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4. Pediatrics MCQs

Practice Set 92 of 334

This practice set contains high-yield board review questions covering key concepts in 4. Pediatrics. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 1821

Topic: Pediatric Hip

A 53-year-old man with a history of severe left hip pain has a significant limp that is the result of a 5-cm limb-length discrepancy. An AP radiograph is shown in Figure 48. The underlying etiology is most likely related to a history of

Anatomy Board Review 2002: High-Yield MCQs (Set 4) - Figure 10

. septic arthritis.
. slipped capital femoral epiphysis.
. femoral head fracture (Pipkin I).
. developmental dysplasia of the hip.
. Legg-Calve-Perthes disease.

Correct Answer & Explanation

. Legg-Calve-Perthes disease.

Explanation

Radiographic abnormalities such as coxa magna, coxa breva secondary to growth arrest, and coxa plana and acetabular deformities are associated with healed Legg-Calve-Perthes disease. Femoral heads that were flat yet congruent with the acetabulum are at risk for disabling arthritis in the sixth decade of life in 50% of these untreated patients. As the normal ball-and-socket joint deforms to a flattened cylinder, the hip loses abduction and rotation capability, while retaining flexion and extension potential. If the femoral head is flat and is not concentric with the acetabulum, early severe arthritis occurs. Hinge abduction and anterior impingement are known sequelae of a flat, incongruent femoral head.

Question 1822

Topic: 4. Pediatrics

The mother of a 3-month-old infant states that she has difficulty positioning the infant's legs during diaper changes. Examination reveals limited abduction of both hips and a negative Ortolani sign. A radiograph reveals bilaterally dislocated hips. Initial management consists of guided reduction in a Pavlik harness, with weekly follow-up. Figures 57a and 57b show the radiograph and CT scan obtained after 6 weeks in the harness. Management should now consist of

. placement of the hips in wider abduction and continued use of the harness.
. increased flexion of the hips and continued use of the harness.
. removal of the harness and application of an Ilfeld splint.
. removal of the harness and application of a von Rosen splint.
. removal of the harness, followed by closed or open reduction.

Correct Answer & Explanation

. removal of the harness, followed by closed or open reduction.

Explanation

In an infant younger than age 6 months with a complete dislocation of the hip that is not initially reducible, the Pavlik harness may be used for a trial of guided reduction. When the harness is used in these patients, the infant should be followed at weekly intervals to see if reduction has been achieved. If the hip does not reduce after 3 to 4 weeks of harness wear, the harness should be discontinued, and closed or open reduction should be considered to avoid secondary deformation of the posterolateral acetabulum, also known as Pavlik harness pathology. Changing to other abduction braces is not indicated. Jones GT, Schoenecker PL, Dias LS: Developmental hip dysplasia potentiated by inappropriate use of the Pavlik harness. J Pediatr Orthop 1992;12:722-726. Atar D, Lehman WB, Grant AD: Pavlik harness pathology. Isr J Med Sci 1991;27:325-330.

Question 1823

Topic: 4. Pediatrics

Figures 43a and 43b show the clinical photographs of a 4-month-old child with bilateral popliteal pterygium. The fixed knee contractures measure 100 degrees bilaterally. What future treatment is most likely to successfully correct this deformity?

. Serial casting of both knees weekly
. Physiotherapy and dynamic splinting
. Soft-tissue releases of the knees, including Z-plasties of skin, excision of fibrotic bands, hamstring lengthenings, and posterior knee capsulotomies
. Femoral shortening osteotomies combined with soft-tissue releases of the knees (Z-plasties of skin, excision of fibrotic bands, hamstring lengthenings, and posterior knee capsulotomies)
. Gradual correction with a circular external fixator without soft-tissue release

Correct Answer & Explanation

. Soft-tissue releases of the knees, including Z-plasties of skin, excision of fibrotic bands, hamstring lengthenings, and posterior knee capsulotomies

