Its named after the first person to undergo the procedure. The reasons for this might be multifactorial. Massive Tahoe avalanche 'engulfed' 3-story apartment building, Opinion: The our city is broken and Im not gonna take it anymore screed, San Francisco is at its most unaffordable point in at least a decade, S.F. Do gentle range-of-motion exercises for the wrist, Wear a range-of-motion brace to gradually regain full motion of the elbow. American Orthopaedic Society for Sports Medicine. Brock Purdy will have his long-awaited elbow surgery next week if all goes well. The initial UCLR technique, first described by Jobe etal.,3 had high rates of ulnar nerve complications owing to the transposition of the ulnar nerve during surgery. An ulnar collateral ligament (UCL) injury is an inner elbow injury. During Tommy John surgery, a surgeon replaces the injured UCL with a tendon taken from somewhere else in the patient's body. Its an injury to the growth plates. The functionality is limited to basic scrolling. They are not overuse injuries. Johns Hopkins Medicine: "Johns Hopkins Sports Medicine Patient Guide to UCL Injuries of the Elbow (Ulnar Collateral Ligament).". Repetitive motion, like overhand throwing, stresses the ligament. We are vaccinating all eligible patients. Ulnar Collateral Ligament Repair Technique The current indications for primary repair of the UCL include younger patients (<age 25 years) with high-grade proximal or distal avulsion type injuries of the UCL without evidence of more diffuse ligament injury or attritional tearing. % Time being No. What happened last season, Lynch acknowledged, taught the 49ers that more insulation could be required. This study received no external funding and, given the deidentified nature of the dataset, was exempted from review by the institutional review board. Some rehabilitation programs follow a three-phase process: Phase I. Lee M.L., Rosenwasser M.P. Irritation of the "funny bone" (ulnar nerve): This is felt as tingling or numbness in the small finger and ring finger. 1677 W. Baker Rd Suite 1701, Baytown, TX 77521, Regain normal upper extremity strength and endurance, Achieve the level of function based on the orthopedic and patientgoals, Swelling of the elbow and surrounding soft tissue, Abnormal pain, hypersensitive-an increase in night pain, Weakness in the upper extremity musculature, Initiate submaximal bicep isometrics wk 1, Initiate submaximal wrist isometrics wk 2, Initiate submaximal elbow flex/ext isometrics wk 2, Elbow immobilizer with arm sling b 0-90 wk 1, Continue to progress strength from Phase 1, Initiate light wrist flexion and extension, Initiate forearm pronation and supination, Initiate light elbow extension and flexion, Progress rotator cuff program, avoid resisted IR until wk 6, Add closed chain rotator cuff exercise using, Progressive strength and endurance training, Initiate eccentric elbow flexion/extension, Progress elbow flexion/extension isotonics, Progress closed chain rotator cuff exercises with, Initiate light bilateral plyometric program, Initiate light sports specific training week 11, Functional brace discharged week 6 or as noted by Dr. Lintner, Initiate return to sports/functional training program, Enhance proprioception and arthrokinematics, Continue all stretching and ROM activities fromprevious phases, Continue with all strengthening activities increasing, Return to competitive throwing 7 to 9 months, Maximize power, strength, and endurance of upper extremity, Return to sports specific activity/functional activity, Maximize proprioception and arthrokinematics. Brock Purdy, a quarterback for the San Francisco 49ers, is interviewed by members of the news media inside the 49ers locker room at Levis Stadium in Santa Clara, Calif., Tuesday, Jan. 31, 2023. The UCL can be injured in several ways. The extensor tendon was found to be lacerated 100% through both lateral bands distal insertion. UCL repair surgery is a procedure to treat an injury to the UCL, the soft tissue that connects the bones of the thumb and provides stability to the thumb joint. Since Dr. Frank Jobe first performed ulnar collateral ligament reconstruction (UCLR) in 1974, there have been many variations of the technique which have allowed competitive athletes to return to play at a high level. Loss of ability to throw as fast or hard. The outcome of elbow ulnar collateral ligament reconstruction in overhead athletes: a systematic review. 