PRINCIPLES IN FRACTURES
MANAGEMENT
ISA BASUKI
DEFINITION OF FRACTURE
• A FRACTURE IS A BREAK IN THE STRUCTURAL CONTINUITY OF BONE.
• IF THE OVERLYING SKIN REMAINS INTAC...
FRACTURES DUE TO INJURY
FATIGUE OR STRESS FRACTURES
• BONE , LIKE OTHER MATERIALS , REACTS TO REPEATED LOADING .
• ON OCCASION , IT BECOMES FATIGU...
PATHOLOGICAL FRACTURES
• FRACTURES MAY OCCUR EVEN WITH NORMAL STRESSES IF THE BONE HAS
BEEN WEAKENED BY A CHANGE IN ITS ST...
DIAGNOSIS
•CLINICAL FEATURES
•RADIOLOGY (X-RAY)
CLINICAL FEATURES
• HISTORY OF TRAUMA
• SYMPTOMS AND SIGNS:
1. PAIN AND TENDERNESS
2. SWELLING
3. DEFORMITY
4. CREPITUS
5....
RADIOGRAPHIC FINDINGS
• PLAIN X-RAY  SHOULD SHOW JOINT ABOVE AND JOINT BELOW IN AT LEAST 2
VIEWS, SPECIAL VIEW ON REQUEST...
FRACTURE CLASSIFICATION
• ANATOMICAL LOCATION
• CONDITION OF OVERLYING ST
• DIRECTION OF FRACTURE LINE
• MECHANISM OF INJU...
AO CLASSIFICATION
•A: SIMPLE FRACTURE
•B: WEDGE FRACTURE
•C: COMPLEX FRACTURE
AO CLASSIFICATION
A= simple fract.
A1 simple fract.
Spiral
A2 simple fract.
Oblique(≥30)
A3 simple fract.
Transverse(<30)
AO CLASSIFICATION
B1 wedge fract
Spiral wedge
B2 wedge fract
Bending wedge
B= Wedge fract.
B1 wedge fract
Spiral wedge
B2 ...
AO CLASSIFICATION
C= complex
fract.
C1 complex
fract.
spiral
C2 complex
fract.
segmental
C3 complex
fract.
irregular
OPEN AND CLOSE FRACTURE
MECHANISM OF INJURY
CLASSIFICATION
•DIRECT TRAUMA
•INDIRECT TRAUMA
DIRECT TRAUMA
• TAPPING FRACTURES
• CRUSHING FRACTURES
• PENETRATING FRACTURES:
• HIGH VELOCITY  > 2500 F/S
• LOW VELOCIT...
INDIRECT TRAUMA
• TRACTION OR TENSION FRACTURES
• ANGULATION FRACTURES
• ROTATIONAL FRACTURES
• COMPRESSION FRACTURES
FRACTURE
MANAGEMENT
•TREATMENT OF CLOSED
FRACTURES
•TREATMENT OF OPEN
FRACTURES
TREATMENT OF CLOSED
FRACTURES
•EMERGENCY CARE (SPLINTING)
•DEFINITIVE FRACTURE TREATMENT
•REHABILITATION (MUSCLE ACTIVITY ...
EMERGENCY CARE (SPLINTING)
• SPLINT THEM WHERE THEY LIE
• ADEQUATE SPLINTING IS DESIRABLE
• TYPE OF SPLINTS:
• IMPROVISED
...
DEFINITIVE FRACTURE TREATMENT
• THE GOAL OF FRACTURE TREATMENT IS TO OBTAIN UNION OF
THE FRACTURE IN THE MOST ANATOMICAL P...
CONSERVATIVE
• REDUCTION: IF DISPLACED  UNDER GENERAL ANASTHESIA, THE SOONER
THE BETTER
• STEPS OF REDUCTION:
• TRACTION
...
CLOSED REDUCTION
TRACTION IN THE
LINE OF THE BONE DISIMPACTION
PRESSING FRAGMENT
INTO REDUCED
POSITION
CLOSED UNDISPLACED
CLOSED, REDUCIBLE
 CONSERVATIVE TREATMENT
Below knee
Above knee
PLASTER OF PARIS (POP)
SLAB OR SPLINT
TRACTION
SURGICAL
•OPEN REDUCTION INTERNAL
FIXATION (ORIF)
•PERCUTANEOUS PINNING
•EXTERNAL FIXATION
OPEN REDUCTION INDICATIONS
• OPERATIVE REDUCTION OF THE FRACTURE IS
INDICATED:
1.WHEN CLOSED REDUCTION FAILS
2.WHEN THERE ...