Explanation

Congenital popliteal webbing with contractures of 60 degrees is a difficult deformity to correct. The anatomy of the web is of considerable importance. MRI can delineate the extent of the posterior fibrous band that often stretches from the ischium to the calcaneus. The sciatic nerve, usually shortened, most often runs just anterior to this fibrous band. For mild contractures of less than 20 degrees, nonsurgical management is usually adequate. Hamstring lengthening and postoperative splinting are usually sufficient for contractures of 20 degrees to 40 degrees. Moderate contractures of up to 60 degrees usually require Z-plasties in the popliteal fossa and postoperative serial casting to avoid undue tension on neurovascular structures. Contractures of more than 60 degrees require a femoral shortening osteotomy or gradual correction with an external fixator. However, rapid recurrence following fixator removal is common if formal soft-tissue procedures and postoperative splinting are not performed. Parikh SN, Crawford AH, Do TT, et al: Popliteal pterygium syndrome: Implications for orthopaedic management. J Pediatr Orthop B 2004;13:197-201.

Question 1824

Topic: 4. Pediatrics

A 3-year-old boy with severe cerebral palsy is unable to sit independently and does not crawl. Examination reveals a 40-degree hip flexion contracture by the Thomas test and 25 degrees of passive abduction. A radiograph of the pelvis shows subluxation of both hips, with a migration index of 30%. Management should consist of

. application of a Pavlik harness.
. botulinum toxin A injections to the adductor and iliopsoas muscles.
. bilateral release of the adductor and iliopsoas muscles.
. bilateral soft-tissue release and proximal femoral varus rotational osteotomies.
. selective dorsal rhizotomy.

Correct Answer & Explanation

. bilateral release of the adductor and iliopsoas muscles.

Explanation

Progressive hip subluxation occurs in up to 50% of children with spastic quadriparesis. The subluxation is the result of chronic muscle hypertonicity, especially in the adductor muscle group. In time, the constant muscle tension will lead to dislocation, dysplastic changes in the acetabulum, and erosive changes in the cartilage of the femoral head. Many of these children will experience pain. Two recent studies have shown that early soft-tissue releases can successfully prevent progressive subluxation in children who are younger than age 4 years and who have a Reimers index (migration index) of less than 40%. Botulinum toxin A injections may reduce tone in the adductors for 4 to 6 months, but it is difficult to inject into the iliopsoas. Additionally, there are no long-term studies documenting the efficacy of botulinum toxin A to treat progressive hip subluxation in patients who have spastic quadriparesis. In general, proximal femoral osteotomy, combined with soft-tissue release as necessary, is indicated in older children (older than age 4 years) with progressive subluxation. Although selective dorsal rhizotomy has been used in nonambulatory patients, outcomes are less well documented than in ambulatory patients. There are no studies documenting the effect of selective dorsal rhizotomy on progressive hip subluxation in nonambulatory children. Miller F, Cardoso Dias R, Dabney KW, et al: Soft-tissue release for spastic hip subluxation in cerebral palsy. J Pediatr Orthop 1997;17:571-584.

Question 1825

Topic: 4. Pediatrics

A patient who underwent closed reduction of the hips as an infant now reports pain. An abduction internal rotation view shows an incongruous joint. Based on the findings shown in Figure 3, what is the most appropriate type of pelvic osteotomy for the right hip?

Pediatrics 2007 Practice Questions: Set 1 (Solved) - Figure 8

. Salter-type innominate
. Pemberton-type
. Triple innominate
. Ganz or Bernese periacetabular
. Chiari

Correct Answer & Explanation

. Chiari

Explanation

Pelvic osteotomies that redirect hyaline cartilage over the femoral head offer the potential for long-term preservation of the hip; however, salvage procedures such as the Chiari osteotomy are indicated in patients without a concentrically reducible hip. Ito and associates reported that moderate dysplasia and moderate subluxation without complete obliteration of the joint space and a preoperative center-edge angle of at least minus 10 degrees are desirable selection criteria. Ohashi H, Hirohashi K, Yamano Y: Factors influencing the outcome of Chiari pelvic osteotomy: A long-term follow-up. J Bone Joint Surg Br 2000;82:517-525.

Question 1826

Topic: Pediatric Hip

Figures 39a and 39b show the current radiographs of an 8-year-old girl who has had pain in the left thigh for the past 3 months. She was recently diagnosed with hypothyroidism and started treatment 1 week ago. Examination reveals a mild abductor deficiency limp on the left side. She lacks 30 degrees internal rotation on the left hip compared with the right hip. Management should consist of

. abductor muscle strengthening.
. a left 1-1/2 hip spica cast.
. closed reduction and pinning of the left hip.
. symptomatic treatment with crutch walking and nonsteroidal anti-inflammatory drugs.
. in situ pinning of both hips.

