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Fulltext A Chinese New Year rash

Keah RSH, Ch'ng KS

Malays Fam Physician, 2013;8(2):62-64.
PMID: 25606287 MyJurnal

A 28-year-old man presented with a chief complaint of rashes all over his body. He had a history of a trip to Langkawi Island, a famous island resort off the west coast of Malaysia, over the Chinese New Year’s weekend. According to him, he had a lot of fun with a group of friends at the sunny beach and the beautiful sea. There were no untoward incidents and they were perfectly well when they returned home after a 2-day trip. On the evening of the second day after his return, he noticed rashes appearing over his body, notably on shoulders and trunk. These rashes were little painful in nature.

Matched MeSH terms: Shoulder
Fulltext Precontoured Clavicular Locking Plate with Broad Lateral End: A Newly Designed Plate for Lateral Third Clavicle Fractures

Kapil-Mani KC, Acharya P, Arun S

Malays Orthop J, 2018 Mar;12(1):15-20.
PMID: 29725507 DOI: 10.5704/MOJ.1803.003

Introduction: Various treatment modalities are available but no consensus has been reached for optimal treatment of lateral third clavicle fractures. Precontoured locking plates with broad lateral end for multiple screws fixation is a newly designed plate for lateral third clavicle fractures. The objective of our study was to analyse the functional outcomes as well as complications of this technique in a significant number of cases with long follow-up duration. Materials and Methods: Forty-six patients with distal third clavicle fractures were treated by precontoured clavicular locking plate with broad lateral end. Functional outcomes were assessed on the basis of Constant-Murley Shoulder Outcome Score and University of California, Los Angeles (UCLA) Shoulder Rating Score, active shoulder range of motion, time for fracture union and coraco-clavicular distance. Results: The mean Constant-Murley score was 92.56±4.47 (range: 79-98) for injured side and 96.22±2.23 (range: 90-100) for normal side with p-Value 0.56. Mean coraco-clavicular distance at final follow-up was 10.52±1.13 mm (range 9.7 to 11.7 mm) in injured side and 10.25±0.98 mm (range 9.6 to 11.2 mm) in normal side. Mean UCLA Shoulder Rating Score was 32.55±2.12 (range: 27-34) for injured side and 33.46±1.88 (range: 31- 35) on normal side with p value 0.58. No major complications that necessitated revision of surgery occurred in our study. Conclusion: This newly designed plate seemed extremely useful in successful union of lateral third clavicle fractures, with reduced rate of complications like fixation failures, iatrogenic rotator cuff injury, AC joint osteoarthritis and sub-acromial bursitis, with good functional outcomes.

Matched MeSH terms: Shoulder
Fulltext Acromio-Clavicular Joint Dislocation Types IV to VI: Does the Outcome with the modified Weaver-Dunn Procedure Justify the Treatment?

Kapil-Mani KC, Niroula A

Malays Orthop J, 2018 Jul;12(2):31-36.
PMID: 30112126 DOI: 10.5704/MOJ.1807.006

Introduction: The optimal surgical treatment for acromioclavicular joint (ACJ) injuries remains controversial. The modified Weaver-Dunn (WD) procedure is one of the frequently used techniques. Recently when it was compared with anatomical autogenous tendon graft reconstruction procedures, the results were inferior. However, these anatomical procedures are technically more demanding with small margin of error and they have tendency for postoperative pain because of extra donor site incision. Materials and Methods: Forty patients with type IV to VI ACJ dislocations were treated by modified WD procedure using non-absorbable synthetic suture passed through the base of coracoid process for augmentation of transferred coraco-acromial (CA) ligament. Functional outcome was assessed using the Oxford Shoulder Score, Nottingham Clavicular Score and Visual Analog Score (VAS) at the final follow-up after surgery. Results: The mean pre-operative Oxford Shoulder Score improved from 25.22±2.64 (range 20 to 30) to 44.75±1.99 (range 40 to 48) and mean pre-operative Nottingham Shoulder Score improved from 49.25±4.91 (range 39 to 58) to 87.27±4.39 (range 79 to 96) at last follow-up after surgery with p-value <0.001. Thirty-five (87.5%) patients had excellent outcomes, four (10%) patients had good outcomes and one (2.5%) patient had fair outcome. Thirty-eight (95%) patients had no pain while two (5%) had moderate pain based on VAS score. Conclusion: Modified Weaver-Dunn is a simple well established technique for grade IV to VI ACJ dislocation. We cannot consider this procedure as old and outdated on the argument that the long term functional outcomes are not suboptimal.

