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4/21/2015
1
Hand & Carpal Fractures
Kim Kraft PT, DPT, CHT
Accessed 2/28/15http://adswithoutproducts.com/2009/07/19/dollar-sign-on-the-muscle-out-for-the-season-broken-knuckles/
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Accessed 2/28/15http://adswithoutproducts.com/2009/07/19/dollar-sign-on-the-muscle-out-for-the-season-broken-knuckles/
Topics
1. Hand Fracture Reduction Methods
2. Fracture Healing Essentials
3. Therapy Basics
4. Characteristics of Specific Fractures
5. Special Cases
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Hand Fracture Reduction Methods
Retrieved 4/2/15
Handsurgery.sp
Open reduction with screws
Open reduction with plate and screws
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Closed Reduction
• Cast vs Splint
• Splint = Orthosis
• Prevents displacement
of a fracture with good alignment
• Protects tendon and soft tissue injuries
• Works by compression of soft tissues
• Three point support of the fracture in all directions
ORIF Open Reduction Internal Fixation
• Unstable fracture
• Displaced fracture
• Soft tissue injury
• Fractures with bone loss
• Rotational deformity
• Angulation
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Surgical FixationRequires…
1. Good soft tissue skills & knowledge of anatomy
2. Understanding of hand incisions
3. Rehabilitation
4. Motion within 2-3 days after surgery
5. Protection
6. Edema management and wound care
Closed Reduction Internal FixationClosed Reduction External Fixation
• Approximates fracture ends
• Has some wiggle
• K Wires, Pins, External Fixation
• Splinting/casting
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Immobilization Position
Ruedi TP, Buckley RE, Moran CG, eds. (2007)AO Principles of Fracture Management. AO Publishing, Switzerland.Copyright by AO Publishing, Switzerland
• MP ligaments are taut in flexion
• IPs are tight in extension• “Safe” position prevents
contractures is MP flexion, IP extension
Video: Abduction with and without MP Flexion
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FRACTURE HEALING ESSENTIALS
Retrieved 3/4/15http://www.intechopen.com/books/gene-therapy-applications/gene-therapy-applications-for-fracture-repair
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How Fractures Heal
No callus
Open reduction
No motion at the fracture
Fracture ends in contact
Cutting cones
Primary
Callus
Casting, Splinting, Wires/Pins
Stress-strain at fracture site
Plastic
Soft callus ossification
Secondary
Primary Bone Healing
Retrieved 3/7/15http://www.dginet.de/web/dgi/gomi/wiki/English/Bone+remodeling/pop_up;jsessionid=64953D049904CE14641F958DFDAB08F2?_36_viewMode=print
Cutting Cone = Zamboni of the Haversian Canal System
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Accessed 2/28/15http://www.nuigalway.ie/anatomy/wilkins/practicals/bone/html/bone_15.html
http://histoweb.co.za/012/012img020.html
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Secondary Bone Healing
• PAIN & SWELLING before callus formation
• Less painful after SOFT CALLUS forms (cartilage)
• HARD CALLUS (cartilage turns to bone)
• Calcification & remodeling
Wolff’s Law of Bone RemodelingResults From Stress & Strain
Retrieved 3/4/15http://www.nature.com/nrrheum/journal/v8/n3/fig_tab/nrrheum.2012.1_F1.html
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Therapy Basics
Edema Control
• Prevents throbbing
• Improves active motion
• Ultimately less scar tissue
Physiological Goals:
Increase tissue hydrostatic pressure
Reduce the intravascular pressure
Support lymphatic return
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Edema Control
1. Compression
Very effective with early low-protein edemaPRECAUTION: VASCULAR COMPROMISE, LACK OF SENSATION, GRAFTS AND WOUNDS, CIRCUMFERENTIAL OR TOO TIGHT BANDAGES CAUSE TOURNIQUET,
NEED TO WAIT UNTIL AROM PERMITTED TO DON GLOVE
Edema Control
2. Elevation “On the shoulder, the sofa, the pillow” Increases intravascular pressure, reduces capillary filtration pressure because peripheral arterial and venous pressures are affected by gravity.
3. Light cardiovascular exercise
Increased diaphragm activity & compression of interstitial spaces, veins, lymphatic vessels, create increased lymphatic activity.