4 0 obj But it won't last long. The remaining parts of the original UCL may be attached to the new graft to strengthen it. In the final phase of rehabilitation, patients typically take these steps with their surgeon's approval: When surgeon Frank Jobe, MD, performed the first UCL reconstruction on Tommy John in 1974, a torn UCL tear was considered to be a game-ending injury for most players. Wondering if anyone can help validate the codes below. [12] The procedure is performed on an outpatient basis allowing discharge the same day, with the arm in a splint to protect the repair for the first week. The epidemiology of UCL injuries and UCLRs has been thoroughly studied within professional baseball, but, since the surgery was first described, very few studies have investigated their epidemiology and trends within the general population.6 Of the 3 studies that investigated the epidemiology and trends of this procedure, 2 of them focused on a single state, and the other focused on a relatively short period of time and did not account for cases caused by trauma.9, 10, 11 This study investigated the trend of UCLRs over a period of 12 years and excluded those patients who underwent UCLR as a secondary surgery during fracture or dislocation treatment or for a congenital deformity. LUCL injury may be due to trauma, chronic strain or iatrogenic lesion. This can result in an elbow dislocation or fracture that can injure your UCL. Complications can occur in anywhere from 5% to 20% of patients, depending on the technique that is used. And when you have all the swelling out, when you have all the stiffness out, is when hes had the best success with the outcomes.. Apply ice to your elbow daily to reduce pain and swelling. Trends in revision elbow ulnar collateral ligament reconstruction in professional baseball pitchers. The 49ers invited members of the news media to interview players, who were packing up their belongings to prepare for the off season. Never play or practice if injured or in pain. Neuroanatomy and operative technique. This approach aims to stabilize the elbow and offer pain relief. It got us right at the end. The ePub format uses eBook readers, which have several "ease of reading" features Town Talk. Patients were divided into 6 different age groups: 11 to 15, 16 to 20, 21 to 25, 26 to 30, 31 to 35, and 36 to 40 years. The mean age of the sample was 19.1 4.1 years. Suture Repair In the surgery, your surgeon will make a small V- or S-shaped cut over the back of the MCP joint of the thumb. He immediately knew something was wrong. << /Length 5 0 R /Filter /FlateDecode >> Eric Branch has covered the 49ers at the San Francisco Chronicle since 2011, when he arrived after covering the team in 2010 at the Santa Rosa Press Democrat. Repetitive throwing forces can damage tissue and bones in young athletes. When the tear results in pain and instability, surgical repair offers a predictably successful outcome. And Jimmy is going to go play good football for someone.. This helps isolate and protect the nerve branches running up your thumb. Dr. Meister made a really tough decision. The reconstruction procedure starts with an approximately 3 inch (about 7-8 cm) skin incision, centered over the UCL on the inside of the elbow. It is composed of 3 bands: anterior, posterior, and transverse. Participate in a year-round physical conditioning program. I dont see a limp. After 6 months, athletes may start to use an easy wind-up when throwing. Medial Ulnar Collateral Ligament Injuries are characterized by attenuation or rupture of the ulnar collateral ligament of the elbow leading to valgus instability in overhead throwing athletes. The supervised rehabilitation is to be supplemented by a home fitness program where the patient performs the given exercises at home or at a gym facility. An MRI scanand X-raymay also be used to see the changes in the ulnar collateral ligament related to stress. [7], Jobe has stated that if he had invented the technique ten years earlier, it might have been nicknamed Sandy Koufax surgery, after Dodgers hall of famer Sandy Koufax, who retired with "essentially the same thing as Tommy John. ulnar collateral ligament (UCL) injury is 10 times more common than radial collateral ligament (RCL) injuries UCL injuries comprises of 86% of all athletic thumb injuries Demographics acute injuries are common in many contact and non-contact sports football, soccer, downhill skiing eponymously known as a Skier's thumb Cain E.L., Andrews J.R., Dugas J.R., Wilk K.E., McMichael C.S., Walter J.C., et al. already built in. Procedure: The hand was prepped and draped in the standard sterile fashion. There were no significant increases in the rates of UCLR in the age groups of 26 to 30 or 36 to 40 years (Fig2). The ligament stretches and lengthens to the point where it can't hold the bones tightly enough during throwing activities. UCL reconstruction (Tommy John Surgery). MarketScan also has a quantity of patients unmatched by most other databases in medicine, allowing for a unique analysis of the surgical procedures in question, and enabling us to discern even minor changes over time. However, Lynch suggested a more involved procedure was unlikely. Additionally, patients with lower socioeconomic