Matched MeSH terms: Shoulder; Shoulder Dislocation
Fulltext Adult Intramuscular Shoulder Angiomyolipoma: a rare case

Kadhim Jawad Obaid, Yahya Mohammad Arpine, Nor Salmah Bakar, Marlina Tanty Ramli Hamid, Ahmed Ramzi Yusof

Journal of Clinical and Health Sciences, 2016;1:37-39.

Intramuscular shoulder angiomyolipomas are very rare. We report a case in a 22-year-old male with a well circumscribed lesion located on the back of the shoulder. This lesion, differs from renal angiomyolipoma in terms of non-association with tuberous sclerosis, circumscription and male predominance. Another characteristic feature is the absence of epithelioid cells. Differential diagnosis includes lipoma, angiolipoma, angioleiomyoma, hemangioma, myolipoma and liposarcoma. It is distinguished from the above mentioned entities by the presence of a combination of thick-walled blood vessels, smooth muscle and fat.

Matched MeSH terms: Shoulder
Fulltext Adult Intramuscular Shoulder Angiomyolipoma: a rare case

Kadhim Jawad Obaid, Yahya Mohammad Arpine, Nor Salmah Bakar, Marlina Tanty Ramli Hamid, Ahmed Ramzi Yusof

Journal of Clinical and Health Sciences, 2016;1(2):37-39.
MyJurnal

Intramuscular shoulder angiomyolipomas are very rare. We report a case in a 22-year-old male with a well circumscribed lesion located on the back of the shoulder. This lesion, differs from renal angiomyolipoma in terms of non-association with tuberous sclerosis, circumscription and male predominance. Another characteristic feature is the absence of epithelioid cells. Differential diagnosis includes lipoma, angiolipoma, angioleiomyoma, hemangioma, myolipoma and liposarcoma. It is distinguished from the above mentioned entities by the presence of a combination of thick-walled blood vessels, smooth muscle and fat.

Matched MeSH terms: Shoulder
Clinical evaluation of the anterior translation of glenohumeral joint using ultrasonography: an intra- and inter-rater reliability study

Joseph LH, Hussain RI, Pirunsan U, Naicker AS, Htwe O, Paungmali A

Acta Orthop Traumatol Turc, 2014;48(2):169-74.
PMID: 24747625 DOI: 10.3944/AOTT.2014.3184

The aim of this study was to investigate the intra- and inter-rater reliability of ultrasonography (US) to measure anterior translation of the humeral head (ATHH) among healthy subjects and patients with sacroiliac joint dysfunction.

Matched MeSH terms: Shoulder Joint/ultrasonography*
Fulltext The outcomes of salvage surgery for vascular injury in the extremities: a special consideration for delayed revascularization

Jagdish K, Paiman M, Nawfar A, Yusof M, Zulmi W, Azman W, et al.

Malays Orthop J, 2014 Mar;8(1):14-20.
PMID: 25279079 MyJurnal DOI: 10.5704/MOJ.1403.012

A seven years retrospective study was performed in 45 consecutive vascular injuries in the extremities to investigate the pattern of injuries, managements and outcomes. Motor-vehicle accidents were the leading cause of injuries (80%), followed by industrial injuries (11.1%) and iatrogenic injuries (4.4%). Popliteal and brachial artery injuries were commonly involved (20%). Fifteen (33.3%) patients had fractures, dislocation or fracture dislocation around the knee joint and 6 (13.3%) patients had soft tissue injuries without fracture. Traumatic arterial transection accounted for 34 (75.6%) cases, followed by laceration in 7 (15.6%) and 9 (6.7%) contusions. Associated nerve injuries were seen in 8 (17.8 %) patients using intra-operative findings as the gold standard, both conventional angiogram (CA) and computerized tomography angiogram (CTA) had 100% specificity and 100% sensitivity in determining the site of arterial injuries. The mean ischemic time was 25.31 hours (4 - 278 hours). Thirty-three (73.3 %) patients were treated more than 6 hours after injury and 6 patients underwent revascularization after 24 hours; all had good collateral circulation without distal pulses or evidence of ischemic neurological deficit. The mean ischemic time in 39 patients who underwent revascularization within 24 hours was 13.2 hours. Delayed amputation was performed in 5 patients (11.1%). Of the 6 patients who underwent delayed revascularization, one patient had early amputation, one -had delayed amputation following infection and multiple flap procedures while the rest of the patients' limbs survived. Joint stiffness was noted in 10 patients (22.2%) involving the knee joint, elbow and shoulder in two patients each. Infection was also noted in 5 patients (11.1%) with two of them were due to infected implants. Other complications encountered included nonunion (2 patients, 4.4%), delayed union (1 patient, 2.2%),limb length discrepancy (1 patient, 2.2%), hematoma (1 patient, 2.2%) and leaking anastomosis in one patient (2.2%). Volkmann's ischemic contracture occurred in 3 (6.7%) patients. There was no complication noted in 8 (17.8%) patients Three patients (6.7%) died of whom two were not due to vascular causes. We conclude that early detection and revascularization of traumatic vascular injuries is important but delayed revascularization also produced acceptable results.

