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Carpometacarpal joint dislocation

Carpometacarpal (CMC) joint dislocations are uncommon dislocations of the hand. Epidemiology There is a strong younger male predominance. These injuries account for less than 1% of hand injuries 4 and are more common in the dominant hand. Associated injuries The following injuries should rai...

Jersey finger

Jersey finger (also called rugby finger or sweater finger) describes a type of injury where there is avulsion of the flexor digitorum profundus (FDP) from the volar aspect of the distal phalanx base 1. It classically occurs during certain sports resulting from sudden hyperextension of an activel...

Ossicular chain disruption

Ossicular chain disruption (or ossicular discontinuity) is loss of normal alignment between the three middle ear ossicles. The condition is a cause of conductive hearing loss. Epidemiology Exact incidence and prevalence are not known. Hearing loss associated with temporal bone fractures in chi...

Classification of sacral fractures

There are several classification systems for sacral fractures, but the most commonly employed are the Denis classification and subclassification systems, and the Isler classification system. These classification systems are important to understand as proper classification can impact management. ...

Atlanto-occipital dissociation injuries

Atlanto-occipital dissociation injuries are severe and include both atlanto-occipital dislocations and atlanto-occipital subluxations. Pathology The tectorial membrane and alar ligaments provide most of the stability to the atlanto-occipital joint, and injury to these ligaments results in inst...

Lover's fracture

Lover's fracture, also known as Don Juan fracture or Casanova fracture is a type of calcaneal fracture. They are fractures of the calcaneal body and may be intra- or extra-articular. History and etymology The name "lover's fracture" is derived from the fact that a suitor may jump from great he...

Anterior humeral line

The anterior humeral line is key to demonstrating normal elbow alignment and should be used whenever reading a pediatric elbow radiograph to exclude a subtle supracondylar fracture. Measurement A line drawn down the anterior surface of the humerus should intersect the middle third of the capit...

Aortic isthmus

The aortic isthmus is the part of the aorta just distal to the origin of the left subclavian artery at the site of the ductus arteriosus. This portion of the aorta is partly constricted in the fetus because of the lack of flow within the aortic sac and ascending aorta. It marks the partial sepa...

Lateral humeral condyle fracture

Lateral humeral condyle fractures also referred to simply as lateral condyle fractures (in the appropriate context), are relatively common elbow fractures that predominantly occur in children. They may be subtle but are hugely important to diagnose in a timely manner because if they are missed, ...

Epicondyle fracture (elbow)

Epicondyle fractures are common injuries in children. They represent 10% of all elbow fractures in children and usually occur in boys after a fall on an outstretched arm. Medial epicondyle fractures comprise most of these injuries. They can usually be treated with splinting and early physiother...

Incomplete fracture

Incomplete fractures are a heterogeneous group of fractures that predominantly occur in the long bones of pediatric patients. Rang 1 describes a continuum of fractures that occur with increasing longitudinal force applied along the length of the bone. At the point where force exceeds the structu...

Volar intercalated segment instability

Volar intercalated segment instability (VISI) is a type of carpal instability featuring volar tilt of the lunate. It is less often encountered than dorsal intercalated segment instability (DISI). Clinical presentation VISI presents in most cases with nonspecific wrist pain and a "clunking" on ...

Macklin effect

The Macklin effect describes one of the pathophysiological processes of pneumothorax and pneumomediastinum in blunt chest trauma. This effect accounts for the formation of ~40% of severe blunt traumatic pneumomediastinum. Exclusion of tracheobronchial and esophageal causes of pneumomediastinum i...

Open book pelvic injury

Open book pelvic injuries are most often the result of high-energy trauma and are associated with significant morbidity and mortality due to associated vascular injuries. Pathology Open book pelvic injuries result from an anteroposterior compression injury to the pelvis and result in a combin...

Volar plate avulsion injury

Volar plate avulsion injuries are a type of avulsion injury. The volar plate of the proximal interphalangeal (PIP) joint is vulnerable to hyperextension injury, in the form of either a ligament tear or an intra-articular fracture. Gross anatomy The volar plate forms the floor of the PIP joint ...

Retrolisthesis

The term retrolisthesis (less commonly known as retrospondylolisthesis or posterolisthesis, or reverse vertebral slip) refers to posterior displacement of a vertebral body relative to the caudal vertebral body. Pathology Causes include: trauma facet joint osteoarthritis congenital anomalies...