4. Active motion when permitted
Soft tissue motion, compression of interstitial spaces, counter pressure of compressive dressing or glove/stocking, increase lymphatic
return.
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Kinesiotape
• “Lifts” epidermis
• Opens lymph channels
• Effective on the back of the hand (metacarpal fractures)
• Creates motion between tissue layers
PRECAUTION: MAY OPEN INCISIONS IF NOT COMPLETELY HEALED, CAN TEAR or CONTUSE
Making Motion: AROM & PROM
Retrieved 3/16/15
http://radiopaedia.org/cases/flexor-and-extensor-insertions-at-the-hand-and-wrist
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Active Motion
• 3-4 days after ORIF • 2-4 weeks for closed
reduction• Balance tendon forces to
prevent deformity• TENDON MOBILITY
prevent adhesion between tissue layers
Retrieved 3/16/15http://radiopaedia.org/cases/flexor-and-extensor-insertions-at-the-hand-and-wrist
Active Motion
• Blocking
• Flexor Digitorum Profundus
• Flexor Digitorum Superficialis
• Flexor Pollicis Longus
• Tendon Gliding
• Fist
• Hook Fist
• Straight Fist
• Reverse Blocking
Retrieved 3/28/15http://biorobotics.harvard.edu/hand_therapy.html
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Video: AROM
Passive Motion
Fracture stability first, in 4-6 weeks with Xray evidence of bone healing
Low-Load Prolonged Stress
Heat
Joint mobility
1. Elastic loops:10 minutes 4x/day
2. Tape: Can be used with heat
3. LMB: 10-15 minutes 4x/day
4. SPLINTING
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Passive Motion
Splinting
30 minutes
4 times per day1. Static
2. Dynamic
3. Static Progressive
Cannon NM. Rehabilitation approaches for distal and middle phalanx fractures of the hand. J Hand Ther 2003; 16: 105-116.
Video: PROM
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Strengthening
• Putty & light resistive exercise
• Begin after 6-8 weeks if healing1.Grip
2.Pinch
3.Opposition
4.Finger & thumb extension
5.Abduction/Adduction
Video: Strengthening
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Phalanx Fractures “P1, P2, P3”
Retrieved 4/2/15
https://www.jaaos.org/content/16/10/586/F2.expansion
Distal Phalanx Fractures
Tuft
• Nailbed injury
• Sensitivity
Shaft
Base
• FDP Avulsion
• Bony Mallet
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Distal Phalanx
• Insertion of FDP palmar base
• Insertion of extensors by terminal tendon dorsal base
• Germinal matrix &nail bed
Retrieved 3/16/15http://eorif.com/WristHand/Phalanx%20distal%20class.html
Retrieved 3/16/15 http://stepbystepintoenglish.blogspot.com/2012/05/fingernailzhijia.html
Distal Phalanx Shaft & Tuft Fractures
• Immobilize IP joints straight “mallet splint” that includes the DIP but not the PIP
• 2-3 weeks before active motion
Hardy MA. Principles of metacarpal and phalangeal fracture management: a review of rehabilitation concepts. J orthop Sports Phys Ther 2004; 34(12):781-99.
Cannon NM. Rehabilitation approaches for distal and middle phalanx fractures of the hand. J Hand Ther 2003; 16: 105-116.
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Distal Phalanx Shaft & Tuft Fractures
DESENSITIZATION• AROM
• FDP Blocking
• FDP Gliding • Vibration
• Rice bucket
• Massage
10 minutes 2-4x/day
Works within 2 weeks
Hardy MA. Principles of metacarpal and phalangeal fracture management: a review of rehabilitation concepts. J orthop Sports Phys Ther 2004; 34(12):781-99.
Distal Phalanx Base FracturesAre TENDON INJURIES
FDP AVULSION
• “Jersey finger”
• Wire to stabilize & dorsal button
• Zone 1 Flexor Tendon Repair: follow Modified Duran flexor tendon repair program
BONY MALLET• “Baseball fracture”
• Immobilized 6 weeks, then at night and heavy activity
• Active fisting ex program
• No DIP BLOCKING
• (causes extension lag)Cannon NM. Rehabilitation approaches for distal and middle phalanx fractures of the hand. J Hand Ther 2003; 16: 105-116.