INTERNAL FIXATION INDICATION
1. FRACTURES THAT CANNOT BE REDUCED EXCEPT BY OPERATION
2. FRACTURES THAT ARE INHERENTLY UNST...
TYPE OF INTERNAL FIXATION
• INTERFRAGMENTARY SCREWS
• WIRES (TRANSFIXING, CERCLAGE AND TENSION-
BAND)
• PLATES AND SCREWS
...
PLATES AND SCREWS
• PLATES HAVE FIVE DIFFERENT FUNCTIONS:
1. NEUTRALIZATION
• TO BRIDGE A FRACTURE AND SUPPLEMENT THE EFFE...
INTRA-MEDULLARY FIXATION
• CENTRO-MEDULLARY
• UNLOCKED
• INTERLOCKING (STATIC – DYNAMIC – DOUBLE
LOCKED)
• CONDYLOCEPHALIC...
AN OBLIQUE FRACTURE OF THE SHAFT OF THE FEMUR, BEFORE AND AFTER REAMED
INTRAMEDULLARY FIXATION WITH A STOUT NAIL AND INTER...
EXTERNAL FIXATION
• INDICATIONS:
1. FRACTURES ASSOCIATED WITH SEVERE SOFT-TISSUE DAMAGE (INCLUDING OPEN
FRACTURES) OR THOS...
REHABILITATION
• RESTORE FUNCTION – NOT ONLY TO THE INJURED PARTS BUT
ALSO TO THE PATIENT AS A WHOLE
• THE OBJECTIVES ARE:...
TREATMENT OF OPEN FRACTURES
•INITIAL MANAGEMENT
•CLASSIFYING THE INJURY
•DEFINITIVE TREATMENT
INITIAL MANAGEMENT
• IT IS ESSENTIAL THAT THE STEP-BY-STEP APPROACH IN ADVANCED TRAUMA LIFE
SUPPORT NOT BE FORGOTTEN
• WHE...
CLASSIFYING THE INJURY
• WITH GUSTILO’S CLASSIFICATION OF OPEN FRACTURES (GUSTILO ET AL.,
1984):
• TYPE 1 – THE WOUND IS U...
CLASSIFYING THE INJURY
• THERE ARE THREE GRADES OF SEVERITY:
• TYPE III A  THE FRACTURED BONE CAN BE ADEQUATELY COVERED B...
PRINCIPLES OF TREATMENT
• ALL OPEN FRACTURES, NO MATTER HOW TRIVIAL THEY MAY
SEEM, MUST BE ASSUMED TO BE CONTAMINATED
• TH...
WOUND EXTENSIONS FOR
ACCESS IN OPEN
FRACTURES OF THE TIBIA
WOUND INCISIONS (EXTENSIONS) FOR ADEQUATE
ACCESS TO AN OPEN TIB...
• THE EXTERNAL FIXATOR MAY BE EXCHANGED FOR INTERNAL FIXATION AT THE TIME OF
DEFINITIVE WOUND COVER AS LONG AS:
1. THE DEL...
AFTERCARE
• IN THE WARD, THE LIMB IS ELEVATED AND ITS CIRCULATION
CAREFULLY WATCHED.
• ANTIBIOTIC COVER IS CONTINUED BUT O...
REFERENCES
1. SOLOMON L, WARWICK DJ, NAYAGAM S. APLEY’S SYSTEM OF ORTHOPAEDICS
AND FRACTURES. CRC PRESS; 2010.