Correct Answer & Explanation

. in situ pinning of both hips.

Explanation

The radiographs confirm a slipped capital femoral epiphysis of the left hip, as well as a widened growth plate on the contralateral hip. This is considered a stable slip because the patient is able to walk. Treatment options for stable slips include in situ pinning, bone graft epiphysiodesis, and in some centers severe slips are treated with primary osteotomy and epiphyseal fixation. Percutaneous in situ fixation is the most popular and widely used method of treatment. This juvenile patient has an endocrine condition and a widened growth plate on the right side; therefore, strong consideration should be given to pinning the contralateral hip "pre-slip." Muscle strengthening, hip spica casting, and closed reduction have no place in the primary treatment of a stable slipped capital femoral epiphysis. Loder RT, Richards BS, Shapiro PS, et al: Acute slipped capital femoral epiphysis: The importance of physeal stability. J Bone Joint Surg Am 1993;75:1134-1140. Loder R, Wittenberg B, DeSilva G: Slipped capital femoral epiphysis associated with endocrine disorders. J Pediatr Orthop 1995;15:349-356.

Question 1827

Topic: 4. Pediatrics

A 12-year-old boy reports limping and chronic knee pain that is now inhibiting his ability to participate in sports. Clinical examination and radiographs of the knee are normal. Additional evaluation should include

. mechanical alignment radiographs.
. stress radiographs of the knee.
. comparison radiographs of both knees.
. an erythrocyte sedimentation rate and a C-reactive protein.
. examination of the hip.

Correct Answer & Explanation

. examination of the hip.

Explanation

While all of the answers may be appropriate, radiating pain from hip pathology must be excluded. At this age, a slipped capital femoral epiphysis is likely. Therefore, the hip must be examined. Kocher MS, Bishop JA, Weed B, et al: Delay in diagnosis of slipped capital femoral epiphysis. Pediatrics 2004;113:322-325.

Question 1828

Topic: 4. Pediatrics

A 4-year-old child was born with bilateral congenital radial clubhands. Which of the following associated conditions is a contraindication to centralization of the hands on the ulna?

. Congenital scoliosis
. Hypoplastic thumb
. Tracheoesophageal fistula
. Imperforate anus
. Lack of elbow flexion

Correct Answer & Explanation

. Lack of elbow flexion

Explanation

Patients born with bilateral radial clubhands may have difficulty getting their hands to their mouth. The centralization procedure would take away that ability if there is a lack of elbow flexion. Green DP, Hotchkiss RN, Pederson WC: Green's Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, pp 344-349.

Question 1829

Topic: 4. Pediatrics

Figure 47 shows the radiograph of a 2-day-old girl who has been referred for swelling and limited use of the right upper extremity. The second of twins, the infant was breech and delivered with forceps at age 38 weeks, weighing 5.37 lb. Difficulty in moving the arm was noted shortly after birth. Examination shows no active motion of the shoulder, elbow, or wrist. Active finger flexion and extension are present. The elbow is mildly swollen, and passive motion shows lack of full extension of 20 degrees, lack of full flexion of 15 degrees, and no restriction of pronation or supination. What is the most likely diagnosis?

Pediatrics Board Review 2001: High-Yield MCQs (Set 4) - Figure 2

. Obstetrical brachial plexus palsy
. Congenital dislocation of the elbow
. Congenital dislocation of the radial head
. Arthrogryposis
. Transphyseal fracture of the distal humerus

Correct Answer & Explanation

. Transphyseal fracture of the distal humerus

Explanation

Fractures involving the entire distal humeral physis may be a complication of a difficult delivery. Basing the diagnosis on radiographs can be difficult at this age because the secondary ossification center of the lateral condyle has not developed. The key to the diagnosis is the constant relationship of the radius and ulna, with medial and posterior displacement of the forearm relative to the humerus. An ultrasound can be obtained to confirm the diagnosis in newborns. Because the fracture is through cartilage, examination may reveal only mild swelling, and crepitation may be muffled or not apparent. The lack of apparent active motion of the shoulder, elbow, and wrist is secondary to pseudoparalysis. Child abuse is a common mechanism of this injury in a child who is age 1 month to age 3 years. Beaty JH, Wilkins KE: Fractures involving the entire distal humeral physis, in Rockwood CA, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, Pa, Lippincott-Raven, 1996, vol 3, pp 790-801. Dias JJ, Lamont AC, Jones JM: Ultrasonic diagnosis of neonatal separation of the distal humeral epiphysis. J Bone Joint Surg Br 1988;70:825-828.