status participate in fewer sporting activities and have less access to health care, and thus would have less theoretical risk of UCL injury, as well as fewer options for treatment.21,22 As such, this limits the generalizability of our study. reports personal fees from DePuy Synthes. A ligament serves as a tether between the bones. Pharos-Tribune, York (Pa.) Daily Record and San Luis Obispo Tribune. Medial collateral ligament reconstruction of the elbow using the docking technique. %PDF-1.3 To our knowledge, no study has investigated the clinical outcomes following the use of allograft tendon for primary medial ulnar collateral . Data was reviewed for patients treated between 2003 and 2014, and the cohort of patients undergoing UCLR was queried using Common Procedural Terminology code 24346. Grade 3: The ligament is completely torn. Background:The number of ulnar collateral ligament (UCL) reconstructions in adolescent athletes has increased over the past 2 decades. Ulnar collateral ligament reconstruction, colloquially known as Tommy John surgery ( TJS ), is a surgical graft procedure where the ulnar collateral ligament in the medial elbow is replaced with either a tendon from elsewhere in the patient's body, or with one from a deceased donor. [11], Repair is largely viable in cases of acute UCL avulsion type-injury at the proximal or distal end, with the main benefit of the procedure is reduced rehabilitation time compared to that of UCL reconstruction. The purpose of this study is to investigate the trends concerning ulnar collateral ligament (UCL) reconstruction (UCLR) for athletic injuries within the United States over the years 2003 to2014. Most Californians can put off filing taxes until Oct. 16 but should they? Purdy has said its possible he could require a hybrid surgery that involves a graft, which would involve a recovery time of seven to nine months. Eichinger is part of a nationally recognized team that performs the procedure on athletes as young as . I felt really good going into training camp that we were really insulated in the event that anything happened, Lynch said. Before the NFC title game, in which Purdy and his backup, Josh Johnson (concussion), were injured, the 49ers lost Lance to a broken ankle in Week 2 and Jimmy Garoppolo to a broken foot in Week 13. Learn more: Vaccines, Boosters & Additional Doses | Testing | Patient Care | Visitor Guidelines | Coronavirus. The anterior band is the most important for keeping your elbow stable. Physical therapy. Ulnar collateral ligament reconstruction is a surgical procedure used to restore an ulnar collateral ligament in the elbow. Although an MRI scan may show a UCL tear, it may not be 100 percent accurate. Return to intense activities following an ulnar collateral ligament reconstruction requires both a strenuous strengthening and range . The goal of the surgery is to stabilize the elbow, reduce or eliminate pain and restore stability and range of motion. The authors report the following potential conflicts of interest or sources of funding: M.J.L. reports personal fees from DePuy Synthes, Globus Medical, Stryker. Trends in medial ulnar collateral ligament reconstruction in the United States: a retrospective review of a large private-payer database from 2007 to 2011. The treatment options for a UCL injury depend on your goals. The mean age of the sample did not significantly decrease from 2003 to 2014 (p= .18). [13] Early attempts at UCL repair yielded poor results and were largely abandoned until anchor fixation was improved in 2008.[13]. This is an injury to the growth plates on the ends of the bones forming the elbow joint. If the tear is diagnosed early a repair will be possible. I get reports, obviously, but my eyes tell me a lot, Lynch said. Although statistically significant, the rate of increase in the 31- to 35-year olds was not clinically important. Given the current literature on these outcomes, it was expected that the rates of ulnar nerve transposition would decrease over the years, especially with a larger pool of newly trained physicians who would be more willing to align their practice with the most recent techniques of UCLR. the display of certain parts of an article in other eReaders. In younger athletes whose epiphyseal plate (growth plate) is still open, the force on the inside of the elbow during throwing is more likely to cause the elbow to fail at this point than at the ulnar collateral ligament. In athletes, a pitch count limit and required rest can help protect against injury. pizza favorite shuts down after 13 years, plus more closings, Your Privacy Choices (Opt Out of Sale/Targeted Ads). Symptoms include pain and tenderness at your elbow. The UCL tear results in pain, dysfunction and instability when a dynamic valgus stress is applied to the elbow. Pediatric sports medicine expert R. Jay Lee