2. F. CHARL...
Principles in fractures management
Principles in fractures management
Principles in fractures management
Principles in fractures management
Principles in fractures management
Principles in fractures management
Principles in fractures management
Principles in fractures management
Principles in fractures management
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Principles in fractures management

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Presented at AW Sjahranie Hospital under supervision of dr. David SpOT

Published in: Health & Medicine

Principles in fractures management

  1. 1. PRINCIPLES IN FRACTURES MANAGEMENT ISA BASUKI
  2. 2. DEFINITION OF FRACTURE • A FRACTURE IS A BREAK IN THE STRUCTURAL CONTINUITY OF BONE. • IF THE OVERLYING SKIN REMAINS INTACT IT IS A CLOSED (OR SIMPLE) FRACTURE • IF THE SKIN OR ONE OF THE BODY CAVITIES IS BREACHED IT IS AN OPEN (OR COMPOUND) FRACTURE • FRACTURES RESULT FROM: 1. INJURY 2. REPETITIVE STRESS 3. ABNORMAL WEAKENING OF THE BONE (A ‘PATHOLOGICAL’ FRACTURE)
  3. 3. FRACTURES DUE TO INJURY
  4. 4. FATIGUE OR STRESS FRACTURES • BONE , LIKE OTHER MATERIALS , REACTS TO REPEATED LOADING . • ON OCCASION , IT BECOMES FATIGUED & A CRACK DEVELOPS • E.G MILITARY INSTALLATIONS , BALLET DANCERS & ATHLETES. • A SIMILAR PROBLEM OCCURS IN INDIVIDUALS WHO ARE ON MEDICATION THAT ALTERS THE NORMAL BALANCE OF BONE RESORPTION AND REPLACEMENT • E.G. PATIENTS WITH CHRONIC INFLAMMATORY DISEASES WHO ARE ON TREATMENT WITH STEROIDS OR METHOTREXATE
  5. 5. PATHOLOGICAL FRACTURES • FRACTURES MAY OCCUR EVEN WITH NORMAL STRESSES IF THE BONE HAS BEEN WEAKENED BY A CHANGE IN ITS STRUCTURE • E.G. IN OSTEOPOROSIS, OSTEOGENESIS IMPERFECTA OR PAGET’S DISEASE • OR THROUGH A LYTIC LESION • E.G. A BONE CYST OR A METASTASIS.
  6. 6. DIAGNOSIS •CLINICAL FEATURES •RADIOLOGY (X-RAY)
  7. 7. CLINICAL FEATURES • HISTORY OF TRAUMA • SYMPTOMS AND SIGNS: 1. PAIN AND TENDERNESS 2. SWELLING 3. DEFORMITY 4. CREPITUS 5. LOSS OF FUNCTION 6. NERVE AND VASCULAR INJURY
  8. 8. RADIOGRAPHIC FINDINGS • PLAIN X-RAY  SHOULD SHOW JOINT ABOVE AND JOINT BELOW IN AT LEAST 2 VIEWS, SPECIAL VIEW ON REQUEST • CT SCAN • MRI  IT IS NOT HELPFUL IN FRACTURE DIAGNOSIS OTHER THAN DELINEATING ASSOCIATED INJURIES TO THE CNS , SUBTROCHANTERIC (ST) DISRUPTION OR OCCASIONALLY FATIGUE FRACTURE
  9. 9. FRACTURE CLASSIFICATION • ANATOMICAL LOCATION • CONDITION OF OVERLYING ST • DIRECTION OF FRACTURE LINE • MECHANISM OF INJURY • WHETHER THE FRACTURE IS LINEAR OR COMMINUTED • AO CLASSIFICATION
  10. 10. AO CLASSIFICATION •A: SIMPLE FRACTURE •B: WEDGE FRACTURE •C: COMPLEX FRACTURE
  11. 11. AO CLASSIFICATION A= simple fract. A1 simple fract. Spiral A2 simple fract. Oblique(≥30) A3 simple fract. Transverse(<30)