Question 1830

Topic: 4. Pediatrics
Figure 24 shows the radiograph of a 10-year-old boy who sustained a valgus injury to the knee. Examination reveals grade III medial laxity. Initial management should consist of
. an MRI scan.
. stress radiographs of the knee.
. activities as tolerated.
. a hinged range-of-motion brace.
. a knee immobilizer.

Correct Answer & Explanation

. stress radiographs of the knee.

Explanation

Based on the mechanism of injury and findings of medial laxity, the most likely diagnosis is injury to either the growth plate or the medial collateral ligament. With the open physeal plate, this area of injury is presumed present until proven otherwise; therefore, stress radiographs should be obtained before implementing any treatment or ordering more extensive and expensive tests.

Question 1831

Topic: 4. Pediatrics

Figure 16 shows the clinical photograph of a 3-month-old infant with a foot deformity that has been nonprogressive since birth. Examination reveals that the deformity corrects actively and with passive manipulation. There is no associated equinus. Management should consist of

Pediatrics Board Review 2004: High-Yield MCQs (Set 2) - Figure 13

. serial casting.
. UCBL orthotics.
. abductor hallucis lengthening.
. observation and parental reassurance.
. corrective shoes.

Correct Answer & Explanation

. observation and parental reassurance.

Explanation

The patient has bilateral metatarsus adductus deformities. In a long-term follow-up study by Farsetti and associates, deformities that were passively correctable spontaneously resolved and no treatment was required. More rigid deformities were successfully treated with serial manipulation, with good results in 90%. There were no poor results. Therefore, observation is the management of choice for passively correctable deformities. In feet that are more rigid, serial manipulation and casting is the management of choice.

Question 1832

Topic: 4. Pediatrics

Figure 19 shows the radiograph of a 6-month-old infant who has limited hip motion. History reveals no complications during pregnancy or delivery. Examination reveals that hip abduction is 45 degrees in flexion bilaterally. The neurologic examination is normal. What is the best course of action?

Pediatrics Board Review 2004: High-Yield MCQs (Set 2) - Figure 25

. Adductor tenotomy
. Physical therapy
. Observation
. Abduction orthosis
. Neurologic consultation

Correct Answer & Explanation

. Observation

Explanation

Diminished hip abduction can occur in normal children and is not always associated with hip pathology; therefore, initial management should consist of observation.

Question 1833

Topic: 4. Pediatrics

A 12-year-old child with spina bifida paraplegia requires brace management for ankle stability. Which of the following principles applies to brace management in this individual?

. A shorter lever arm is more effective in limiting pressure.
. Limbs with mild contractures do better with bracing than flaccid limbs through increased force concentration.
. Three-point pressure effect works best to prevent the joint from buckling.
. Four-point pressure effect works best to prevent the joint from buckling.
. Smaller base support provides increased stability.

Correct Answer & Explanation

. Three-point pressure effect works best to prevent the joint from buckling.

Explanation

Bracing for spina bifida paraplegia provides both support and improved function of the movable limb. An orthosis has value in controlling unstable joints. The three-point pressure effect applies a force above and below the joint to prevent it from buckling. A four-point pressure effect is only required for a two-joint system (this patient has problems only at the ankle). A longer lever arm brace and a brace with a greater area of support provide better stability. Finally, a straighter limb, without contracture, applies less pressure to the brace and lessens overload to the skin. Gage JR: An overview of normal walking. Instr Course Lect 1990;39:291-303. Bleck EE: Current concepts review: Management of the lower extremities in children who have cerebral palsy. J Bone Joint Surg Am 1990;72:140-144.

Question 1834

Topic: 4. Pediatrics

Split posterior tibial tendon transfer is used in the treatment of children with cerebral palsy. Which of the following patients is considered the most appropriate candidate for this procedure?

