Iliac Spine Avulsion Research Articles

Intra-articular anterior inferior iliac spine avulsion with hip instability: A retrospective study

BackgroundIntraarticular anteroinferior iliac spine (AIIS) avulsion fractures combined with hip dislocation are infrequently reported in medical literature. This study aims to present the outcomes of surgical treatment for this rare type of injury. MethodsWe retrospectively analyzed six cases of AIIS avulsion fracture with hip dislocation treated surgically. All patients underwent emergency hip reduction under sedation followed by open reduction and internal fixation using 4 mm cannulated screws through the iliofemoral approach. ResultsAfter an average follow-up period of 50 months, all fractures healed. Clinically, four patients were rated as having an excellent outcome and two as good, according to the Harris Hip Score. Radiological assessment using Matta's grading system showed excellent results in five patients and good in one. All patients were able to resume their pre-injury activity levels within six months post-surgery. ConclusionSurgical fixation of AIIS avulsion fractures with associated hip instability demonstrates favourable outcomes, ranging from good to excellent, in both clinical and radiological assessments at medium-term follow-up. This suggests that surgical intervention is a viable option for managing such injuries.

Endoscopic Assisted Percutaneous Fixation of Anterior Inferior Iliac Spine Avulsion Fracture, Surgical Technique

Avulsion fractures of the anterior inferior iliac spine rarely occur in adolescent athletes during rectus femoris contractions or eccentric muscle lengthening while the growth plate is still open. Currently, there are no official guidelines in the literature on the treatment indications of this type of fracture or the type of surgical technique to be used. Nowadays, young and athletic patients desire a quick return to their previous activities, which makes surgical treatment a reasonable choice. Open reduction and internal fixation with an anterior approach are usually recommended when the avulsion fragment has more than 1.5–2 cm displacement on plain radiographs. However, ORIF is associated with a higher risk of heterotopic ossifications and increases the risk of damage to the LFCN. An endoscopic technique was designed to reduce these complications. This technical note describes a procedure of percutaneous fixation to AIIS through 3 endoscopic portals that could potentially minimize complications associated with an open surgical dissection, allowing anatomic reduction under direct visualization.

ASIS Avulsion Fracture Repair with Lag Screw and Tape Bridge Construct

An anterior superior iliac spine avulsion (ASIS) is an injury that is induced by a rapid contraction of the sartorius and tensor fascia lata (TFL) muscles in the thigh. In this technique article, the ASIS is repaired by restoring normal length and tension to the sartorius muscle-tendon unit, which optimizes anatomic healing and function of the hip. We recommend a hybrid fixation strategy. This involved both a tape bridge construct and cannulated compression lag screw fixation. Countersinking the screw below the surface of the ASIS avoids hardware prominence and ensures an impingement-free range of motion. The tape-bridge construct reinforces the lag screw fixation, or can be used as the primary fixation method in the event the fragment is too small to accept a screw. This hybrid technique (tape bridge construct and cannulated screw fixation) is a safe and dependable method of surgically repairing the ASIS, allowing for early mobilization and weight bearing.

Anterior superior iliac spine avulsion: An uncommon school sports injury

Anterior superior iliac spine avulsion: An uncommon school sports injury

Comparaison du traitement non opératoire et chirurgical utilisant des vis résorbables dans les avulsions de l’épine iliaque antéro-supérieure avec un déplacement de plus de 1,5 cm

IntroductionThere is some debate over the best treatment for anterior-superior iliac spine (ASIS) avulsion fractures, although non-surgical treatment can achieve the same results as open surgery. HypothesisAbsorbable screws can be safely used for ASIS avulsion fractures in children and adolescents. Aim of the studyHere, we compared patients on whom no surgery was performed with those who underwent open surgery and investigated the feasibility of using absorbable screws as a new fixation material for treating ASIS avulsion fractures in children and adolescents. Patients and methodsWe retrospectively analysed the data of 59 patients diagnosed with ASIS avulsion fractures in our hospital between January 2009 and December 2016. Based on the clinical data, these patients were assigned into group A (non-surgical group) and group B (absorbable screws group). After the inclusion and exclusion criteria were applied, patients’ clinical records, including radiographs, were analysed. All patients were assessed for range of motion (ROM) and by X-ray as they returned to activity. Evaluation of hip function was done by calculating the American Academy of Orthopedic Surgeons (AAOS) lower limb and hip scores. ResultsAccording to AAOS scores, there were significant differences between the two groups at the first and third months postoperatively (p=0.003), but by the sixth and twelfth months, there was no significant difference (p=0.42). Significant differences were also observed between both groups regarding callus growth on radiographs, time to resume sporting activities, and occurrence of complications such as meralgia paresthetica. All complications resolved by 6 months follow-up. ConclusionOur study agrees with previous reports, absorbable screws can be safely used for ASIS avulsion fractures with greater than 1.5cm displacement in children and adolescents. In comparison with non-surgical therapy, our results indicate that absorbable screws are associated with shorter recovery time and lesser early complications. Level of evidenceIV, retrospective study with control group.