Matched MeSH terms: Shoulder
Fulltext Minimal Invasive Plate Osteosynthesis (MIPO) Technique Using Anterolateral Approach for Treating Closed Proximal Humerus Fracture

Ismail H, Boedijono D, Hidayat H, Simbardjo D

Malays Orthop J, 2012 Mar;6(1):18-24.
PMID: 25279037 DOI: 10.5704/MOJ.1203.008

ABSTRACT: Proximal humerus fracture is the second most common fracture of the upper extremity and presents several unique problems such as anatomical complexity, high risk of avascular necrosis, minimal bone stock for purchase, significant morbidity, and lack of a universally accepted treatment. Recent treatments for proximal humerus fractures include use of minimally invasive plate osteosynthysis (MIPO). The aim of this cross-sectional study was to evaluate the outcomes of our less invasive technique using a modified anterolateral approach for treatment of proximal humerus fractures. Ten such operative procedures were performed in patients of varying age and with varied mechanism of injury from 2002-2011. All cases were conducted in an acute setting. There were no cases of infection and the functional outcome scores were good. This approach represents an alternative treatment for closed proximal humerus fracture but more extensive studies are needed.
KEY WORDS: Proximal humerus fracture, MIPO, less invasive,anterolateral approach.

Matched MeSH terms: Shoulder Fractures
Fulltext Coracoid Process Morphology using 3D-CT Imaging in a Malaysian Population

Imma II, Nizlan NM, Ezamin AR, Yusoff S, Shukur MH

Malays Orthop J, 2017 Jul;11(2):30-35.
PMID: 29021876 MyJurnal DOI: 10.5704/MOJ.1707.012

Introduction: The aims of this study are to define the coracoid process anatomy in a Malaysian population, carried out on patients in Hospital Serdang with specific emphasis on the dimension of the base of coracoid process which is important in coraco-acromial (CC) ligament reconstruction, to define the average amount of bone available for use in coracoid transfer, and to compare the size of coracoid process based on gender and race, and with findings in previous studies. Materials and Methods: Fifteen pairs of computed tomography (CT) based 3-dimensional models of shoulders of patients aged between 20 to 60 years old were examined. The mean dimensions of coracoid were measured and compared with regards to gender and race. The data were also compared to previously published studies. Results: The mean length of the coracoid process was 37.94 ± 4.30 mm. Male subjects were found to have larger-sized coracoids in all dimensions as compared to female subjects. The mean tip of coracoid dimension overall was 19.99 + 1.93mm length × 10.03 + 1.48mm height × 11.63 + 2.12mm width. The mean base of coracoid dimension was 18.96 + 3.71mm length × 13.84 + 1.76mm width. No significant differences were observed with regards to racial denomination. The overall coracoid size measurements were found to be smaller compared to previous studies done on the Western population. Conclusion: This study may suggest that Malaysians have smaller coracoid dimension compared to Caucasians. The findings further suggest that the incidence of coracoid fracture and implants pull out in Malaysian subjects may be higher.