Anterolisthesis

The term anterolisthesis refers to anterior displacement (forward slip) of a vertebral body relative to the one below. Its severity can be graded by the Meyerding classification and its etiology classified according to the Wiltse classification.

Bronchial fracture (mnemonic)

A mnemonic for the features of a bronchial fracture on a chest radiograph is: Ps (or written as PPP or PPPP) Mnemonic Ps: progressive or persistent pneumothorax or pneumomediastinum

Reverse Segond fracture

Reverse Segond fracture is one of the avulsion fractures of the knee, which is due to the avulsion of the deep fibers of the medial collateral ligament (also known as the meniscotibial or coronary ligament) involving the medial proximal tibia adjacent to the articular surface. It is the opposite...

Splenic artery pseudoaneurysm

Splenic artery pseudoaneurysms are a rare type of pseudoaneurysm arising from any portion of the splenic artery and its branches. Clinical presentation Unlike splenic artery true aneurysms, splenic artery pseudoaneurysms will nearly always present with symptoms 2. While their occurrence may b...

Spinal compression fracture

Spinal compression fractures occur as a result of injury, commonly fall onto the buttock or pressure from normal activities, to the weakened vertebrae due to osteoporosis. Epidemiology They have a reported incidence of 1.2 per 1000 person-years after 85 years of age in the United States. Howev...

Trapezium fracture

Trapezium fractures are uncommon carpal bone injuries. They can either occur in isolation or combination with another carpal bony injury. Epidemiology Isolated fractures of the trapezium are only thought to account for 3-5% of all carpal fractures 1,2. Pathology They can be broadly classifie...

Light bulb sign (posterior shoulder dislocation)

The light bulb sign refers to the abnormal AP radiograph appearance of the humeral head in posterior shoulder dislocation. When the humerus dislocates it also internally rotates such that the head contour projects like a light bulb when viewed from the front 1. See also light bulb sign (hepat...

Subdural hygroma

Subdural hygromas (alternative plural: hygromata 9) refer to the accumulation of fluid in the subdural space. In many cases, it is considered an epiphenomenon of head injury when it is called a traumatic subdural hygroma. Epidemiology Subdural hygromas are encountered in all age-groups but ar...

Femoral artery pseudoaneurysm

Femoral artery pseudoaneurysms are usually iatrogenic, as the femoral artery is the vessel of choice for most endovascular arterial interventions. Pathology Etiology iatrogenic anticoagulation therapy inadequate compression following femoral arterial puncture for endovascular intervention ...

Interphalangeal joint dislocation

Interphalangeal joint dislocations are common upper extremity dislocations. Although considered minor injuries by many, they can result in significant disability. Isolated dislocations of the distal interphalangeal (DIP) joints are rare and usually are associated with avulsion fractures of the...

Proximal humeral fracture

Proximal humeral fractures are common upper extremity fractures, particularly in older patients, and can result in significant disability. Epidemiology Proximal humeral fractures represent around 5% of all fractures ?. They are most common in older populations and especially in those who are ...

Frykman classification of distal radial fractures

The Frykman classification of distal radial fractures is based on the AP appearance and encompasses the eponymous entities of Colles fracture, Smith fracture, Barton fracture, chauffeur fracture. It assesses the pattern of fractures, involvement of the radioulnar joint and presence of a distal u...

Humeral shaft fracture

Humeral shaft fractures are readily diagnosed and usually, do not require internal fixation. Epidemiology Humeral shaft fractures account for 3-5% of all fractures 1,3. Although they occur in all age groups, a bimodal distribution is noted. The first peak is seen in the third decade in males ...

Flexion supracondylar fracture

Flexion supracondylar humeral fractures account for only 2-4% of all supracondylar fractures 1. Epidemiology Unlike the much more common extension supracondylar fracture which are seen in children, flexion fractures are seen in older (adult) patients. Pathology They are usually the result of...

Gartland classification of supracondylar humeral fractures

The Gartland classification of supracondylar fractures of the humerus is based on the degree and direction of displacement, and the presence of intact cortex. It applies to extension supracondylar fractures rather than the rare flexion supracondylar fracture. Classification type I: undisplaced...