. A 6-year-old child with athetosis and a flexible equinovarus deformity of the foot
. A 6-year-old child with spastic hemiplegia and a rigid equinovarus deformity of the foot
. A 6-year-old child with spastic hemiplegia and a flexible equinovarus deformity of the foot
. A 10-year-old child with spastic quadriplegia and rigid valgus deformities of the feet
. A 15-year-old child with spastic diplegia and rigid equinovalgus deformities of the feet

Correct Answer & Explanation

. A 6-year-old child with spastic hemiplegia and a flexible equinovarus deformity of the foot

Explanation

Split posterior tibial tendon transfers are best performed in patients with spastic cerebral palsy who are between the ages of 4 and 7 years and have flexible equinovarus deformities. Rigid deformities typically require bony reconstruction procedures. Tendon transfers in patients with athetosis are unpredictable. Green NE, Griffin PP, Shiavi R: Split posterior tibial-tendon transfer in spastic cerebral palsy. J Bone Joint Surg Am 1983;65:748-754.

Question 1835

Topic: 4. Pediatrics

A 7-year-old boy sustains an acute injury to the distal radial metaphysis, along with a completely displaced Salter-Harris type I fracture of the ulnar physis, as shown by the arrows in Figure 12. After satisfactory reduction of both injuries, what is the major concern?

Trauma 2000 Practice Questions: Set 1 (Solved) - Figure 31

. Loss of reduction of the ulnar physis
. Loss of reduction of the radial metaphysis
. Physeal arrest of the distal radius
. Physeal arrest of the distal ulna
. Osteonecrosis of the ulnar epiphysis

Correct Answer & Explanation

. Physeal arrest of the distal ulna

Explanation

While injury of the distal radial metaphysis is a rather common occurrence, the incidence of physeal arrest is only about 4% to 5% of patients. While injury of the distal physis of the ulna is rare, the incidence of physeal arrest is greater than 50% in fractures of this structure. These patients need to be followed closely both clinically and radiographically to look for the signs of distal ulnar/physeal arrest such as loss of the prominence of the ulna and ulnar deviation of the hand. Radiographically, progressive shortening of the ulna is observed. Nelson OA, Buchanan JR, Harrison CS: Distal ulnar growth arrest. J Hand Surg Am 1984;9:164-170.

Question 1836

Topic: 4. Pediatrics

A 12-year-old boy who has had a 1-month history of right thigh pain and a limp reports worsening of the pain after a fall, and he can no longer walk or bear weight on the involved extremity. Radiographs of the pelvis reveal a slipped capital femoral epiphysis with moderate to severe displacement. While positioning the patient on the fracture table for screw fixation, partial reduction of the slip is achieved. No further reduction maneuvers are attempted, and the epiphysis is stabilized with a single cannulated screw. What complication is most likely to develop following this procedure?

. Infection
. Chondrolysis
. Nonunion
. Osteonecrosis
. Epiphyseal arrest

Correct Answer & Explanation

. Osteonecrosis

Explanation

Traditional classification of slipped capital femoral epiphyses is based on the following temporal criteria: acute (symptoms that persist for less than 3 weeks); chronic (symptoms that persist for more than 3 weeks); or acute on chronic (acute exacerbation of long-standing symptoms). A newer classification differentiates between a stable slip where weight bearing is possible, and an unstable slip if it is not. Reduction of an unstable slip often occurs unintentionally with induction of anesthesia and positioning of the patient for surgery. The rate of satisfactory results is lower primarily because of a much higher incidence of osteonecrosis following internal fixation of an unstable slip. Loder RT, Richards BS, Shapiro PS, Reznick LR, Aronson DD: Acute slipped capital femoral epiphysis: The importance of physeal stability. J Bone Joint Surg Am 1993;75:1134-1140.

Question 1837

Topic: 4. Pediatrics

Figures 36a and 36b show the radiographs of a 3-year old child who has a congenital upper extremity deformity. Which of the following features would be a major contraindication to a centralization procedure?