Matched MeSH terms: Shoulder
Fulltext Luminescent measurement systems for the investigation of a scramjet inlet-isolator

Idris AC, Saad MR, Zare-Behtash H, Kontis K

Sensors (Basel), 2014;14(4):6606-32.
PMID: 24721773 DOI: 10.3390/s140406606

Scramjets have become a main focus of study for many researchers, due to their application as propulsive devices in hypersonic flight. This entails a detailed understanding of the fluid mechanics involved to be able to design and operate these engines with maximum efficiency even at their off-design conditions. It is the objective of the present cold-flow investigation to study and analyse experimentally the mechanics of the fluid structures encountered within a generic scramjet inlet at M = 5. Traditionally, researchers have to rely on stream-thrust analysis, which requires the complex setup of a mass flow meter, a force balance and a heat transducer in order to measure inlet-isolator performance. Alternatively, the pitot rake could be positioned at inlet-isolator exit plane, but this method is intrusive to the flow, and the number of pitot tubes is limited by the model size constraint. Thus, this urgent need for a better flow diagnostics method is addressed in this paper. Pressure-sensitive paint (PSP) has been applied to investigate the flow characteristics on the compression ramp, isolator surface and isolator sidewall. Numerous shock-shock interactions, corner and shoulder separation regions, as well as shock trains were captured by the luminescent system. The performance of the scramjet inlet-isolator has been shown to improve when operated in a modest angle of attack.

Matched MeSH terms: Shoulder
Viscosity effects of polyvinyl siloxane impression materials on the accuracy of the stone die produced

Ho W, Lin Seow L, Musawi A

J Clin Transl Res, 2018 May 28;4(1):70-74.
PMID: 30873496

Background: The purpose of the present study was to investigate the effect of different viscosities of polyvinyl siloxane (PVS) impression materials on the accuracy of the stone die produced.
Methods: A three-unit bridge master model was fabricated using cold-cure acrylic resin. Four combinations of different viscosities of PVS impression materials - regular body (monophase) alone, light body with regular body, light body with heavy body, and light body with putty - were used to make an impression of the master model. Ten impressions from each group were taken and Type IV gypsum stone was used to generate the dies. The dies were measured at the inter-abutment distance, occlusogingival length, and shoulder width with a measuring microscope and were compared with the master model using one-way analysis of variance and Tukey (honest significant difference) test.
Results: Differences were found for inter-abutment distance between the master model and the light body with regular body and light body with putty dies (both P < 0.02). A difference was found for shoulder width between the master model and the regular body alone die (P = 0.01). No differences were found for occlusogingival distance (all P > 0.08).
Conclusion: Results suggested inter-abutment distance was most accurate when using a PVS light body combination. Occlusogingival length was accurate using any of the studied PVS combinations, and shoulder width was more accurate when using the regular body PVS.
Relevance for patients: These results should be considered when choosing the viscosity of the PVS to use for producing impressions of high accuracy and fabricating a well-fitting fixed prosthesis.

Matched MeSH terms: Shoulder
Fulltext Preventing shoulder-surfing attack with the concept of concealing the password objects' information

Ho PF, Kam YH, Wee MC, Chong YN, Por LY

ScientificWorldJournal, 2014;2014:838623.
PMID: 24991649 DOI: 10.1155/2014/838623

Traditionally, picture-based password systems employ password objects (pictures/icons/symbols) as input during an authentication session, thus making them vulnerable to "shoulder-surfing" attack because the visual interface by function is easily observed by others. Recent software-based approaches attempt to minimize this threat by requiring users to enter their passwords indirectly by performing certain mental tasks to derive the indirect password, thus concealing the user's actual password. However, weaknesses in the positioning of distracter and password objects introduce usability and security issues. In this paper, a new method, which conceals information about the password objects as much as possible, is proposed. Besides concealing the password objects and the number of password objects, the proposed method allows both password and distracter objects to be used as the challenge set's input. The correctly entered password appears to be random and can only be derived with the knowledge of the full set of password objects. Therefore, it would be difficult for a shoulder-surfing adversary to identify the user's actual password. Simulation results indicate that the correct input object and its location are random for each challenge set, thus preventing frequency of occurrence analysis attack. User study results show that the proposed method is able to prevent shoulder-surfing attack.