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Distal Phalanx Fracture
Middle Phalanx Fractures
Condyles and lateral ligaments for stability with DIP joint
Special Considerations• Volar plate injury
• Insertion of FDS at the base
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Middle Phalanx Fractures “P2”
• IP Gutter
• Extension gutter or buddy tapes if shaft fracture
• Slight flexion of PIP for 6 weeks if a dorsal dislocation with volar plate injury or articular fracture ORIF
Hardy MA. Principles of metacarpal and phalangeal fracture management: a review of rehabilitation concepts. J orthop Sports Phys Ther 2004; 34(12):781-99.
Cannon NM. Rehabilitation approaches for distal and middle phalanx fractures of the hand. J Hand Ther 2003; 16: 105-116.
Active MotionMiddle Phalanx Fractures
1. FDS blocking
2. Reverse blocking
3. Tendon gliding
• Fist
• Hook
• Straight fistHardy MA. Principles of metacarpal and phalangeal fracture management: a review of rehabilitation concepts. J orthop Sports Phys Ther 2004; 34(12):781-99.
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Middle Phalanx Fracture
Proximal Phalanx Fractures Base, Shaft, Head
• NO complicating tendon insertions
• Immobilization in MP flexion where collateral ligaments are elongated
• Intrinsics flex proximal piece; extensors extend distal piece
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Splinting Proximal Phalanx Fractures “P1”
• Forearm based radial gutter / ulnar gutter
• Include neighboring digit for stability
• SAFE Position
MP Flexion
IP Extension
Hardy MA. Principles of metacarpal and phalangeal fracture management: a review of rehabilitation concepts. J orthop Sports Phys Ther 2004; 34(12):781-99.
Proximal Phalanx Fracture
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Thumb Fractures
• Proximal and distal phalanx (P1, P2)
• Tendon insertions: EPB, APB, EPL, FPL
• Fractures displaced by tendon pull, pinch/grip
Metacarpal Fractures
Retrieved 4/2/15
http://www.aliem.com/trick-of-the-trade-reducing-the-metacarpal-fracture/
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Metacarpal Fractures
Special problems
1. angulation
2. malrotation
3. shortening
Metacarpal Malunion
1. Angulation
• Apex dorsal because of pull of interossei
• 30⁰ tolerated in small finger, 20 ⁰ ring⁰
2. Shortening
• Relative lengthening of the common finger extensors.
• 2mm of metacarpal shortening = 7⁰ extensor lag at the MP joint
3. Malrotation
• 5⁰ at the shaft creates 1.5 cm of overlap of the digit during fisting
• Buddy tape while immobilized to prevent malrotation
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Boxer’s Fracture
Special fracture of the 5th
metacarpal
Usual mechanism of injury: hitting a wall or
other hard object
Boxer’s Fracture
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Thumb Metacarpal Fractures
Thumb Fractures
Special Problems
• Tendon adherence
FPL/EPL
• Loss of web space
• Loss of pinch strength
Rolyan Wrist and Thumb Immobilizer
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Metacarpal NeckFracture
Bennett’s First Metacarpal Fracture
• Partial articular fracture dislocation at the base of the first metacarpal
• Mechanism: Axial load on a flexed first CMC joint, FOOSH
• Causes OA
Retrieved 1/6/15/lifeinthefastlane.com/education/who-was/eponymous-fractures/
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.
Bennett’s Fracture
Gedda, K-O., and Eric Moberg. "Open reduction and osteosynthesis of the so-called Bennett's fracture in the carpo-metacarpal joint of the thumb." Acta Orthopaedica 22.1-4 (1952): 249-257.
Palmar oblique
ligament
Thumb extensors
Abductor pollicislongus
4 Adductor pollicis
Bennett’s Fracture“Before”
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Bennett’s Fracture
Rolando’s First Metacarpal Fractures
• 3 piece intra-articular fracture at the base of the first metacarpal
• “T” or “Y” shaped
• Complete articular fracture
Retrieved 1/6/15/lifeinthefastlane.com/education/who-was/eponymous-fractures/
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Rolando’s Fracture
Rolando Fracture
Carlsen BT, Moran SL. "Thumb trauma: Bennett fractures, Rolando fractures, and ulnar collateral ligament injuries." The Journal of hand surgery 34.5 (2009): 945-952.
Proubasta IR. "Rolando's fracture of the first metacarpal. Treatment by external fixation." Journal of Bone & Joint Surgery, British Volume 74.3 (1992): 416-417.
