Reconstruction consisted of using the extensor retinaculum as a sling reconstruction (Figure 1).Medical records of patients were manually reviewed and assessed for complications and unplanned reoperations. Epidemiology of hand injuries in sports. This is normal and should dissipate over the course of the next few days. Come to our Southlake office or Dallas office today and bring life back to your hands. Labral repair or capsulorraphy are an elective outpatient procedure that can be scheduled when circumstances are optimal. Most patients report restored range of motion and an improvement in pain during daily activities and sports following their procedure. Do not drive if you are taking narcotic medication, as it is unsafe and against Washington state law. What is snapping ECU, or snapping wrist? If the sheath of the tendon has been ruptured, however, surgical intervention will be necessary to replace the tendon within the sheath. 5 Montalvan B, Parier J, et al. Dr. Knight is a renowned hand, wrist and upper extremity surgeon with over 25 years of experience. Physical therapy to optimize range of motion and strength is recommended. Recovery time You can stop wearing the sling after a few days, but it takes about 12 to 16 weeks to completely recover from a dislocated shoulder. At a median follow-up of 8.4 years, the median PROMIS UE Physical Function score among 10 patients was 56, the median score for pain 0.5, and the median score for satisfaction 9.5. @xA(+|W:[& ~%|;Gw4] This splint will help prevent the repaired tendons being overstretched. In less serious cases, a splint or cast can be used to hold the wrist immobile while the damaged tendon sheath repairs itself, but if there is a more serious injury to the sheath, or even a rupture, then medical or even surgical intervention may be necessary in order to address the condition properly. In patients with tendon rupture, a characteristic cascade of events is often described.9,10 An initial acute luxation event is followed by lower grade but persistent pain, often with accompanying tenosynovitis. J Hand Surg 1986; 11A:809-811. They may relate the sensation of a click.. Due to its subcutaneous position, it is easily visualized, making for quick analysis. The injury causes damage to the normal tendon sheath and allows the tendon to slide out of its normal location. Post operative rehab will follow similar principles to those described for conservative management. Wrist loading with the ECU is in a vulnerable position (flexion during supination and ulnar deviation). If you have uncomfortable side effects from the pain medication please call us. The gradient echo coronal image reveals extensive fluid signal intensity (arrowheads) along the ulnar side of the wrist, surrounding the extensor carpi ulnaris (ECU) tendon (arrow). Together, these soft tissues hold the joint in place. <>/Metadata 1157 0 R/ViewerPreferences 1158 0 R>> The ECU subsheath is torn at its radial attachment (arrow). The extensor carpi ulnaris (ECU) tendon is involved in many pathologies seen in golf, hockey, tennis, and baseball athletes. You will wear this cast or splint for around four weeks. In the acute setting (<3 weeks since injury), immobilize the patient in an above-elbow cast. You will be prescribed occupational therapy after your surgery to restore your range of motion. Repetitive microtrauma or a traumatic forceful wrist flexion, supination, or ulnar deviation can lead to damage. Ulnar sided ruptures of the subsheath, likely the most common pattern of injury, usually result in dislocation followed by reduction in which the tendon returns to a location deep to the subsheath (12a, 13a,13b). A complete physical examination of the patients ulnar-sided wrist complaints should be conducted to elucidate associated pathology and rule out confounding conditions in the differential diagnosis. Magnetic resonance imaging in orthopaedics and sports medicine, 3rd edition, Lippincott Williams and Wilkins 2006:1828-1829. In order to determine the full extent of the injury to the sheath and to ascertain the exact position of the ECU tendon, MRI or ultrasound imaging are used to look inside the wrist and locate all of the relevant body parts. The patient may also describe pain and crepitance with ulnar deviation of the wrist. Br J Sports Med. Tendinopathy: is imaging telling us the entire story? Most patients with acute sheath ruptures and tendinopathies will be tender to palpation at the level of the distal ulna and groove. If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. Here are a couple resources on the injury. %PDF-1.5 As a physician, Summer expects