Matched MeSH terms: Shoulder
Fulltext Acromioclavicular Reconstruction using Autogenous Semitendinosus Tendon Graft and the Importance of Postoperative Rehabilitation: A Case Report

Ho JP, Ahmad Faizal A, Sivapathasundaram N

Malays Orthop J, 2013 Nov;7(3):30-2.
PMID: 25674306 MyJurnal DOI: 10.5704/MOJ.1311.012

We present a case of chronic acromioclavicular joint dislocation (Rockwood type 5) in which the choice of acromioclavicular reconstruction using autogenous semitendinosus tendon graft was made due to its superiority in anatomical reconstruction of the coracoclavicular ligaments, and the impact of postoperative rehabilitation on the recovery of this patient. We also discuss the rationale behind this.

Matched MeSH terms: Shoulder Dislocation
Patterns of work-related musculoskeletal disorders among workers in palm plantation occupation

Henry LJ, Jafarzadeh Esfehani A, Ramli A, Ishak I, Justine M, Mohan V

Asia Pac J Public Health, 2015 Mar;27(2):NP1785-92.
PMID: 23417907 DOI: 10.1177/1010539513475657

This study investigated the patterns of ongoing work-related musculoskeletal disorders (WRMDs) and exposure risk to musculoskeletal injuries for various body regions among palm plantation workers. Standard Nordic Musculoskeletal Questionnaire (SNMQ) was used to assess the prevalence of musculoskeletal disorders symptoms. The Quick Exposure check (QEC) was used to assess the exposure risk of farmers to WRMDs. The common pattern of WRMDs was back pain (40%), followed by shoulder pain (19%). The QEC revealed high exposure risk for neck (56%), followed by back (45.6%). The results from the SNMQ showed that 58% reported pain in 1 region, followed by 2 regions (10.7%) and 3 regions (3.6%). Back pain and shoulder pain were found to be common among workers in palm plantation occupation. Nevertheless, the neck region appeared to have the highest risk of exposure to injuries.

Matched MeSH terms: Shoulder Pain/epidemiology
Fulltext Factors influencing functional outcome of Philos Plate fixation for proximal humerus fractures

Hazwan Ab. Wahid, Khairul Nizam bin Siron, Ahmad Zakiran

International Medical Journal Malaysia, 2017;16(11):42-42.
MyJurnal

Displaced and unstable proximal humerus fractures are difficult to treat
and they have high morbidity. The main goal is to achieve painless shoulder with full
recovery of the shoulder joint motion. Impingement syndrome is one of the commonest
postoperative complication. This study aim is to appreciate the functional outcomes of
Philos-plate fixation for proximal humerus fractures and to establish association with
high plate positioning with impingement syndrome of the shoulder after Philos-plate
fixation. (Copied from article).

Matched MeSH terms: Shoulder; Shoulder Fractures; Shoulder Joint
Fulltext Sports-related shoulder dislocations: a state-hospital experience

Hazmy CHW, Parwathi A

Med J Malaysia, 2005 Jul;60 Suppl C:22-5.
PMID: 16381278

This retrospective study was conducted in a state hospital set-up and aimed at identifying the incidence of sports-related shoulder dislocations and their characteristics and the sports events involved. All patients with shoulder dislocation related to sporting activities admitted to the hospital from January 1999 to December 2002 were included in the study. There were 18 sports-related shoulder dislocations out of 106 all shoulder dislocations admitted during this 4-year period. The average age of the patients was 25.4 years. All but two were male. All were anterior dislocations. Recurrent dislocation constitutes 78% of the cases with an average of 3 times re-dislocation. Rugby and badminton were the major contributors to the injuries followed by volleyball, soccer and swimming. Conservative treatment was successfully instituted for 88% of the patients and 12% opted for surgical intervention.

Matched MeSH terms: Shoulder Dislocation/etiology; Shoulder Dislocation/epidemiology*; Shoulder Dislocation/therapy
Fulltext The epidemiology of shoulder dislocation in a state-hospital: a review of 106 cases