Upper extremity dislocations

Upper extremity dislocations are relatively common on account of the great range of motion the upper limb is capable of (a general principle is that the greater the range of motion of a joint, the more prone it is to dislocation). In many instances dislocations are associated with fractures eith...

Olecranon fracture

Olecranon fractures are clinically and radiographically obvious, and usually require open reduction and internal fixation. Mechanism Olecranon fractures occur as the result of one of four mechanisms 2: direct blow (or fall directly on the elbow) fall on outstretched hand with elbow flexed a...

Fracture article structure

Articles describing fractures require a different set of subheadings from a 'standard' article, as the usual epidemiology, clinical presentation, pathology etc., may not be relevant. Example article: clavicular fractures =======================================================================...

Bado classification of Monteggia fracture-dislocations

The Bado classification is one of the more widely used classifications for Monteggia fracture-dislocations and mainly focuses on the radial component. Four types are recognized and are generally based on the principle that the direction in which the apex of the ulnar fracture points is the same ...

Mallet finger

Mallet finger refers to injuries of the extensor mechanism of the finger at the level of the distal interphalangeal joint (DIP). They are the most prevalent finger tendon injury in sport. They may represent an isolated tendinous injury or occur in combination with an avulsion fracture of the dor...

Central cord syndrome

Central cord syndrome is the most common type of incomplete spinal cord syndrome, usually, the result of trauma, accounting for ~10% of all spinal cord injuries. As the name implies, this syndrome is the result of damage to the central portion spinal cord and in the setting of trauma most common...

Buckle rib fracture

Buckle rib fractures are incomplete fractures involving only the inner cortex. They typically occur due to an anterior compressive force to the chest, most commonly external cardiac massage, but can be seen following any such traumatic injury. Pathology Buckle rib fractures occur in all ages, ...

Rotator cuff tear

Rotator cuff tears are one of the most common causes of shoulder pain mostly in older patients. Clinical presentation The prevalence of tears increases with age. The most significant findings are impingement and "arc of pain" sign (pain while lowering the abducted arm) 1. Supraspinatus weaknes...

Trampoline fracture

Trampoline fractures are transverse fractures of the proximal tibial metaphysis that occur in children while jumping on a trampoline (or inflatable castle). The fracture is thought to occur when a second, usually heavier individual causes the jumping surface to recoil upwards as the unsuspectin...

Globe rupture

Globe rupture is an ophthalmologic emergency. A ruptured globe or an open-globe injury must be assessed in any patient who has suffered orbital trauma because open-globe injuries are a major cause of blindness. In blunt trauma, ruptures are most common at the insertions of the intraocular muscl...

Pulled elbow syndrome

Pulled elbow (also known as nursemaid's elbow) is a subluxation of the radial head into the annular ligament, which usually spontaneously or easily reduces and rarely demonstrates abnormal radiographic features. If the clinical presentation is atypical, pulled elbow should be distinguished from ...

Radial head dislocation

Radial head dislocation occurs when the radial head is displaced from its normal articulation with the ulna and the humerus. The dislocation may be acquired or congenital (see the separate article on congenital radial head dislocation). Additionally, radial head dislocation should be distinguis...

Thoracolumbar spinal fracture classification systems

Thoracolumbar spinal fracture classification systems are numerous and represent attempts by various authors to create systems that allow uniform and reproducible classification and description of thoracolumbar fractures which in turn can help with treatment decision making and prognostication. ...

Magerl classification of thoracolumbar spinal fractures

The Magerl classification, one of many thoracolumbar spinal fracture classification systems, was adopted as the original AO classification in 1994 but has since then been superseded: see the current AO classification of thoracolumbar injuries. Usage Although the Magerl classification is based ...

McAfee classification of thoracolumbar spinal fractures

McAfee classification of acute traumatic spinal injuries is one of a number of thoracolumbar spinal fracture classification systems and based on the three-column concept of the spine (of Denis). It requires CT for an accurate assessment. Usage The McAfee classification uses terminology that is...

Three column concept of spinal fractures

The three-column concept of thoracolumbar spinal fractures (of Denis) forms the basis of a number of widely used thoracolumbar spinal fracture classification systems. Usage While the three-column concept was initially developed for classification of thoracolumbar spinal fractures, it can also ...