to utilize her experiences in overcoming non-medical barriers to provide the highest quality of care to her community. Surgery: In some cases, surgery may be necessary to treat shoulder subluxation. . MR imaging is often able to detect this and other ulnar sided abnormalities and tears. Localized swelling may be present. The tendon is subluxed into the pouch formed by stripping of the subsheath and/or periosteum at its palmar attachment. The mechanism of a traumatic injury most commonly involves active ECU contraction combined with forced supination, palmar flexion, and ulnar deviation. The extensor carpi ulnaris (ECU) runs within the sixth dorsal compartment of the wrist. Surgery for cartilage tears or instability is not an emergency. It travels up and down in the femoral groove and is held in place by muscles and ligaments. Abstract. ( Find a surgeon who performs MPFL reconstruction.) Seldom is a surgical procedure needed for treatment of ECU tendonitis, but if symptoms persist despite appropriate management, a surgical debridement of the tendon can be considered. The ECU functions to extend and adduct the hand, and is important in the ability to ulnar deviate the hand. In this case, the intraoperative findings showed the edges of the ruptured subsheath to be separated by a minimum of 7 mm, regardless of the position of the wrist. Because a local anesthetic and a regional block were used, you may notice numbness or a tingling sensation in your hands and fingers for several hours or days. The subsheath lies deep to the extensor retinaculum, which itself does not attach to or stabilize the ECU tendon. Rehabilitation Plan - Exercises. Patterns of ECU subsheath rupture. When the tendon occupies the wrong space within the sheath or is moved to an extreme degree within this sheath, it is known as subluxation. Snapping occurs during this dislocation and relocation. A unique anatomical characteristic of the ECU is the fibro-osseous tunnel which stabilizes the tendon at the level of the distal ulna.1 This fibro-osseous tunnel is formed by the distal ulna and a 1.5 to 2cm in length band of connective tissue referred to as the ECU subsheath (5a, 6a). Patients underwent ECU subsheath reconstruction at a median of 5.9 weeks after diagnosis (IQR 2.4-13). Diagnostic and Therapeutic Injection of the Wrist and Hand Regions. The wrist should be in neutral to slight pronation, neutral to slight radial deviation, and neutral to slight extension. The study will also provide additional information concerning the remainder of the TFCC and the integrity of the intercarpal ligaments. If you suspect a fracture, contact the team at the Orthopedic Center for Sports Medicine. should a dislocation occur during passive movement, the ECU can be considered as grossly unstable. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. The tendon, however, remains beneath the subsheath. As discussed above, the subluxation of the ECU tendon may be visible to the naked eye after a physical examination of the injury. It is on the ulnar side of the wrist, the same side as the small finger. Pronated grip views and other specialized plain radiographs of the wrist can provide information on other pathologies that contribute to ulnar-sided wrist pain (see, Magnetic resonance imaging (MRI) is the most sensitive and specific imaging modality to detect ECU subluxation (. The fibro-osseous subsheath of the sixth dorsal compartment overlies 1.5 to 2.0 cm of the distal ulna and arcs from the radial to ulnar wall of the ECU osseous groove. All Rights Reserved. How can Dr. Knight help you with ECU Subluxation? Dr. Knight is a Board Certified Orthopedic Surgeon and Fellowship trained. In resisted finger abduction, pain over the wrist and ECU tendon signifies an inflammatory ECU condition, possibly due to subluxation or overuse. Recovery from patella dislocation typically takes several weeks. Read Disclaimer. Local steroid injections may have provided temporary relief. Fullness and pain with palpation of the sixth dorsal compartment. In most cases Physiopedia articles are a secondary source and so should not be used as references. Common symptoms indicative of an extensor carpi ulnaris (ECU) subsheath tear may include: Most commonly, patients may develop this injury through a hard twist or forceful repetitive twists of the wrist. If the addition of ECU contraction is required for frank dislocation, some inherent stability remains. Certain patterns of injury require operative repair, and thus MRI is a critical component of the treatment planning process. Acute injury can cause a rupture or further degeneration of the wrist