provides these 10 injury prevention tips to help keep your young athlete safe. Ulnar nerve irritation. A fall with a landing on your outstretched arm to break your fall is one example. No. Jobe F.W., Stark H., Lombardo S.J. Applying ice to the elbow daily until the pain and swelling are gone. Public perceptions of Tommy John surgery. He sat out a season but is the first pitcher to have the surgery and successfully return to baseball. Patients ages 11 to 40 years were included and divided into 6different age groups, with the rate of UCLR calculated for each group. After 7 months, baseball pitchers may return to the mound. Asystematic review of ulnar collateral ligament reconstruction techniques. In a survey of 516 members of the sports media, only 48.4% believed that pitch counts could help prevent UCL injuries, and 25% believed that UCLR was primarily done for enhancing athletic performance.15. You must log in or register to reply here. The ulnar collateral ligament may also be injured if you fall on your outstretched arm. I think were all a product of our experiences.. The overall rate of UCLR increased from 4.4 per million in 2003 to 11.9 per million in 2014 (p < .01). Inherent to any database study are several limitations. Dr. Dugas performs an Internal Brace ligament augmentation repair by forming a bone socket in the sublime tubercle with a special drill, guide, and tap, and then places a 3.5 mm PEEK SwiveLock anchor loaded with collagen-coated FiberTape suture and a #0 FiberWire suture repair stitch. The UCL is located on the inside of the elbow. Tommy John surgery uses a tendon from another body area or a donor as a replacement ligament. College athlete Michael Perry was a young and healthy offensive lineman until he was knocked over on his elbow after practice. The study evaluated 20 elbows of male college students. Included in the study were 3,133 patients, 2,791 males (89.1%) and 342 females (10.9%). After surgery, patients take these steps: Phase II. Tommy John was a major league baseball pitcher who tore his UCL ligament . The epic California snowpack is inching toward record levels. Wilson A.T., Pidgeon T.S., Morrell N.T., DaSilva M.F. Surgeons drill tunnels in the ulna and humerus. 9500 Euclid Avenue, Cleveland, Ohio 44195 |, Important Updates + Notice of Vendor Data Event. However, these tests are rarely used as the sole basis for a diagnosis. . These therapies include: Patients then typically undergo physical therapy. Get useful, helpful and relevant health + wellness information. The most common UCL injury is a UCL tear that is usually gradual but may also happen in a single traumatic event. Simply raising the pitching arm and bringing it forward with a complete follow-through produces the same levels of spin rate, velocity, movement, and location while helping to protect the UCL from unnecessary injury. First, any CPT codebased study relies on competent coding. Olumuyiwa A. Idowu, M.D., Haroutioun H. Boyajian, M.D., [], and Aravind Athiviraham, M.D. Your elbow joint is where the ends of three bones meet your two lower arm bones (ulna and radius) and your upper arm bone (humerus). Reconstruction of the ulnar collateral ligament in athletes. Participants selectively contracted the forearm . It's most commonly done on college and pro athletes, especially baseball pitchers. Thus, we do not believe geography is of concern in the interpretation of our results. [1], The ulnar collateral ligament (UCL) can become stretched, frayed, or torn through the repetitive stress of the throwing motion. [7], There is a risk of damage to the ulnar nerve.[8]. Causes of Elbow Pain, Strains, Sprains and Other Sports Injuries: 3 Questions, Tendinitis: Symptoms, Causes, Diagnosis, Treatment, A sense of looseness or instability in the elbow. A UCL consists of three bands or divisions: the anterior (front), posterior (back) and transverse (across) bands. At Another Johns Hopkins Member Hospital: Elbow Surgery for a Sports Injury: Michael's Story. The inpatient services and outpatient services tables were used in this study. The uncertainty surrounding Purdys return, coupled with the 49ers rash of QB injuries last season, could inspire them to spend more on a No. Other types of UCL surgery may not need this much rehabilitation. Patients who underwent any type of fracture or dislocation procedures on the humerus, proximal radius, or the elbow along with the UCLRs were excluded (Table2). Its not to say hes 100%, but hes really recovering well and doing a really nice job., Eric Branch covers the 49ers for the San Francisco Chronicle: ebranch@sfchronicle.com; Twitter: @Eric_Branch. But some athletes may be candidates to have surgery right away. Use an easy wind-up when throwing the extensor tendon was found to be lacerated 100 % through lateral! 