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Carpal Fractures
Retrieved 4/2/15https://blog.solidconcepts.com/evolution-custom-manufacturing/best-3d-printing-articles-of-2013/
RETRIEVED 3/31/15
TRULIFE.COM
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Scaphoid Fracture
• Men 15-29 years old
• Most common carpal fracture in kids
• 80% of the scaphoid are articular surfaces
• Onset: FOOSH, MVA, direct blow to radial wrist https://sites.google.com/site/activecarep
hysiotherapyclinic/scaphoid-injury
Retrieved 3/25/15orthopedicsone.com
Scaphoid Fracture
1. Palpation in the anatomic snuffbox with ulnar deviation, or
2. Transverse wrist crease
3. 2% don’t appear on initial X-ray
•Blood flow from distal to proximal
•Healing 8-24 weeks
•Return to sport/activity 10-12 weeks after cast removed
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Scaphoid Fracture
http://radiopaedia.org/images/5848770
TrapeziumFracture
• 1-5 % of carpal fractures
• Chip fractures are not treated
• Axial force of the 1st
MC causes splaying of waist fractures
• Palpation: base of the 1st metacarpal in small finger opposition
Retrieved 3/25/15orthopedicsone.com
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HamateFracture
• Injury by compression (bat swing is classic), treated with wire, excision, or cast
• Fracture becomes displaced by ligaments
• Ulnar nerve sensitivity
Brach P, Goitz R. An update on the management of carpal fractures. J Hand Ther 2003; 16: 152–160.
Retrieved 3/25/15orthopedicsone.com
CapitateFracture
• 6 weeks casted before beginning AROM
• 1% carpal fractures
• ORIF: Mobilize scar, Continuous US with steroid
Retrieved 3/25/15orthopedicsone.com
Retrieved 3/25/15orthopedicsone.com
Retreieved 4/2/14http://www.thefemalecelebrity.info/Fractured-Scaphoid-Treatment.html
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Pisiform
• Caused by a direct blow, maybe repetitive stress
• Excision common (nonunion)
• Scar sensitivity & grip weakness
Pisiform Fracture
Retrieved 3/25/15orthopedicsone.com
TriquetrumFracture
• Second most common carpal fracture
• 4 weeks in cast
• Complaints of ulnar wrist pain, local tenderness
• Pisiform lies on top
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LunateFracture
• Caused by impact with wrist extension
• Casted 6-8 weeks
• Associated with ligament injuries
“It’s Complicated”
• Keinbock’s = avascular necrosis of the lunate
• May lose wrist ROM
Hand Physeal Closure Ages
Lightdale-Miric N, Kozin SH. Fractures and dislocations of the hand and carpal bones in children. In :Flynn JM, Skaggs DL, Waters PM, editors. Rockwood and Wilkin’ Fractures in Children 2015, Walters Kluwer Health Philadelphia. P265.
Middle and Distal Phalanges 14-16 years
Proximal Phalanges 14-16 years
Metacarpal Head14-16 years
Thumb Metacarpal14-16 years
• Open physis is weaker than surrounding bone
• Differential growth of the physis can correct for some malalignment of the fracture site
• Physeal arrest from mishandling
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Salter-Harris
Retrieved 4/3/15Studyblue.com
HAND PHYSES
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Special Pediatric Fractures
1. Seymour fracture• Fracture of the physis of the distal phalanx
• Results in infection, growth arrest, mallet deformity
2. Tuft fracture• 2-3 year olds
• Very painful-needs cushioning and protection (tip protector)
Osteoporotic Fractures
1. Age
2. Post-menopausal female
3. Glucocorticoids
4. Smoking
5. Alcoholism
6. High protein diet
7. Balance deficit
8. Failure of fixation
Biophosphonates-Treatment for osteoporosis, slows osteoclast activity; also slows fracture healing; half life in bone is 1.5-10 years, shows a higher rate of non-union
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Fracture Complications
• Nonunion, delayed union, malunion, avascular necrosis, osteomyelitis, amputation, stiffness/motion loss, instability, laxity, poor durability, lack of coverage, contracture, tendon adhesions, motion lag, numbness, hypersensitivity , pain, CRPS, ischemia, venous congestion, sensitivity, joint laxity
Hand Compartment Syndrome
Retrieved 3/29/15Galleryhip.com
Retrieved 3/29/15Scienceopen.com
• Pressure in enclosed space• Soft tissue injury from crush,
burn, tight bandaging
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References
1. Baldwin PC, Wolf JM. Outcomes of hand fracture treatments. In: Lawton JN, Chung KC, editors. Management of hand fractures. Philadelphia: Elsevier; 2013; 621-630.2. Brach P, Goitz R. An update on the management of carpal fractures. J Hand Ther 2003; 16: 152–160.3. Cannon NM. Rehabilitation approaches for distal and middle phalanx fractures of the hand. J Hand Ther 2003; 16: 105-116.4. Carlsen BT, Moran SL. Thumb trauma: Bennett fractures, Rolando fractures, and ulnar collateral ligament injuries. J Hand Surg 2009; 34: 945-52.5. Day CS, Stern PJ. Fractures of he metacarpals and phalanges. In: Wolfe SW, Hotchkiss RN, Pederson WC, e al,editors. Green's operative hand surgery. 6th edition.