  12. 12. AO CLASSIFICATION B1 wedge fract Spiral wedge B2 wedge fract Bending wedge B= Wedge fract. B1 wedge fract Spiral wedge B2 wedge fract Bending wedge B3 wedge fract fragmented wedge
  13. 13. AO CLASSIFICATION C= complex fract. C1 complex fract. spiral C2 complex fract. segmental C3 complex fract. irregular
  14. 14. OPEN AND CLOSE FRACTURE
  15. 15. MECHANISM OF INJURY CLASSIFICATION •DIRECT TRAUMA •INDIRECT TRAUMA
  16. 16. DIRECT TRAUMA • TAPPING FRACTURES • CRUSHING FRACTURES • PENETRATING FRACTURES: • HIGH VELOCITY  > 2500 F/S • LOW VELOCITY  < 2500 F/S
  17. 17. INDIRECT TRAUMA • TRACTION OR TENSION FRACTURES • ANGULATION FRACTURES • ROTATIONAL FRACTURES • COMPRESSION FRACTURES
  18. 18. FRACTURE MANAGEMENT •TREATMENT OF CLOSED FRACTURES •TREATMENT OF OPEN FRACTURES
  19. 19. TREATMENT OF CLOSED FRACTURES •EMERGENCY CARE (SPLINTING) •DEFINITIVE FRACTURE TREATMENT •REHABILITATION (MUSCLE ACTIVITY AND EARLY WEIGHTBEARING ARE ENCOURAGED)
  20. 20. EMERGENCY CARE (SPLINTING) • SPLINT THEM WHERE THEY LIE • ADEQUATE SPLINTING IS DESIRABLE • TYPE OF SPLINTS: • IMPROVISED • CONVENTIONAL
  21. 21. DEFINITIVE FRACTURE TREATMENT • THE GOAL OF FRACTURE TREATMENT IS TO OBTAIN UNION OF THE FRACTURE IN THE MOST ANATOMICAL POSITION COMPATIBLE WITH MAXIMAL FUNCTIONAL RETURN OF THE EXTREMITY • 2 TYPES OF DEFINITIVE FRACTURE TREATMENT: • CONSERVATIVE • SURGICAL
  22. 22. CONSERVATIVE • REDUCTION: IF DISPLACED  UNDER GENERAL ANASTHESIA, THE SOONER THE BETTER • STEPS OF REDUCTION: • TRACTION • ALIGN (WHICH FRAGMENT) • REVERSE MECHANISM OF INJURY • IMMOBILIZATION: POP (PLASTER OF PARIS) CAST, SLAB, TRACTION (FIXED OR BALANCED) • REHABILITATION
  23. 23. CLOSED REDUCTION TRACTION IN THE LINE OF THE BONE DISIMPACTION PRESSING FRAGMENT INTO REDUCED POSITION
  24. 24. CLOSED UNDISPLACED CLOSED, REDUCIBLE  CONSERVATIVE TREATMENT Below knee Above knee
  25. 25. PLASTER OF PARIS (POP)
  26. 26. SLAB OR SPLINT
  27. 27. TRACTION
  28. 28. SURGICAL •OPEN REDUCTION INTERNAL FIXATION (ORIF) •PERCUTANEOUS PINNING •EXTERNAL FIXATION
  29. 29. OPEN REDUCTION INDICATIONS • OPERATIVE REDUCTION OF THE FRACTURE IS INDICATED: 1.WHEN CLOSED REDUCTION FAILS 2.WHEN THERE IS A LARGE ARTICULAR FRAGMENT THAT NEEDS ACCURATE POSITIONING 3.FOR TRACTION (AVULSION) FRACTURES IN WHICH THE FRAGMENTS ARE HELD APART
  30. 30. INTERNAL FIXATION INDICATION 1. FRACTURES THAT CANNOT BE REDUCED EXCEPT BY OPERATION 2. FRACTURES THAT ARE INHERENTLY UNSTABLE AND PRONE TO RE-DISPLACE AFTER REDUCTION 3. FRACTURES THAT UNITE POORLY AND SLOWLY 4. PATHOLOGICAL FRACTURES IN WHICH BONE DISEASE MAY PREVENT HEALING 5. MULTIPLE FRACTURES WHERE EARLY FIXATION REDUCES THE RISK OF GENERAL COMPLICATIONS AND LATE MULTISYSTEM ORGAN FAILURE 6. FRACTURES IN PATIENTS WHO PRESENT NURSING DIFFICULTIES
