decreased after 1 to 5 weeks. These results suggest that stromal cells which play a role in supporting microenvironment for bone marrow hematopoiesis augment induction of laminin-1 expression and activation upon administration of cyclophosphamide.

An Epidemiologic Study of Metastatic Bone Tumor (전이성 골종양의 역학적 연구)

  • Kim, Jae-Do;Lee, Duk-Hee;Park, Jeong-Ho;Son, Young-Chan;Hong, Yonng-Gi;Son, Jeong-Hwan
    • The Journal of the Korean bone and joint tumor society
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    • v.1 no.1
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    • pp.38-44
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    • 1995
  • Metastatic bone tumor is the most common bone tumor and 32.5% of all primary malignant tumors are eventually metastasize to bone. Metastatic bone tumor has been more frequently encountered disease in the orthopedic fields due to the greater longevity of life of the patients with primary visceral cancers by major advances in early detection, diagnosis, and surgical/radiotherapeutic/chemotherapeutic treatment of primary and metastatic lesions. Therefore, the epidemiologic data about the incidences and the patterns of bone metastasis is important. We reviewed 417 patients who were diagnosed and treated for metastatic bone tumor at Kosin University Medical Center from 1985 to 1993 to analyse the primary lesion, age and sex distributions, location of bone metastasis, patterns of metastasis according to the primary. The results were as follows : 1. The common origin of bone metastasis were lung(29.5%), stomach(15.3%), breast(11.3%), unknown(7.7%), cervix(5.3%), liver(4.8%) in order of frequency. 2. There were 251 men and 166 women and their mean age was 54.8 years and the peak age incidence was in 6th decades. Most cases(85.3%) were occured beyond 5th decades. 3. The preferred sites of metastatic deposits were spine(64.0%), pelvis(40.5%), rib(38.8%), femur(36.7%), skull(21.1%), humerus(13.9%), scapula(13.0%) in order of frequency. In the spine, thoracic(42.1%), lumbar(39.1%), cervical(13.2%), sacral(5.6%) vertebrae were involved in order of frequency. 4. Multiple bone metastases were more common(73.1%) than single metastasis(26.9%). 5. In the lung cancer, the peak age incidence was 6th decades, and the preferred sites of bone metastasis were spine, pelvis, femur. 6. In the stomach cancer, the peak age incidence was 6th decades, and the preferred sites of bone metastasis were spine, femur, pelvis. 7. In the breast cancer, the peak age incidence was 5th decades, and the preferred sites of bone metastasis were spine, rib, pelvis. 8. In the bone metastasis with unknown primary site, the peak age incidence was 7th decades, the preferred sites of bone metastasis were spine, femur, pelvis, and the common histologic types were adenocarcinoma and squamous cell carcinoma.

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Expression of nitric oxide synthases in the mandibular condyle of anterior repositioned rat mandibles (백서의 하악골 전방 재위치 시 하악과두 조직에서의 nitric oxide synthases 발현 양상)

  • Kim, Hyun-Sook;Kim, Ho-Young;Heo, Sung-Su;Kang, Kyang-Hwa;Kim, Sang-Cheol
    • The korean journal of orthodontics
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    • v.40 no.4
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    • pp.239-249
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    • 2010
  • Objective: The aim of this study was to identify the expression of nitric oxide synthases (NOS) in the mandibular condyle during mandible advancement by functional appliance and to correlate it with the histologic changes and bone remodeling. Methods: Twenty-four female, 35-day-old Sprague-Dawley rats were randomly divided into 3 experimental groups. In all experimental groups, the mandibles of the rats were kept in a continuous forward position with a fixed bite jumping appliance. The rats were sacrificed on the 3rd, 14th, and 30th days of experiment. More than 2 rats in each group were used for staining. Results: There were no remarkable histologic changes and NOS expression differences in the control group. The most prominent histologic changes occurred in the 14th day experimental group. NOS decreased in the 30th day experimental group. There was increased expression of $NOS_2$ and $NOS_3$ in all experimental groups, comparative to the control group. In all the experimental groups and control group, the expression of $NOS_2$ was greater than that of $NOS_3$. Conclusions: It is postulated that $NOS_2$ and $NOS_3$ in the mandibular condyle might play an important role in bone remodelling of the mandibular condyle.

A Study on Woman's Experience of Being Bereaved of Her Husband by an Accident (사고로 남편을 잃은 여성의 경험)