Hazmy CHW, Parwathi A

Med J Malaysia, 2005 Jul;60 Suppl C:17-21.
PMID: 16381277

This retrospective study was conducted in a state hospital set-up and aimed at identifying the magnitude of shoulder dislocations and their demographic data, characteristics of the injury, mechanism and predisposing factors, and the instituted treatment. Patients with radiographic evidence of shoulder dislocation admitted to the hospital from January 1999 to December 2002 were included. Data were recorded from the case notes. There were 105 shoulder dislocations with male predomination in 77% cases and age ranged between 11 and 90 years (average 30.9 years). The right shoulder was affected in 68% of the cases. The contributing events were fall in 37% of cases, road traffic accident 23%, sports 17% and pathological conditions 13%. Anterior dislocation occurred in 96.2% of the cases. Posterior and inferior dislocations encountered in two patients for each type. Twelve dislocations were associated fracture of the greater tuberosity, two each with humeral neck fracture and cerebral injuries. First time dislocation occurred in 73.6% of the cases. The recurrences ranged between 2 to 6 times (average 3.4 times). Closed manipulative reduction and strapping was the definitive treatment in 92.4% of the cases and the remaining needed surgical reconstruction. Four patients had open reduction and internal fixation of the associated fractures while another four had arthroscopic Bankart's repair. In conclusion, shoulder dislocation represents the most common shoulder problems. It afflicted young adults of reproductive age (21-40 years) and participation in sports was a risk factor in men. Women over 40 years and fall were at risk to develop shoulder dislocation.

Matched MeSH terms: Shoulder Dislocation/etiology; Shoulder Dislocation/epidemiology*; Shoulder Dislocation/therapy
Call center ergonomics issues: A case study

Hari Krishnan, T.

Journal of Occupational Safety and Health, 2012;9(3):17-22.
MyJurnal

Introductions: Call center has been defined as a working environment in which uses telephone and computer for the purpose of marketing and manage communication with prospect clients or existing clients (Rocha, Glina, Morinho and Nakasato, 2005; Sprigg, Smith and Jackson, 2003).
Methodology: The study was conducted via observation of working condition and face to face interview with call center operators. Measurement of anthropometrics was also conducted.
Results: Ergonomics issues found at call center were inappropriate work condition and workstation which lead to awkward sitting posture (sitting with forward leaning posture, raised shoulder, feet not supported on floor). Besides that organizational policy which required high job demand and subsequently lead to prolonged sitting and static posture (very minimal posture changes). Combination all these factors lead to musculoskeletal symptoms and the operators reported of having neck, shoulder, upper back and lower back pain compared to other body parts.
Conclusion: The management should embark on organization wide ergonomics management program and should review the current policy and create safe and healthy working environment by providing suitable workstation for the operators in order to prevent musculoskeletal.

Matched MeSH terms: Shoulder
Fulltext Anthropometrics evaluation of children between genders

Hanani Yuhaniz, Asnawi Seraila, Siti Rafedah Abdul Karim, Suhaimi Muhammed, Abdul Hamid Saleh

Malaysian Journal of Public Health Medicine, 2016;16(101):22-25.
MyJurnal

In developing ergonomically sound furniture, there is a need in evaluating anthropometrics from various aspect such as gender differences. The objectives of this study was to evaluate anthropometrics differences between genders of children in Malaysia in order to determine the need in having specified chairs for each gender. Represented by four states in Malaysia, a total of 2400 children were involved in the study. A custom made measurer and an anthropometer were used to measure the subjects. Six body measurements, which are, sitting shoulder height, sitting subscapular height, shoulder breadth, buttock popliteal length, popliteal height and hip width were documented for evaluation. From this study, there were some significant differences on some body parts while other body parts were similar to male and female. Therefore, chairs are needed to be made according to the suitability of both gender.

Matched MeSH terms: Shoulder
Fulltext Sitting anthropometrics groupings of school children from grades 1 to 5

Hanani Yuhaniz, Asnawi Seraila, Suhaimi Muhammed, Abdul Hamid Saleh

Malaysian Journal of Public Health Medicine, 2016;16(10):0-0.
MyJurnal

This study on anthropometrics of Primary School children from grade 1 to 5 in Peninsular Malaysia involves 2310 students aged seven to eleven years old. The objectives were to analyze the differentiation of anthropometrics between children of grades 1 to 5 and grouping them to suitable levels in which they are appropriate to propose chair dimensions. A multi-stage sampling method was used, and rural and urban areas were also included in providing anthropometric database that represents the whole Peninsular Malaysia population. There were six dimensions measured in this study, which are sitting shoulder, sitting subscapular height, sitting elbow height, hip width, buttock-popliteal length and popliteal height. All the measurements were chosen to represent dimensions needed to construct ergonomic school chair. From the results, ANOVA showed p-values of

Matched MeSH terms: Shoulder

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