Philadelphia: Elsevier Churchill Livingstone; 2011; 239-90.6. Flowers K, LeStayo P. Effect of total end range time on improving passive range of motion. J Hand Ther 1994; 7:150-5.7. Foster RJ, Hastings H II. Treatment of Bennett, Rolando, and vertical intraarticular trapezial fractures. Clin Orth Rel Res 1987; 21: 121-29.8. Gedda KO, Moberg E. Open reduction and osteosynthesis of the so-called Bennett's fracture in the carpo-metacarpal joint of the thumb. Acta Orth 1952; 1-4: 249-57.9. Hardy MA. Principles of metacarpal and phalangeal fracture management: a review of rehabilitation concepts. J Orthop Sports Phys Ther 2004; 34(12): 781-99.10. Hardy MA, Freeland AE. Hand fracture fixation and healing : skeletal stability and digital mobility. In: Skirven TM, Osterman AL, Fedorczyk, et al, editors. Rehabilitation of the
hand and upper extremity. 6th
edition. Philadelphia: Elsevier Mosby; 2011; 361-76.11. Hays PL, Rozental TD. Rehabilitative strategies following Hand Fractures. In: Lawton JN, Chung KC, editors. Management of hand fractures. Philadelphia: Elsevier; 2013; 585-
600.12. Lightdale-Miric N, Kozin SH. Fractures and dislocations of the hand and carpal bones in children. In :Flynn JM, Skaggs DL, Waters PM, editors. Rockwood and Wilkin’ Fractures
in Children 2015, Walters Kluwer Health Philadelphia; 2015; 265. 13. Markiewitz AD. Complications of hand fractures and their prevention. In: Lawton JN, Chung KC, editors. Management of hand fractures. Philadelphia: Elsevier; 2013; 601-
620. 14. McNemar TB, Howell JW, Chang E. Management of Metacarpal Fractures. J Hand Ther;2003:16:143-151.15. Michlovitz SL. Is there a role for ultrasound and electrical stimulation following injury to tendon and bone? J Hand Ther 2005; 18:292-296.16. Michlovitz SL, Harris BA, Watkins MP. Therapy interventions for improving joint range of motion: a systematic review. J Hand Ther 2004; 17:118-31.17. O'Brien L. The evidence on ways to improve patient's adherence in hand therapy. J Hand Ther 2012; 25:247-50..18. Proubasta IR. Rolando's fracture of the first metacarpal. Treatment by external fixation. J Bone Joint Surg, Br 1992; 74.3: 416-17.19. Ruedi TP, Buckley RE, Moran CG, eds. AO Principles of Fracture Management. AO Publishing, Switzerland 2007.20. Sarmiento A, Latta L. The Nonsurgical Treatment of Fractures in Contemporary Orthopedics. Joyce Brothers, New Delhi 2011.21. Shin AY, Amadio PC. The stiff finger. In: Wolfe SW, Hotchkiss RN, Pederson WC, e al,editors. Green's operative hand surgery. 6th edition. Philadelphia: Elsevier Churchill
Livingstone; 2011; 355-88.22. Villeco JP. Edema: A silent but important factor. J Hand Ther 2012; 25:153-62.23. Watson HK, Weinzweig, eds. The Wrist. 2001, Lippincot Williams & Wilkins, Philadelphia PA.
Questions? Answers? Pearls?
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