. Complete absence of the thumb
. Thrombocytopenia
. Patient age of less than 5 years
. Lack of elbow motion
. Absence of the radial artery

Correct Answer & Explanation

. Lack of elbow motion

Explanation

The patient has bilateral absent radii or radial clubhand. Patients who lack elbow flexion take advantage of the hand position to reach their mouths, and a centralization procedure would take away that ability. This procedure can be performed on patients with partial to complete absence of the radius. A hypoplastic thumb can be addressed at a staged procedure; it does not represent a contraindication to centralization. Complete thumb absence can be addressed by pollicizing the index ray. Green DP: Operative Hand Surgery, ed 2. New York, NY, Churchill Livingstone, 1988, pp 269-271.

Question 1838

Topic: Pediatric Hip

A 5-year-old boy has had right hip pain and a limp for the past 3 months. Examination of the right hip reveals irritability and restricted abduction and internal rotation. AP and lateral radiographs of the hips are shown in Figures 31a and 31b. Initial management should consist of

. a Salter innominate osteotomy.
. a shelf acetabuloplasty.
. a varus femoral osteotomy.
. symptomatic treatment, including traction, activity modification, and nonsteroidal anti-inflammatory drugs.
. abduction bracing.

Correct Answer & Explanation

. symptomatic treatment, including traction, activity modification, and nonsteroidal anti-inflammatory drugs.

Explanation

A favorable prognosis can be expected in up to 70% of children with Legg-Calve-Perthes disease who are younger than age 6 years. Containment treatment has not been shown to alter the outcome in this age group. The goals of treatment in this patient are to reduce pain (synovitis), restore motion, and improve function. Symptomatic treatment modalities include bed rest, traction, crutches, activity modification, and nonsteroidal anti-inflammatory drugs. Herring JA: The treatment of Legg-Calve-Perthes disease: A critical review of the literature. J Bone Joint Surg Am 1994;76:448-458.

Question 1839

Topic: 4. Pediatrics

A 5-year-old girl sustained a comminuted Salter-Harris type IV fracture of the left distal tibia 2 years ago. The AP radiograph shown in Figure 54a reveals a growth arrest and a 1.4-cm limb-length discrepancy. The ankle is in approximately 20 degrees of varus. Figure 54b shows a coronal reconstruction image of the distal tibial physis, and Figure 54c shows a sagittal reconstruction image of the same area. On the sagittal reconstruction image, the bar extends from the 9-mm mark to the 24-mm mark in 3-mm increments. On the coronal image, the bar extends from the 9-mm mark to the 24-mm mark, also in 3-mm increments. A map of the physeal bar based on these measurements is shown in Figure 54d. Initial treatment should consist of

. bony bar resection and distal fibula epiphysiodesis.
. bony bar resection and corrective osteotomy.
. bony bar resection and physiodesis of the opposite distal tibial physis.
. corrective osteotomy and a limb-lengthening procedure.
. corrective osteotomy and physiodesis of the opposite distal tibial physis.

Correct Answer & Explanation

. bony bar resection and corrective osteotomy.

Explanation

Mapping of a physeal bar from biplane polytomography or CT helps to identify lesions that should be treated surgically and aids in planning the surgical approach and resection. Criteria for surgical excision are at least 2 years of longitudinal growth remaining and involvement of no more than 50% of the physis. Osteotomy is required if angular deformity is greater than 20 degrees. Although this physeal bar is large, it is slightly less than 50% of the total area of the physis. Limb lengthening in this case should be reserved for failure of bar resection. Physiodesis of the opposite distal tibia at this age would result in disproportionate shortening of both tibiae. Carlson WO, Wenger DR: A mapping method to prepare for surgical excision of a partial physeal arrest. J Pediatr Orthop 1984;4:232-238.

Question 1840

Topic: 4. Pediatrics

A newborn girl is referred for evaluation of suspected hip instability. What information from her history would place her in the highest risk category?

. History of maternal diabetes mellitus
. Frank breech presentation
. Female gender
. Concomitant metatarsus adductus
. Twin gestation

Correct Answer & Explanation

. Frank breech presentation

Explanation

Breech positioning has been noted as the risk factor that most increases the relative risk of developmental dysplasia of the hip in multiple series and meta-analysis. All the other factors also increase the risk but to a lesser magnitude. Lehmann HP, Hinton R, Morello P, et al: Developmental dysplasia of the hip practice guideline: Technical report. Committee on Quality Improvement, and Subcommittee on Developmental Dysplasia of the Hip. Pediatrics 2000;105:E57.

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