Tension pneumothorax

Tension pneumothoraces occur when intrapleural air accumulates progressively with hemodynamic compromise 10. It is a life-threatening occurrence requiring both rapid recognition and prompt treatment to avoid a cardiorespiratory arrest. For a general discussion, refer to the pneumothorax article...

Flexion teardrop fracture

Flexion teardrop fractures represent a fracture pattern occurring in severe axial/flexion injury of the cervical spine. They are important to recognize because they indicate extensive underlying ligamentous injury and spinal instability. Associated spinal cord injury is common, especially anteri...

Pelvic fractures

Pelvic fractures can be simple or complex and can involve any part of the bony pelvis. Pelvic fractures can be fatal due to pelvic hemorrhage, and an unstable pelvis requires immediate management. Epidemiology Pelvic fractures can be seen in any group of patients. Like much trauma, there is a ...

Anterior dislocation of the hip

Anterior hip dislocation is much less common than a posterior hip dislocation. It constitutes only 5-18% of all hip dislocations. Pathology While the posterior dislocation is often associated with fractures, the anterior dislocation is mostly an isolated injury 1. Subtypes It can be classifi...

Biffl scale for blunt cerebrovascular injury

The Biffl scale or grade illustrates the spectrum of blunt cerebrovascular injury (BCVI) seen on angiography (both CTA and DSA). Some authors refer to the grading scale as the Denver scale, which is not to be confused with the Denver criteria, a series of clinical indications to screen for blunt...

Diffuse axonal injury

Diffuse axonal injury (DAI), also known as traumatic axonal injury (TAI), is a severe form of traumatic brain injury due to shearing forces. It is a potentially difficult diagnosis to make on imaging alone, especially on CT as the finding can be subtle, but it has the potential to result in seve...

Coup-contrecoup injury (brain)

A coup-contrecoup injury is a term applied to head injuries and most often cerebral contusions and traumatic subarachnoid hemorrhage. It refers to the common pattern of injury whereby damage is located both at the site of impact (often less marked) and on the opposite side of the head to the poi...

Scalp hematoma

A scalp hematoma (plural: hematomas or hematomata) commonly occurs either following a perinatal injury at delivery or as part of head trauma. Classification There are three types of hematoma, which are defined by their location within the scalp, in particular their location as related to the g...

Subgaleal hematoma

Subgaleal hematoma describes scalp bleeding in the potential space between the periosteum and the galeal aponeurosis. It is a rare but possibly lethal emergency. Epidemiology Moderate to severe presentations occur in 1.5 of 10,000 live births. It most commonly occurs after vacuum-assisted and ...

Cerebral hemorrhagic contusion

Cerebral hemorrhagic contusions are a type of intracerebral hemorrhage, also sometimes considered a "brain bruise", and are common in the setting of significant head injury. They are usually seen on CT as hyperattenuating foci in the frontal lobes adjacent to the floor of the anterior cranial fo...

Deep sulcus sign (chest)

The deep sulcus sign on a supine chest radiograph raises suspicion of a pneumothorax. On a supine chest radiograph (common in intensive care units or as part of a trauma radiograph series), it may be the only suggestion of a pneumothorax because air collects anteriorly and basally, within the n...

Clay-shoveler fracture

Clay-shoveler fractures are fractures of the spinous process of a lower cervical vertebra. Clinical presentation Often these injuries are unrecognised at the time and only found incidentally years later when the cervical spine is imaged for other reasons. Acutely they tend to be associated wi...

Gunshot injuries

Gunshot injuries often require imaging assessment, and this evaluation has both clinical relevance (assessment of organ damage, surgical planning, and prognostication), and often also forensic implications. Epidemiology Incidence of gunshot injuries to the head is increasing in some countries,...

Transverse temporal bone fractures

Transverse temporal bone fractures are oriented perpendicular to the long axis of the petrous temporal bone, with the line of force running roughly anterior to posterior. Although more current classifications of the extent of temporal bone fractures focus on the integrity of the otic capsule rat...

Longitudinal temporal bone fractures

Longitudinal temporal bone fractures are petrous temporal bone fractures that occur parallel to the long axis of the petrous temporal bone. Although more current classifications of the extent of temporal bone fractures focus on the integrity of the otic capsule rather than the fracture orientati...

Temporal bone fracture

Temporal bone fracture is usually a sequela of significant blunt head injury. In addition to potential damage to hearing and the facial nerve, associated intracranial injuries, such as extra-axial hemorrhage, diffuse axonal injury and cerebral contusions are common. Early identification of tempo...