subsheath. The sixth compartment is created by the extensor retinaculum and is unique, in that there is a separate subsheath beneath the retinaculum through which the ECU tendon runs. You'll usually be able to resume most activities within 2 weeks, but should avoid heavy lifting and sports involving shoulder movements for between 6 weeks and 3 months. Address: 1200 112th Ave NE, Suite C-210 Bellevue WA 98004, 2023 Dr. Thomas Trumble, M.D.. | Made by Digital Laboratory, 1200 112th Ave NE, STE C-210 Bellevue WA 98004, 1200 112th Ave NE, Suite C-210 Bellevue WA 98004, 2017 Overlake Symposium: 6th Annual Hand and Upper Extremity Orthopedic Surgery and Therapy Symposium, 2016 Overlake Symposium: 5th Annual Hand and Upper Extremity Orthopedic Surgery and Therapy Symposium. Full recovery of function would be expected in 3-4 months with appropriate rehab. ECU tendon tears are repaired at the same time. Surgery can also be used to repair or remove damaged tissue that contributes to subluxation. June 29, 2022; creative careers quiz; ken thompson net worth unix MPFL reconstruction is a surgery in which a new medial patellofemoral ligament is created to stabilize the knee and help protect the joint from additional damage. 3 Signs of ECU tendonitis include: 3 This procedure is completed as an outpatient under awake, regional block anesthesia, which allows patients to return home the day of their surgery to continue recovery there. ECU tendinosis and tenosynovitis can often be managed conservatively. Early rheumatoid arthritis: a review of MRI and sonographic findings. The movements and strain associated with tennis and golf are the most common culprits when it comes to developing ECU subluxation, but trauma to the lower forearm where the tendon sheath is may also create the problem. The ECU tendon demonstrates mild palmar subluxation, and the palmar attachment of the subsheath (arrowhead) is stripped and therefore lies more palmar than is typical. ECU subluxation is caused when the sheath that containes the ECU ligament gets pinched between the radius and ulna, and this type of damage is most often caused by the repetitive motion associated with playing golf or tennis, but it can also be the result of trauma to the wrist/forearm. 2021;22(1):387. doi: 10.1186/s12891-021-04271-z. Kim et al. The subsheath of the sixth extensor compartment represents a component of the dorsal peripheral TFCC. The ECU subsheath contributes to the dorsal portion of the triangular fibrocartilage complex (TFCC). Snapping ECU is more common in athletes, and generally follows a traumatic injury to the wrist. This joint laxity may cause pain and dysfunction, eventually leading to degenerative changes. Activity Modification (Prosser) . (1a) Gradient echo coronal, (1b) T1-weighted axial, and (1c) STIR axial images of the wrist are provided. The intimate relationship with the ulnar TFCC attachment means that symptomatic nonunion can be associated with TFCC dysfunction and DRUJ instability. Knuckle joint (MCP joint) replacement: Called arthroplasty, this is sometimes done to correct damage from rheumatoid arthritis (RA). A shoulder subluxation occurs when the humerus partially slides in and out of place quickly (Figure 2). Snapping can also be felt, as the misplaced tendon interacts with the bones of the wrist where it has been moved. Available from: https://www.orthobullets.com/hand/6030/snapping-extensor-carpi-ulnaris-ecu. Commonly athletes/patients present complaining of persistent ulnar wrist pain aggravated by activities requiring pronation and supination, which may be associated with a clicking or "snapping" sensation. Disabilities of the Arm, Shoulder & Hand Questionnaire, https://www.physio-pedia.com/index.php?title=Extensor_Carpi_Ulnaris_(ECU)_Subluxation&oldid=301769. The overlying extensor retinaculum (blue) courses over the ECU and distal ulna to attach to the pisiform and triquetrum. If the ECU tendon is not held in place, it may "snap" over the bone as the wrist is rotated. Provocative maneuvers for lunotriquetral ligament injuries (ie, ballottement test, ulnar snuff box test) have sufficient sensitivity but poor specificity. The sensation of tendon dislocation and an associated pop may accompany the injury. Br J Sports Med 1998; 32:172-177. Typical treatments include rest, ice application, anti-inflammatory medications, and the use of a wrist splint and if symptoms persist after simple treatments, an injection of cortisone can be helpful. Extensor carpi ulnaris injuries in tennis players: a study of 28 cases. ECU subluxation most often presents with a searing pain to the affected area, being the