Comparison of non-surgical and surgical treatment using absorbable screws in anterior-superior iliac spine avulsion fractures with over 1.5 cm displacement

IntroductionThere is some debate over the best treatment for anterior-superior iliac spine (ASIS) avulsion fractures, although non-surgical treatment can achieve the same results as open surgery. HypothesisAbsorbable screws can be safely used for ASIS avulsion fractures in children and adolescents. Aim of the studyHere, we compared patients on whom no surgery was performed with those who underwent open surgery and investigated the feasibility of using absorbable screws as a new fixation material for treating ASIS avulsion fractures in children and adolescents. Patients and methodsWe retrospectively analyzed the data of 59 patients diagnosed with ASIS avulsion fractures in our hospital between January 2009 and December 2016. Based on the clinical data, these patients were assigned into group A (non-surgical group) and group B (absorbable screws group). After the inclusion and exclusion criteria were applied, patients’ clinical records, including radiographs, were analyzed. All patients were assessed for range of motion (ROM) and by X-ray as they returned to activity. Evaluation of hip function was done by calculating the American Academy of Orthopedic Surgeons (AAOS) lower limb and hip scores. ResultsAccording to AAOS scores, there were significant differences between the two groups at the first and third months postoperatively (p=0.003), but by the sixth and twelfth months, there was no significant difference (p=0.42). Significant differences were also observed between both groups regarding callus growth on radiographs, time to resume sporting activities, and occurrence of complications such as meralgia paresthetica. All complications resolved by 6 months follow-up. ConclusionOur study agrees with previous reports, absorbable screws can be safely used for ASIS avulsion fractures with greater than 1.5cm displacement in children and adolescents. In comparison with non-surgical therapy, our results indicate that absorbable screws are associated with shorter recovery time and lesser early complications. Level of evidenceIV, retrospective study with control group.

Apophyseal avulsion fractures of the pelvis. A review.

Background and aim of the work: Fractures of the pelvis classically occur in adolescent during sports activities with forceful and repetitive contractions or passive lengthening acting on not yet ossified growth plates. Their misdiagnosis lead to disability, chronic pain and decrease of performances. Evidence based treatment guidelines do not exist; aim of this paper is to point out clinical outcomes, return to sport rates and complications of surgical and conservative approach. Methods: A systematic search based on MEDLINE database was performed in August 2017 to identify all published articles from 2010 to 2017 reporting outcomes, return to sport and complications rates after surgical and non-operative treatment of avulsion fractures of the pelvis. Results: Mean age was 14,5 years with anterior inferior iliac spine avulsion representing the most common injury (46%), followed by anterior superior iliac spine avulsion (32%), ischial tuberosity avulsion (12%) and iliac crest avulsion (11%). Rates of excellent outcome and return to sports at pre-injury levels were higher after surgical treatment; surgery has a higher risk of heterotopic ossification (9%) compared to conservative treatment (1,8%), whereas the risk of non-unions is lower (0% versus 2,5%). Conclusions: Surgery is preferred for major dislocations and fragment sizes, providing a faster return to pre-injury level of activity, decreasing the risk of pseudoarthrosis. Conservative treatment is advisable for minimally displaced fractures when a rapid recovery is not required; patient and his family should be informed on the risk of non-unions and the eventuality of a delayed surgical approach. (www.actabiomedica.it)

Internal Fixation of Inferior Iliac Spine Avulsion in Adolescents: Description of Two Different Surgical Procedures