  • Park, Sung-Hark;Choi, Mi-Hye;Chung, Yeon-Kang
    • Research in Community and Public Health Nursing
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    • v.7 no.2
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    • pp.294-312
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    • 1996
  • Relatively young widows, who are left with young children by a sudden death of their husbands, will be faced with not only psychological troubles such as individual anxiety and frustration but also the dual burden of playing both father and mother roles in a family, Also, family members have difficulty in adapting themselves to new circumstances of the family system, the training and raising of family members, and management of the family economy. In this study, the realistic resources on the experience of middle-aged women who are bereaved of their husbands by accidents were explored. The purpose of this study is to help widows adapt to life in society and live a more positive life by setting a new goals and recovering from a lost and twisted life. 11 women, who have experienced the loss their husbands and live in the Seoul metropolitan area were studied. The research took 116 days from December 15, 1995 to April 8, 1996. The method of research was direct interviews. While having interviews with them, the contents were recorded with their consent. The ground theory was that used by Strauss & Corbin(1990) in the analysis of the data. 81 concepts were analyzed and they were subdirided into 22 subordinate categories through the course of the analysis. These were then classified into 9 general categories. In the course of being categorized, 'absurdity' was showed as a core category. The subordinate categories 'surprise', 'gloom', 'grudge', 'helplessness', 'emptiness', and 'loss' were united in the core category 'absurdity'. Ominous presentiment, belated notice, death, surprise, gloom, grudge, helplessness, emptiness, loss, the situation of the children, lack of support from neighbors, support from neighbors, mulling over ways to live, choosing a job, strengthening, reinforcement, burden, sadness, smoldering, yearning, overcoming these 22 subordinate categories were re-composed into 9 general ones the husband's death, absurdity, presence of children, existence of support, self-support ability, preparation of countermeasures, self-reinforcement, toilsomeness, and overcoming. 'Absurdity' widows experience was shown in the results of 'toilsomeness' and 'overcoming' through reaction, confrontation, and adaptation. According to the analysis the central phenomenon was absurdity, the causal condition of the death of a husband, the presence of children and the existence of support, and the meditated situation of self-support. To solve absurdity, the preparation of countermeasures and self-reinforcements were shown resulting in toilsomeness and overcoming. Through the contrast in the data, the following statements were deduced: (1) If the death of the husband is expected, the more a widow will feel absurdity. (2) The more children she has and the younger she is, the more a widow will feel absurdity. (3) The lower support she is given, the more a widow will feel absurdity. (4) The larger self-ability she has, the more actively she will prepare countermeasures. (5) The smaller self-ability she has, the more passively she will prepare countermeasures. (6) The larger self-ability she has, the weaker self-reinforcement she will preform. (7) The smaller self-ability she has, the stronger self-reinforcement she will perform. (8) The more actively she prepares countermeasures for absurdity, the better she will overcome. (9) The more passively she prepares counter measure for absurdity, the worse she will overcome. (10) The stronger self-reinforcement for absurdity she performs, the better she will overcome. (11) The weaker self-reinforcement for absurdity she performs, the worse she will overcome. Through the results in this study, the following suggested: 1) A study whose object is all family members, and a comparative study on the case of a husband who has lost his wife should be done. These studies can be expected to develop a more refined theory. 2) Because of the collapse of the extended family system and the changes of family culture in Korea, a widow's status and position are apt to be ambiguous between her husband's home and her parent's. Therefore a new study on family culture should be made. 3) A continuous study on growing social Self Help Groups should be requested for the widows of this study to re-establish and recover from their twisted and scattered lives.

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Broden photographing method for Calcaneus Subtentaculum tali observation of Ankle plaster patient (발목부상을 당한 석고환자의 발꿈치뼈·목말받침돌기 관찰을 위한 Broden 촬영법 연구)

  • An, Byeongju
    • Journal of the Korean Society of Radiology
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    • v.7 no.2
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    • pp.107-112
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    • 2013
  • There is an Ankle Oblique(Broden' low) as an examination for the patient whose ankle was encased in orthopedic plaster. Some types of Ankle Joint coalition - Calcaneonavicular coalition, Talocalcaneal coalition and Naviculocuneiform coalition. This study is focused on the relation between Ankle Joints and the structural change of soft tissues, also finding the most proper angle to obtain good images of Ankle Joint from the patient who wore a plaster on his ankle, when we x-ray with Harris-Beath View($30^{\circ}{\sim}55^{\circ}$) - for observing Subtalar joint, Calcaneus Fracture, Subtentaculum, Tali Fracture and Talocalcaneal coalition. We intend to get the angle which makes us achieve the good image that shows Calcaneus Fracture, Subtentaculum, and Tali Fracture by changing internal angles of the patient's ankle. We evaluated the images obtained from 51 patients with PACS monitor. The result of the evaluation, subtalar joint was not seperated but opened, and Subtentaculum Tali Fracture was seen overlaid. at the angle 30, we could observe Calcaneus Fracture, Subtentaculum Tali Frature and the front part of behind side of subtalar joint well. And Calcaneo Navicularcoalition, Talocal Canealcoalition, Naviculo Cuneiform coalition condition were clearly seen at that angle. At the angle 35, we could achieve the clear images of subtalar comminuted fracture, talus, the behind joint of heel bone and get the high definition image on the degree of talocalcaneal joint separation. In addition to, We could obtain the good wide image of Sinus Tarsi. At the area of 45, We can distinguish the soft tissues from gyps separation. The outer-talus and density of the bone were definitely seen and Calcaneus is more separated than that of at the angle of 35, but this image is distorted. Calcaneus, Subtentaculum Tali show $1.20{\pm}0.414$ at the angle 25, $2.47{\pm}0.516$ at the angle 30, $2.27{\pm}0.458$ at the angle 45. This difference is statistically meaningful. (p<0.05). Including the degree of distortion, The distortion appears less at the area of $30^{\circ}$ but at the area of 40, there is heavy distortion. So, We could get the best image for making a diagnosis. At the $30{\sim}35^{\circ}$ degree for X-raying ankle. and at the $30{\sim}40^{\circ}$ for Calcaneus Fracture, Subtentaculum Tali Fracture.