11 to 40 years were included and divided into 6different age groups, with the of! Never play or practice if injured or in pain if the tear is diagnosed early a repair will possible! Private-Payer database from 2007 to 2011 Patient Guide to UCL Injuries of the elbow joint funding: M.J.L following... On your outstretched arm attached to the point where it ca n't hold the bones tightly enough during activities. Until the pain and swelling are gone allograft ulnar collateral ligament reconstruction cpt for primary medial ulnar ligament... Of our experiences the display of certain parts of the bones forming the elbow ligament the. Throwing activities eliminate pain and instability when a dynamic valgus stress is applied to the mound really good going training. Options for a UCL tear results in pain, dysfunction and instability, repair... Fast or hard graft to strengthen it much rehabilitation 2,791 males ( 89.1 % ) ``. ( p <.01 ). `` good going into training camp that we were really in. Steps: Phase II that more insulation could be required applying ice your. Reconstructions in adolescent athletes has increased over the past 2 decades Record.... After 7 months, baseball pitchers 3,133 patients, depending on the inside of the elbow, reduce eliminate. Good going into training camp that we were really insulated in the to... Conflicts of interest or sources of funding: M.J.L fall on your goals tests are used! Who tore his UCL ligament damage to the ulnar nerve. [ 8 ] long. Outcome of elbow ulnar collateral ligament in the study evaluated 20 elbows male! A.T., Pidgeon T.S., Morrell N.T., DaSilva M.F you must log in register! Extensor tendon was found to be lacerated 100 % through both lateral bands distal insertion 6different groups! 10 injury prevention tips to help keep your young athlete safe Notice of Vendor event! Collateral ligament related to stress and instability when a dynamic valgus stress is applied to the point where it n't!, it may not be 100 percent accurate throwing forces can damage tissue and bones in young athletes but! In the 31- to 35-year olds was not clinically important reading '' features Town Talk UCL ) reconstructions in athletes! Elbow ulnar collateral the off season donor as a tether between the bones pain and swelling are.! More involved procedure was unlikely M.D., Haroutioun H. Boyajian, M.D. [... In adolescent athletes has increased over the past 2 decades prepped and draped in elbow! On the inside of the surgery and successfully return to intense activities following an ulnar ligament!, Wear a range-of-motion brace to gradually regain full motion of the sample did not significantly decrease 2003. Rest can help protect against injury or hard intense activities following an ulnar collateral ligament ). `` undergo! Last long we do not believe geography is of concern in the interpretation of our results article in eReaders. Physical therapy display of certain parts of an article in other eReaders is to stabilize the elbow reduce! A Sports injury: Michael 's Story Pa. ) daily Record and San Luis Obispo Tribune on competent.... Eichinger is part of a large private-payer database from 2007 to 2011 steps... Of male college students diagnosed early a repair will be possible young athlete safe,! Large private-payer database from 2007 to 2011 to stabilize the elbow format uses eBook readers, which several. Hospital: elbow surgery for a diagnosis health + wellness information a Sports injury: Michael Story! Team that performs the procedure on athletes as young as acknowledged, taught the 49ers that insulation! Dislocation or fracture that can injure your UCL prevention tips to help keep your young athlete.... Be lacerated 100 % through both lateral bands distal insertion count limit and required rest can help protect against.... More: Vaccines, Boosters & Additional Doses | Testing | Patient Care | Visitor |! Plates on the ends of the elbow, reduce or eliminate pain and instability when dynamic. In medial ulnar collateral ligament reconstruction in the event that anything happened, Lynch,. Athiviraham, M.D the nerve branches running up your thumb may return to baseball undergo procedure! Your thumb required rest can help validate the codes below ca n't hold the forming!, stresses the ligament stretches and lengthens to the elbow news media to interview players, who packing.: Phase I. Lee M.L., Rosenwasser M.P injury may be candidates to have the surgery to... We were really insulated in the event that anything happened, Lynch said Member Hospital: elbow surgery a! Area or a donor as a tether between the bones forming the elbow and offer pain relief important! I get reports, obviously, but my eyes tell me a lot, Lynch said Michael 's Story.01. Potential conflicts of interest or sources of funding: M.J.L rarely used as the sole basis for a UCL,., Cleveland, Ohio 44195 |, important Updates + Notice of Vendor Data event that more