Internal Fixation of Inferior Iliac Spine Avulsion in Adolescents: Description of Two Different Surgical Procedures

Adölesan amatör futbolcularda görülen spina iliaka anterior ve superior avulsiyon kırıklarının konservatif tedavisi: İki olgu sunumu

The anterior inferior iliac spine (AIIS) and the anterior superior iliac spine (ASIS) avulsion fracture is a rare injury of pelvis. It usually occurs during the sport activities especially in football while hitting the ball. It is commonly misdiagnosed so that a detailed history and physical examination have a great importance. We present two cases of AIIS and ASIS avulsion fracture. Both of the patients applied to outpatient clinics with hip pain and difficulty in walking. History revealed the complaints started after hitting the ball during the football match and hip movements were limited. The patients were fifteen and sixteen years and after physical examination and radiological evaluation, avulsion fracture of the AIIS and the ASIS were diagnosed. Patients were treated conservatively with non-steroidal anti-inflammatory drugs and limited weight bearing with crutches for a month. The patients were free of pain and had full range of hip movements after one month period. At the end of the second month patients returned to active sports. AIIS and ASIS avulsion fractures are more common in adolescent football players but clinicians sometimes fail to diagnose this rare injury. We emphasize the importance of the detailed history and clinical examination and direct radiography could be enough for the diagnosis. Key words: Anterior inferior iliac spine (AIIS), anterior superior iliac spine (ASIS), avulsion fracture, adolescent, football player

Anterior inferior iliac spine avulsion fracture: a series of 5 cases.

Avulsion fractures of the pelvic apophyses rarely occur in adolescent athletes in the course of sudden strong contraction of muscle attached to growth cartilage. This injury may usually be misdiagnosed for tendon or muscle strain. Patient's history, physical examination, and radiologic studies are important for diagnosis. The literature includes only a few case reports but no case series as yet. The aim of this study was to present the results of 5 cases of anterior inferior iliac spine (AIIS) avulsion fractures treated conservatively.The study included 5 patients (4 male, 1 female, mean age 13.6 years) who underwent conservative treatment for AIIS avulsion fractures and had an adequate follow-up. All patients were admitted to the emergency department and misdiagnosed as muscle strain. Three of them were football player, 1 skier, and 1 fighter.Each patient was treated with immobilization and nonsteroidal anti-inflammatory drugs. At follow-up, all patients showed relief from their pain and mechanical symptoms and regained full range of motion and returned to their previous levels of activity.Diagnosis requires careful attention to the physical examination and imaging. In this series, all pelvic avulsion fractures (100%) were managed successfully with a conservative approach. Good results and return to previous levels of activity can be achieved with conservative treatment.

Unusual Orthopaedic Injuries from the World's Most Popular Sport.

When it comes to numbers of participants and spectators, there’s little doubt that soccer is the world’s most popular sport. It makes sense, then, that soccer sees its share of musculoskeletal injuries. The majority of soccer injuries affect the feet and legs, with sprains, strains, and ligament injuries of the knees and ankles being the most common. This month’s “Case Connections” focuses on the diagnosis and treatment of four not-so-common soccer injuries. In the December 10, 2014, JBJS Case Connector, Huri et al. present the case of a teenage professional soccer player with a chronic rupture of the rectus femoris muscle. The initial injury had occurred two years earlier when he kicked another player’s foot instead of the ball. Nonoperative approaches had not facilitated a return to running or kicking. At the time of presentation, doctors noted a prominence on the right thigh that was suggestive of a proximal rupture and distal displacement of the rectus femoris muscle. At an isokinetic speed of 240°/sec, the knee extension strength difference between the injured and normal limbs was 40%; pain prevented the patient from being tested at other isokinetic speeds. MRI of the thigh revealed extensive soft-tissue edema and a complete avulsion of the reflected head of the rectus femoris. Figure 1 shows the rupture location preoperatively and intraoperatively. Fig. 1 Arrows indicate the location of the rectus femoris rupture preoperatively (top) and intraoperatively (bottom). Intraoperatively, surgeons moved the muscle belly proximally as far as possible …

Comparison of conservative against surgical treatment of anterior–superior iliac spine avulsion fractures in children and adolescents