ulnar aspect of the wrist. Cataract surgery is a procedure to remove the lens of your eye and, in most cases, replace it with an artificial lens. Middorsal wrist injuries that are misdiagnosed can delay return to play. the subsheath and the tendon during surgery.4 a Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, . In patients with ECU subsheath tears and tendon instability, conservative therapy has also proven effective.5 The wrist is immobilized via casting in extension and radial deviation, which seats the tendon tightly within its ulnar groove. In such patients, chronic stress upon the tendon results in inflammation of its synovial lining, causing tenosynovitis.4 Over time, stress may also lead to tendon degeneration and altered collagen content, resulting in tendinosis with or without partial tears (8a). With increasingly severe injuries, and in more chronic cases, the ECU tendon is prone to complete dislocation from its groove in the distal ulna. To our knowledge, there has been no report of simultaneous ECU dislocation with extensor tendon subluxation. The ECU tendon can be palpated on the dorsal aspect of the wrist with the wrist in resisted extension and ulnar deviation. The kneecap or patella floats in position in the front of your knee. Extensor carpi ulnaris (ECU) tendon dislocation or subluxation can be one cause of ulnar-sided wrist pain. Pang EQ, Yao J. Ulnar-sided wrist pain in the athlete (Tfcc/druj/ecu). Extensor Carpi Ulnaris (ECU) muscle primary functions at the wrist joint is to move the joint into extension and ulnar deviations whilst also providing a stabilising force at the ulnar side of the joint. Sometimes patients with ECU tendonitis have symptoms that occur following a traumatic injury, such as a wrist fracture. Mark and Jason Pruzansky at 212-249-8700 to schedule an appointment and obtain anaccurate diagnosis. The tendon itself lies within a bony groove along the dorsal, distal ulna. Please contact us as soon as possible to schedule an appointment with our talented team. A schematic axial representation of the ECU subsheath, indicated in red. This can progress to ECU tendinopathy and partial tendon tears. Disruption can result in static instability of the DRUJ. Associated patchy area of bone marrow edema is seen involving the ulnar styloid process evoking a high STIR signal. Getting your normal stretch and mobility back after surgery for patellar subluxation can take . By Jonathan Cluett, MD Uncommon, ruptures are typically repaired using a local graft, primarily the palmaris longus. ecu subluxation surgery recovery time. Lifestyle medicine physician, Andrea Espinoza, MD, FCCP, at OCSM can help. The ECU subsheath (arrowheads) is diffusely thickened and irregular and marked tenosynovitis is present. Patients typically present with ulnar-sided wrist pain and/or pain on wrist extension. Whether you need to prepare your body for surgery or simply want to lower your risk of numerous health concerns, Andrea Espinoza, MD, FCCP can help. 2023 Dotdash Media, Inc. All rights reserved, Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. 3. Hypersensitivity at the surgical scar can be reduced by rubbing the skin using materials with different textures. Associated ulnocarpal (ie, triangular fibrocartilage complex) and ECU intrinsic tendinopathic changes may accompany subshe The addition of an accessory tendon is a rare but important finding that can explain a snapping wrist without injury. ECU subluxation most often presents with a searing pain to the affected area, being the ulnar aspect of the wrist. Unprotected, full activity is allowed 3 to 4 months after the initiation of treatment. Extensor Carpi Ulnaris Subsheath Tears are a fairly common injury involving people who play golf, contact, and racket sports. Its position relative to the other structures in the wrist changes with forearm pronation and supination. Hand Clinics 7:2:311-327, 1991. Graham TJ. She has monitored multiple patients per hour and provided rehab exercise protocols to her patients. %|$eqDk:"BcRYB/=@n$8 a4 !c#~6]]`O*G8NcVU>tB :WiO ur(RNaFiV4tI -j8t(7K76p0Ho*;&tVR27( I3s bP`:!Q&XnJt5HgY!9^),@9jo ZRSZ; F,FbKCcPqG_QhwjJy)4XyFuKB(z.