Nasal bone fracture

Nasal bone fractures are the most common type of facial fractures, accounting for ~45% of facial fractures, and are often missed when significant facial swelling is present. Clinical presentation Unsurprisingly, nasal bone fractures occur when the nose impacts against a solid object (e.g. fis...

Calcaneal fracture

Calcaneal fractures are the most common tarsal fracture and can occur in a variety of settings. Epidemiology The calcaneus is the most commonly fractured tarsal bone and accounts for about 2% of all fractures 2 and ~60% of all tarsal fractures 3. Pathology Calcaneal fractures can be divided ...

Coronoid process fracture

Fractures of the coronoid process of the ulna are uncommon and often occur in association with elbow dislocation. Pathology Mechanism Fracture of the coronoid process is thought to result from elbow hyperextension with either avulsion of the brachialis tendon insertion or shearing off by the...

Urethral stricture

Urethral strictures are relatively common and typically occur either in the setting of trauma or infection. Epidemiology The demographics of the affected population is dictated by the etiology, but in general, it is safe to say that adult males make up the vast majority of cases. Clinical pre...

Urinary bladder trauma

Urinary bladder trauma describes a spectrum of damage that can be caused to the urinary bladder, usually in the context of significant trauma. Epidemiology Bladder trauma is generally associated with high energy injuries, and is associated with pelvic fractures in the majority of cases 3,6. Th...

Triquetral fracture

Triquetral fractures are carpal bone fractures generally occurring on the dorsal surface of the triquetrum. The triquetral may be fractured by means of impingement from the ulnar styloid, shear forces, or avulsion from strong ligamentous attachments. They are the second commonest carpal bone fra...

Greenstick fracture

Greenstick fractures are incomplete fractures of long bones and are usually seen in young children, more commonly less than 10 years of age. They are commonly mid-diaphyseal, affecting the forearm and lower leg. They are distinct from torus fractures. Pathology Mechanism Greenstick fractures ...

Anterior cruciate ligament tear

Anterior cruciate ligament (ACL) tears are the most common knee ligament injury encountered in radiology and orthopedic practice. Epidemiology The anterior cruciate ligament (ACL) is the most commonly disrupted ligament of the knee, especially in athletes who participate in sports that involve...

Nightstick fracture (ulna)

Nightstick fractures are isolated fractures of the ulna, typically transverse and located in the mid-diaphysis and usually resulting from a direct blow. It is a characteristic defensive fracture when the patient tries to ward off an overhead blow from an assailant (or local law enforcement offic...

Acute aortic syndrome

Acute aortic syndrome describes the presentation of patients with one of a number of life-threatening aortic pathologies that give rise to similar clinical presentations. Exactly which entities are included under the umbrella term acute aortic syndrome varies somewhat from publication to public...

Chopart fracture-dislocation

Chopart fracture-dislocations occur at the midtarsal (Chopart) joint in the foot, i.e. talonavicular and calcaneocuboid joints which separate the hindfoot from the midfoot. The commonly fractured bones are the calcaneus, cuboid and navicular. The foot is usually dislocated medially and superior...

Inferior shoulder dislocation

An inferior shoulder dislocation is the least common form of shoulder dislocation. The condition is also called luxatio erecta because the arm appears to be permanently held upward, in fixed abduction. The patient will often present with their hand placed on the head or near it. Pathology It i...

Anterior shoulder dislocation

Anterior shoulder dislocation is by far the commonest type of dislocation and usually results from forced abduction, external rotation and extension 1. Epidemiology Broadly speaking, anterior shoulder dislocations occur in a bimodal age distribution. The first, and by far the more prevalent a...

Posterior shoulder dislocation

Posterior shoulder dislocations are far less common than anterior shoulder dislocations and can be difficult to identify if only AP projections are obtained. A high index of suspicion is helpful. Epidemiology Posterior shoulder dislocations account for only 2-4% of all shoulder dislocations (t...

Pneumopericardium

Pneumopericardium represents gas (usually air) within the pericardium, thus surrounding the heart. Pathology Etiology Underlying causes include: positive pressure ventilation thoracic surgery/pericardial fluid drainage penetrating trauma blunt trauma (rare) infectious pericarditis with ...