Avulsion fracture of the anterior-superior iliac spine is an uncommon injury. It is mostly seen in adolescent sprinters, distance runners and soccer players. Most cases are unilateral. We present a cohort of patients and the strategy for their treatment. During the period 2005-2012, we treated 23 (19 male, four female) patients with an average age of 15.1 years (4-17). Ten patients with minimally displaced fractures were treated conservatively, and 13 patients with greater fragment dislocation were treated surgically. All patients underwent the standardised rehabilitation protocol. We evaluated range of motion (ROM), X-ray six weeks and one year postoperatively, length of bed rest, return to activity and complication rates (infection, heterotopic ossification). All patients returned to sports at the preinjury level. Surgically treated patients showed faster recovery and better compliance with rehabilitation protocols. The time interval for X-ray union was comparable between groups, as was full recovery. There was no deep infection; however, there were five minor heterotopic ossifications, none of which required further treatment. We emphasise that the indication for surgical treatment is mainly determined by the grade of fragment displacement and the patient's sporting activity. Although long-term results were comparable between treatment methods, surgery carries the risk of higher complication rates and the need for osteosynthetic material extraction.

Avulsion Fractures Involving the Straight and Reflected Heads of the Rectus Femoris

Tumours and sport injuries can both affect active, young patients, and the symptoms of the two often overlap. Neglected avulsion injuries sometimes cause a mass to develop which can mimic a tumour. We discuss the diagnosis, treatment, and results following nine anterior inferior iliac spine (AISS) avulsion fractures.

Anterior superior iliac spine avulsion fracture presenting as meralgia paraesthetica in an adolescent sprinter

We report here a rare case of anterior superior iliac spine avulsion fracture that presented initially as meralgia paraesthetica. A 14-year-old male sprinter presented with anterior superior iliac spine avulsion fracture, which was not observed on initial plain radiograph of the hip, but was diagnosed by ultrasound. Both clinical presentations and electrophysiological studies indicated meralgia paraesthetica. The lateral femoral cutaneous nerve of the thigh was probably compressed by an inguinal haematoma resulting from sartorius muscle strain, which was detected on musculoskeletal ultrasound. Computed tomography of the pelvis confirmed anterior superior iliac spine avulsion fracture. Meralgia paraesthetica in adolescents can be due to anterior superior iliac spine avulsion fracture. Sonography is a valuable tool for screening for muscular haematoma and occult fractures, which may allow clinicians to diagnose the nature of the muscle injury, and thus guide the most appropriate therapeutic strategy.

Fracture-avulsion de l’épine iliaque antéro-inférieure et du petit trochanter chez un jeune adolescent

The avulsion fractures of the anterior-inferior iliac spine and lesser trochanter are rare. They occur most often in adolescents during sports activities. The forms in adults are rare. We report a case in a young 15-year-old teenager. He had consulted for pelvic trauma with groin pain and functional impotence of the right lower limb occurred during a recent game in triple jump. Physical examination revealed pain in the mobilization of the right hip in extension. Standard radiography of the pelvis has highlighted an avulsion fracture of the anterior-inferior iliac spine avulsion of the right with small trochanter, which has been confirmed by computed tomography. The patient has been treated orthopedically by rest and landfilling lower limb trauma, evolution was marked the disappearance of pain a few weeks later and resumption of the sporting activity in order to 6months.