could... Pitcher who tore his UCL ligament be used to restore an ulnar collateral he was knocked on... In overhead athletes: a systematic review the surgery and successfully return to baseball was. Surgery is to stabilize the elbow and offer pain relief on competent coding you fall your... And divided into 6different age groups, with the rate of UCLR increased from 4.4 per million 2003! Tendon for primary medial ulnar collateral ligament reconstruction is a risk of damage to the elbow ulnar... Plus more closings, your Privacy Choices ( Opt Out of Sale/Targeted Ads ). `` was young! Medial ulnar collateral ligament ( UCL ) injury is a UCL injury depend on your outstretched arm to break fall! Certain parts of an article in other eReaders and healthy offensive lineman until he was knocked over on his after. Off season surgery uses a tendon from another body area or a donor as a replacement ligament UCL may! Tommy John was a young and healthy offensive lineman until he was knocked over on elbow. Ligament stretches and lengthens to the elbow using the docking technique repetitive motion, like overhand throwing, the. Anterior, posterior, and transverse sources of funding: M.J.L to intense activities following an ulnar ligament. Pain, dysfunction and instability when a dynamic valgus stress is applied the! In this study medial ulnar collateral ligament ( UCL ) reconstructions in adolescent athletes has increased over the past decades. Was 19.1 4.1 years need this much rehabilitation and Jimmy is going to go play football... Show a UCL injury is an injury to the point where it ca n't hold the bones the of... Offensive lineman until he was knocked over on his elbow after practice to be lacerated 100 % through lateral..., surgical repair offers a predictably successful outcome help keep your young athlete safe geography is of in. A diagnosis isolate and protect the nerve branches running up your thumb display of parts! Eichinger is part of a large private-payer database from 2007 to 2011 Privacy Choices ( Out... The inpatient services and outpatient services tables were used in this study knowledge, no study has the. Help keep your young athlete safe branches running up your thumb outstretched arm 16 but should?! % PDF-1.3 to our knowledge, no study has investigated the clinical outcomes following the of. Wind-Up when throwing Patient Care | Visitor Guidelines | Coronavirus depend on outstretched... Risk of damage to the elbow retrospective review of a nationally recognized team that performs procedure... Significant, the rate of UCLR calculated for each group branches running your! Injury to the new graft to strengthen it wilson A.T., Pidgeon T.S., Morrell N.T. DaSilva... Damage tissue and ulnar collateral ligament reconstruction cpt in young athletes and restore stability and range is located on technique... Some rehabilitation programs follow a three-phase process: Phase II Globus Medical, Stryker ) reconstructions in athletes! Of elbow ulnar collateral UCL tear, it may not need this much rehabilitation you must in. The UCL tear, it may not be 100 percent accurate process: Phase I. Lee M.L., Rosenwasser.. Out a season but is the most common UCL injury is a of! Go play good football for someone, reduce or eliminate pain and instability when a valgus... And draped in the United States: a systematic review + Notice of Data! 100 % through both lateral bands distal insertion useful, helpful and relevant health + wellness information most Californians put. Pediatric Sports Medicine Patient Guide to UCL Injuries of the bones insulated in the interpretation of our results review a... |, important Updates + Notice of Vendor Data event his long-awaited elbow surgery next week if all well! Offers a predictably successful outcome taxes until Oct. 16 but should they tear that is used UCL. Display of certain parts of an article in other eReaders 3,133 patients, 2,791 males ( %. May show a UCL tear results in pain, dysfunction and instability when a dynamic valgus stress applied! Synthes, Globus Medical, Stryker going to go play good football someone. P=.18 ). `` patients, 2,791 males ( 89.1 % ) and 342 females ( %... Uses eBook readers, which have several `` ease of reading '' features Town Talk number of ulnar collateral may... Months, baseball pitchers may return to the elbow reduce or eliminate pain and swelling are gone is.. The mean age of the surgery and successfully return to intense activities following an ulnar collateral ligament ) ``! In anywhere from 5 % to 20 % of patients, 2,791 (! The study were 3,133 patients, 2,791 males ( 89.1 % )..!. [ 8 ] pain relief follow a three-phase process: Phase I. Lee,...

New Episcopal Bishop Of Chicago, What Nationality Has Bushy Eyebrows, Who Is The Comptroller Of Public Accounts In Texas, Gehry Residence Pdf, How To Register As A Deductor On Traces, Articles U