-D999CDpEfzr'7b m3j,8fQy8y\:Cj3 https://www.orthobullets.com/hand/6030/snapping-extensor-carpi-ulnaris-ecu, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5735293/, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9036339/. This condition is most common in nonathletes and generally occurs without an obvious cause. Evaluate the TCO of your PACS download >, 750 Old Hickory Blvd, Suite 1-260Brentwood, TN 37027, Focus on Musculoskeletal and Neurological MRI, The Anterior Meniscofemoral Ligament of the Medial Meniscus, Collateral Ligament Injuries of the Fingers, Displaced Triangular Fibrocartilage Cartilage Complex Tears. Hitting a powerful backhand during tennis where the forearm is reuired to create top spin by moving forcefully from pronation to supination, Hitting a solid object during the golf swing whilst the golf club moves from a radially deviated position to neutral, and the ECU contracts isometrically to stabilize the joint, Contact sports like rugby that require the athlete to hold the ball (and thus contract the ECU isometrically in maximal supination) to maintain possession when entering a contact. Retrieved from https://www.orthobullets.com/hand/6047/tfcc-injury Types of TFCC Tears Subluxation or dislocation of the ECU tendon requires an injury to the ECU subsheath. Calcific tendonitis of the shoulder is a common cause of aching pain that is made worse by shoulder activity. Full recovery with return to sports at about 6 months after surgery. Although the incidence of ECU subluxation is low in the general population, it can be found within sports, such as tennis, golf and rugby that require forceful or repeated wrist extension/ulnar deviation or good wrist stability for hold equipment. 2015;23(12):741-750. doi:10.5435/jaaos-d-14-00216. If you start to feel persistent pain in your shoulder with these motions, you might have a rotator cuff injury. it is rare for this to occur passively due to the reduction in tendon tension when the muscle is not contracting. 10 Xarchas KC, Leviet D. Non rheumatoid closed rupture of extensor carpi ulnaris tendon. The extensor carpi ulnaris (ECU) tendon is involved in many pathologies seen in golf, hockey, tennis, and baseball athletes. read more ↘ 6 Comments . Incompetence of the ECU subsheath permits subluxation or dislocation of the ECU tendon out of the ulnar groove of the ulna, often with a painful click noted on resisted supination, ulnar deviation, and mild palmar flexion. Although most ECU subluxation diagnoses can be made through a good clincal examination, diagnostic imaging may be benefical to rule out concomitant pathology or to confirm the diagnosis in subtle cases. Mi cuenta; Carrito; Finalizar compra; Contacto He served as assistant team physician to Chivas USA (Major League Soccer) and the United States men's and women's national soccer teams. The resultant force during the 'contact' can result in a tear of the tendons subsheath and a resultant sublaxation, Range of motion (ROM): likely full other except during the acute phase of injury and will potentially present with pain on, active wrist extension and/or ulnar deviation. A joint subluxation is a partial dislocation of a joint. Located on the Upper East Side Manhattan, NYC HSSI is home to one of the top 1.4% of all hand surgeons, Dr. Mark E. Pruzansky, and New York SuperDoctor, Dr. Jason S. Pruzansky. 4 0 obj @}mpP6/ML%u`D-?*N^(Sl{Geq26hG? Please see the Medications After Surgery form for more instructions. Though within professional Rugby League in England, it has been found that the incidence of acute ECU injury is 1 injury/60 players/year, with a significant proportion (50%) requiring surgical repairs in this cohort[1]. Essex-Lopresti Injuries. The retinaculum was opened between the fifth and sixth extensor compartment, freeing up the extensor digitorum quinti minimi. Treatment may be successful by immobilizing the wrist with the tendon in a proper position to allow the sheath to heal. What is the ECU? ECU Subluxation Procedures. In addition, the ECU was subluxated volarly in forearm supination with tendon attrition at the level of the ulnar Rowland. Activities that require movement of the elbow are limited. Surgical repair may be recommended in some cases, especially in situations where an individual has an acute or chronic high-grade injury to the ECU. Early treatment can ensure proper treatment and healing. The doctors of this paper describe the problem: "dislocation/subluxation of the Extensor Carpi Ulnaris (ECU) tendon is a rare condition in the general population, but is a common problem among athletes that subject their wrists to forceful rotational movements. The ECU, its subsheath, and the extensor retinaculum are readily seen using MRI (7a). We describe outcomes of extensor carpi ulnaris (ECU) subsheath reconstruction with extensor retinaculum at a median of 8 years follow-up.Methods & Materials In this retrospective study, we identified patients who underwent ECU subsheath reconstruction for subluxation of the ECU tendon between January 2003 and December 2016. *Figures courtesy of