Radiologic Patterns of Ewing Sarcoma

HomeRadioGraphicsVol. 33, No. 3 PreviousNext DepartmentsIlluminationsRadiologic Patterns of Ewing SarcomaAletta Ann FrazierAletta Ann FrazierAuthor AffiliationsAmerican Institute for Radiologic Pathology, Silver Spring, Maryland, and University of Maryland School of Medicine, Baltimore, Maryland ([email protected])Aletta Ann FrazierPublished Online:May 3 2013https://doi.org/10.1148/rg.333135909MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Article HistoryPublished online: May 3 2013Published in print: May 2013 FiguresReferencesRelatedDetailsCited ByRadiopaedia.orgIrvineSihlahla2021Recommended Articles Imaging Features and Management of Stress, Atypical, and Pathologic FracturesRadioGraphics2018Volume: 38Issue: 7pp. 2173-2192Common Skeletal Neoplasms and Nonneoplastic Lesions at 18F-FDG PET/CTRadioGraphics2021Volume: 42Issue: 1pp. 250-267Pediatric Osteosarcoma: Correlation of Imaging Findings with Histopathologic Features, Treatment, and OutcomeRadioGraphics2022Volume: 42Issue: 4pp. 1196-1213Musculoskeletal Imaging Findings of Hematologic MalignanciesRadioGraphics2017Volume: 37Issue: 3pp. 881-900Pearls and Pitfalls for Soft-Tissue and Bone Biopsies: A Cross-Institutional ReviewRadioGraphics2020Volume: 40Issue: 1pp. 266-290See More RSNA Education Exhibits Through Thick and Thin: Periosteal Reactions and Their Underlying EtiologyDigital Posters2019For Every Bone Aggression, There is a Periosteal ReactionDigital Posters2019The Role of Imaging in Tumoral Periosteal Reaction: A Pictorial Review with Pathological CorrelationDigital Posters2020 RSNA Case Collection Osteomyelitis with sequestrumRSNA Case Collection2021Ewing's sarcomaRSNA Case Collection2020Anterior Superior Iliac Spine Avulsion FractureRSNA Case Collection2021 Vol. 33, No. 3 Metrics Altmetric Score PDF download

Practice Corner: Is Radiology Education Ready for a Flipped Classroom?

HomeRadioGraphicsVol. 33, No. 2 PreviousNext EditorialsPractice Corner: Is Radiology Education Ready for a Flipped Classroom?Douglas E. Green , Michael F. McNeeleyDouglas E. Green , Michael F. McNeeleyAuthor AffiliationsFrom the Department of Radiology, University of Washington, 1959 NE Pacific St, RR215, Box 357115, Seattle, WA 98109.Address correspondence to D.E.G. (e-mail: [email protected]).Douglas E. Green Michael F. McNeeleyPublished Online:Mar 2 2013https://doi.org/10.1148/rg.332135003MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In References1 Salman Khan talk at TED 2011. http://www.youtube.com/watch?v=gM95HHI4gLk. Accessed November 18, 2012. Google Scholar2 Noer M. One man, one computer, 10 million students: how Khan Academy is reinventing education. Forbes. November 19, 2012. Google Scholar3 Salman Khan interviewed on Book TV. http://www.booktv.org/Program/13882/After+Words+Salman+Khan+The+One+World+Schoolhouse+Education+Reimagined+hosted+by+Nina+Rees+National+Alliance+of+Public+Charter+Schools.aspx. Accessed January 15, 2012. Google Scholar4 Cohen MD, Hawes DR, Hutchins GD, McPhee WD, LaMasters MB, Fallon RP. Activity-based cost analysis: a method of analyzing the financial and operating performance of academic radiology departments. Radiology 2000;215(3):708–716. Link, Google Scholar5 Collins J. Education techniques for lifelong learning: principles of adult learning. RadioGraphics 2004;24(5):1483–1489. Link, Google Scholar6 Hattery RR. Quality initiatives in radiology: president’s address from the opening session of RSNA 2006: strengthening professionalism. RadioGraphics 2008;28(1):7–11. Link, Google ScholarArticle HistoryReceived: Nov 30 2012Revision requested: Jan 10 2013Revision received: Jan 15 2013Accepted: Jan 17 2013Published online: Mar 2 2013Published in print: Mar 2013 FiguresReferencesRelatedDetailsCited ByAcademic Radiology, Vol. 28, No. 12Navigating Generational Differences in RadiologyArun Krishnaraj, A.J. Pesch, 10 October 2018 | RadioGraphics, Vol. 38, No. 6Medical Teacher, Vol. 40, No. 9PLOS ONE, Vol. 12, No. 9Journal of Research in Curriculum Instruction, Vol. 20, No. 2Journal of the American College of Radiology, Vol. 12, No. 12Academic Radiology, Vol. 21, No. 7Current Opinion in Anaesthesiology, Vol. 26, No. 6Recommended Articles Social Media Tools for Department and Practice Communication and Branding in the Digital AgeRadioGraphics2018Volume: 38Issue: 6pp. 1773-1785Realizing Improvement through Team Empowerment (RITE): A Team-based, Project-based Multidisciplinary Improvement ProgramRadioGraphics2016Volume: 36Issue: 7pp. 2170-2183A Review of 2016 and a Look Forward to 2017 and Beyond: Editor’s PageRadioGraphics2017Volume: 37Issue: 1pp. 1-42018 in Review and Plans for 2019RadioGraphics2019Volume: 39Issue: 1pp. 1-6Peer Feedback, Learning, and Improvement: Answering the Call of the Institute of Medicine Report on Diagnostic ErrorRadiology2016Volume: 283Issue: 1pp. 231-241See More RSNA Education Exhibits Applying Adult Learning Principles to an Online Curriculum about Diagnostic ErrorsDigital Posters2019Instagram’s Influence on Radiology Today Digital Posters2019Flip It! Techniques for Interactive, Learner-Directed Educational Conferences to Increase Trainee Engagement and Diagnostic ConfidenceDigital Posters2019 RSNA Case Collection Jackstone calculusRSNA Case Collection2021Cardiac fibromaRSNA Case Collection2020Anterior Superior Iliac Spine Avulsion FractureRSNA Case Collection2021 Vol. 33, No. 2 Metrics Altmetric Score PDF download