Anterior superior iliac spine avulsion injury

Anterior superior iliac spine (ASIS) avulsion injuries typically occur in athletes during forceful muscular contraction. The anterior superior iliac spine is the site of attachment for sartorius and tensor fascia latae muscles. Pathology Anterior superior iliac spine avulsion, like other pelv...

Birth trauma

Birth trauma (a.k.a. birth injury) relates to those conditions caused by both physical/mechanical and hypoxic injuries. Epidemiology Birth trauma occurs in ~5 per 1000 births 2. Risk factors asphyxia breech presentation shoulder dystocia instrument delivery macrosomia obstructed labor ...

Diaphragmatic rupture

Diaphragmatic rupture often results from blunt abdominal trauma. The mechanism of injury is typically a motor-vehicle collision. Epidemiology Given that the most common mechanism is motor vehicle collisions, it is perhaps unsurprising that young men are most frequently affected. The estimated ...

Zygomaticomaxillary complex fracture

Zygomaticomaxillary complex (ZMC) fractures, also known as tripod, tetrapod, quadripod, malar or trimalar fractures, are seen in the setting of traumatic injury to the face. They comprise fractures of the: zygomatic arch inferior orbital rim, and anterior and posterior maxillary sinus walls l...

Galeazzi and Monteggia fracture-dislocations (mnemonic)

There are several mnemonics for the difference between a Galeazzi and a Monteggia fracture-dislocation: GRIMUS MUGR (pronounced as mugger) FROG GRUesome MURder Manchester United / Glasgow Rangers It is useful to note that it is the head of the non-fractured bone that is disl...

Pneumorrhachis

Pneumorrhachis refers to the presence of gas within the spinal canal (either intra- or extradural). It is rare. Clinical presentation Patients can often be asymptomatic 3. Pathology Etiology Pneumorrhachis can result from a number of causes: trauma (traumatic pneumorrhachis): can occur in ...

Flail chest

Flail chest or flail thoracic segment occurs when three (3) or more contiguous ribs are fractured in two (2) or more places. Clinically, a segment of only one or two ribs can act as a flail segment, hence there is some controversy between the clinical and radiological definitions. Clinical pres...

Torus fracture

Torus fractures, also known as buckle fractures, are incomplete fractures of the shaft of a long bone that is characterized by bulging of the cortex. They result from trabecular compression due to an axial loading force along the long axis of the bone. They are usually seen in children, frequent...

Pilon fracture

A pilon fracture is a type of distal tibial fracture involving the tibial plafond. These are considered to represent 1-10% of all lower limb fractures 6. Mechanism Typically high energy injuries and occur as a result of an axial loading which drives the talus into the tibial plafond. Classif...

Joint effusion

A joint effusion is defined as an increased amount of fluid within the synovial compartment of a joint. There is normally only a small amount of physiological intra-articular fluid. Abnormal fluid accumulation can result from inflammation, infection (i.e. pus) or trauma and might be exudate, tr...

Rectus sheath hematoma

Rectus sheath hematomas, as the term implies, occur when a hematoma forms in the rectus abdominis muscle/rectus sheath. It is most common in its lower segment and is generally self-limiting. Epidemiology Rectus sheath hematomas are more common in women with a 3:1 F:M ratio. Clinical presentat...

Birth fracture of the clavicle

Birth fractures of the clavicle occur in 0.5-1% of vaginal deliveries and are the most frequent birth-related fracture. They are most commonly seen following normal, uncomplicated births but there is recognized increased incidence with high birth weight babies, forceps delivery and shoulder dyst...

Large joint dislocation

Large joint dislocations are a frequent presentation to emergency departments. Described in descending order of commonality: shoulder dislocation elbow dislocation posterior dislocation of the hip knee dislocation

Elbow dislocation

Elbow dislocation is the second most common large joint dislocation in adults and the most common in children. Epidemiology Elbow dislocations are common and account for 10-25% of all elbow injuries in the adult population 1. They are the most common dislocation in children 4. Associations ...

Terrible triad of the elbow

The terrible triad of the elbow is a severe elbow fracture-dislocation pattern and is so-called because it has poor medium-to-long term outcome. Epidemiology The terrible triad primarily occurs in adults; the flexibility of ligaments in children make this constellation unlikely 4. In the uppe...

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