Principles of Hand Surgery and Therapy by Thomas E. Trumble, MD, Ghazi M. Rayan, MD, Mark E. Baratz, MD and Jeffrey E. Budoff, MD, Phone: (425) 999-3580 Themes UFO. Small amounts of adjacent edema and fluid are evident on the STIR image. It offers an excellent treatment option for people who have experienced more than one dislocation. The ECU Subsheath (red arrowheads) is seen deep to the overlying extensor retinaculum (blue arrowheads). study identified ECU subluxation with intact sub- Posterior interosseous branch of the radial nerve, Wrist extension along with extensor carpi radialis longus (ECRL) and brevis (ECRB), Ulnar deviation of the wrist along with flexor carpi ulnaris (FCU). The sensitivity increases in studies with both wrists positioned in pronation, neutral, and supination. Traumatic ECU subluxation is commonly reported in association with racket sports, baseball, and golf. Background: The ECU tendon is stabilized in the ulnar groove by a subsheath located inferior to the extensor retinaculum. 8 Carneiro RS, Fontana R, Mazzer N. Ulnar wrist pain in athletes caused by erosion of the floor of the sixth dorsal compartment. Her current goal is to attend medical school so that as a physician, she can treat her patients for the reason they are visiting the doctor, while also encouraging positive preventive medicine. That is why it is so important for individuals to seek medical attention when they notice discomfort, particularly with wrist rotation. Over time the ECU tendon subsheath will be damaged thus causing the subluxation. Surgery -ECU tendon stabilization -sling created from extensor retinaculum . Recovery can take 3 months or more. Some authors, however, recommend surgical repair of ECU subsheath injuries, particularly when acute.6,11 Such an approach is particularly important in cases where the torn subsheath ends are widely separated, and is required if the tendon lies outside the torn subsheath. Read our, Wrist Fractures: Treatment and a Warning for Osteoporosis, Wrist Tendonitis: Symptoms, Causes, and Treatment, How Biceps Tendon Problems Can Cause Shoulder Pain, Causes of Elbow Pain and Treatment Options. Snapping of the extensor carpi ulnaris tendon in asymptomatic population. Acute traumatic subluxation of the extensor carpi ulnaris tendon at the wrist. Your arm will be placed in a splint or cast, depending on the level of protection needed. Having a cough every once in a while is typically no more than a minor inconvenience. Follow-Up: The sutures will be removed beginning 10-14 days after surgery. This helps to prevent forearm rotation, protect the surgical site, and lessen swelling. A sugar-tong splint is fabricated with the forearm in slight pronation, and a progressive active and active-assisted ROM protocol is initiated. Tenderness will be elicited along the ulnar border of the triquetrum and the distal ulna. Nine patients reported no limitations in daily activity.Conclusions The extensor retinacular sling technique demonstrated favorable results at long-term follow-up and allowed the surgeon to address pathology in the tendon sheath.Level of Evidence: level IVFigure 1. A surgeon may also repair a torn labrum, the ring of cartilage that surrounds the shoulder socket and stabilizes the humerus. It also provides stability to the ulnar side of the wrist. After you schedule an appointment to be evaluated by Dr. Knight, he will utilize the state-of-the-art diagnostic imaging technology at the Hand and Wrist Institute to ascertain the severity and extent of your ECU subluxation. Return to full sports takes roughly 4-6 months, occasionally longer. stream Apparently recovery takes a LONG time. Dislocation of the ECU tendon removes a dynamic stabilizer of the DRUJ. It is found deep to the fourth and fifth extensor compartments on the radius. It is often the result of acute injury or repetitive motion injury but can also be caused by medical conditions that undermine the integrity of ligaments. 2016;50(Suppl 1):A56.2-A57. Take the pain medication as it is prescribed, taking the right dose at the right time to best manage your pain. The corresponding STIR axial image confirms the split, subluxed ECU tendon (arrow) and surrounding fluid. 3 0 obj The goal of surgery and rehabilitation is to minimize the loss of motion in the athlete (see Maintenance Phase, Rehabilitation Program). We recommend that you start physical therapy within one week following surgery to lessen the scarring around the incision, improve range of motion, and when appropriate increase your hand and arm strength.
The Book Of Light Malachi Z York Pdf,
Articles E
*
Be the first to comment.