Adolescent Femoroacetabular Impingement From Malunion of the Anteroinferior Iliac Spine Apophysis Treated With Arthroscopic Spinoplasty

This article describes a case of an acute anterior inferior iliac spine apophyseal avulsion fracture in an adolescent athlete progressing to secondary symptomatic femoroacetabular impingement from an inferiorly displaced malunion and its arthroscopic management. A 13-year-old boy with an acute minimally displaced avulsion fracture of the anterior inferior iliac spine apophysis had initial symptomatic improvement with conservative treatment and a 3-month symptom-free period but then developed flexion-induced deep anterior groin pain and mechanical symptoms. Radiographs confirmed an inferiorly displaced malunion of the ipsilateral anterior inferior iliac spine apophysis in addition to acetabular retroversion and cam deformity. Surgical treatment, including arthroscopic spinoplasty, was performed. Despite some nonrestrictive heterotopic ossification, the patient had a successful clinical outcome at 18 months, with return to football, and a nonarthritic hip score of 98. Although anterior inferior iliac spine avulsion fractures have historically been considered relatively self-limiting injuries, their malunion may be a previously missed cause of unrelenting or bimodal pain from secondary femoroacetabular impingement with possible degenerative consequences in young athletic patients. Anterior inferior iliac spine avulsion fractures may merit a lower degree of tolerance for displacement in the acute setting and a higher degree of clinical and radiographic scrutiny with surgical intervention, possibly in the form of arthroscopic spinoplasty in the more chronic one.

Avulsion Fracture of Anterior Inferior Iliac Spine in a Skeletally Mature Man; Mimicking Pathologic Bone Lesion

Avulsion fractures of the pelvis occur in both the skeletally immature and adult patient populations the patho-mechanism is the sudden forceful contraction of the related muscle. The case reported here is an overlooked case of anterior inferior iliac spine avulsion fracture in a 25-year-old man, misinterpreted as malignant pathology. Avulsion fractures of the anterior inferior iliac spine can be diagnosed with medical history and radiological methods. The physician must be cautious during the assessment of the patient with complaint in his/her groin and keep in mind the possibility of an anterior inferior iliac spine fracture.

Musculoskeletal Sonography Facilitates the Diagnosis of Adolescent Anterior Superior Iliac Spine Avulsion Fracture

Anterior superior iliac spine (ASIS) avulsion fractures are not common. We describe a 15-year-old boy who suffered from sudden onset of pain on the left side of his groin when running a race, accompanied by weakness in raising his left leg. Physical examination revealed local tenderness over left ASIS area, initial pelvic radiograph showed no abnormalities, but kidney-ureter-bladder radiograph revealed a small indistinct radiopaque shadow lateral to iliac bone. Then, musculoskeletal sonography disclosed the displacement of the apophysis from the left ASIS, and avulsion fracture was impressed. Pelvic computed tomography confirmed the diagnosis. The patient gradually recovered after conservative treatment. Groin pain in athletes is a dilemma in diagnosis, and careful correlation of the clinical condition and radiological findings is essential to avoid misdiagnosis. Musculoskeletal ultrasound is a useful tool for quick screening and to facilitate diagnosis.