  31. 31. TYPE OF INTERNAL FIXATION • INTERFRAGMENTARY SCREWS • WIRES (TRANSFIXING, CERCLAGE AND TENSION- BAND) • PLATES AND SCREWS • INTRAMEDULLARY NAILS
  32. 32. PLATES AND SCREWS • PLATES HAVE FIVE DIFFERENT FUNCTIONS: 1. NEUTRALIZATION • TO BRIDGE A FRACTURE AND SUPPLEMENT THE EFFECT OF INTERFRAGMENTARY LAG SCREWS 2. COMPRESSION • USED IN METAPHYSEAL FRACTURES WHERE HEALING ACROSS THE CANCELLOUS FRACTURE GAP MAY OCCUR DIRECTLY 3. BUTTRESSING • ‘OVERHANG’ OF THE EXPANDED METAPHYSES OF LONG BONES 4. TENSION-BAND • ALLOWS COMPRESSION TO BE APPLIED TO THE BIOMECHANICALLY MORE ADVANTAGEOUS SIDE OF THE FRACTURE 5. ANTI-GLIDE • TO PREVENT SHORTENING AND RECURRENT DISPLACEMENT OF THE FRAGMENTS
  33. 33. INTRA-MEDULLARY FIXATION • CENTRO-MEDULLARY • UNLOCKED • INTERLOCKING (STATIC – DYNAMIC – DOUBLE LOCKED) • CONDYLOCEPHALIC • CEPHALLOMEDULLARY
  34. 34. AN OBLIQUE FRACTURE OF THE SHAFT OF THE FEMUR, BEFORE AND AFTER REAMED INTRAMEDULLARY FIXATION WITH A STOUT NAIL AND INTERLOCKING SCREWS. THIS TREATMENT ALLOWS NEAR IMMEDIATE AMBULATION FOR THE PATIENT.
  35. 35. EXTERNAL FIXATION • INDICATIONS: 1. FRACTURES ASSOCIATED WITH SEVERE SOFT-TISSUE DAMAGE (INCLUDING OPEN FRACTURES) OR THOSE THAT ARE CONTAMINATED 2. FRACTURES AROUND JOINTS THAT ARE POTENTIALLY SUITABLE FOR INTERNAL FIXATION BUT THE SOFT TISSUES ARE TOO SWOLLEN TO ALLOW SAFE SURGERY 3. PATIENTS WITH SEVERE MULTIPLE INJURIES 4. UNUNITED FRACTURES, WHICH CAN BE EXCISED AND COMPRESSED 5. INFECTED FRACTURES
  36. 36. REHABILITATION • RESTORE FUNCTION – NOT ONLY TO THE INJURED PARTS BUT ALSO TO THE PATIENT AS A WHOLE • THE OBJECTIVES ARE: 1. TO REDUCE OEDEMA 2. PRESERVE JOINT MOVEMENT 3. RESTORE MUSCLE POWER 4. GUIDE THE PATIENT BACK TO NORMAL ACTIVITY
  37. 37. TREATMENT OF OPEN FRACTURES •INITIAL MANAGEMENT •CLASSIFYING THE INJURY •DEFINITIVE TREATMENT
  38. 38. INITIAL MANAGEMENT • IT IS ESSENTIAL THAT THE STEP-BY-STEP APPROACH IN ADVANCED TRAUMA LIFE SUPPORT NOT BE FORGOTTEN • WHEN THE FRACTURE IS READY TO BE DEALT WITH: 1. THE WOUND IS CAREFULLY INSPECTED 2. ANY GROSS CONTAMINATION IS REMOVED 3. THE WOUND IS PHOTOGRAPHED 4. THE AREA THEN COVERED WITH A SALINE-SOAKED DRESSING 5. THE PATIENT IS GIVEN ANTIBIOTICS 6. TETANUS PROPHYLAXIS IS ADMINISTERED 7. THE LIMB CIRCULATION AND DISTAL NEUROLOGICAL STATUS CHECKED REPEATEDLY
  39. 39. CLASSIFYING THE INJURY • WITH GUSTILO’S CLASSIFICATION OF OPEN FRACTURES (GUSTILO ET AL., 1984): • TYPE 1 – THE WOUND IS USUALLY A SMALL, CLEAN PUNCTURE THROUGH WHICH A BONE SPIKE HAS PROTRUDED. THERE IS LITTLE SOFT-TISSUE DAMAGE WITH NO CRUSHING AND THE FRACTURE IS NOT COMMINUTED (I.E. A LOW-ENERGY FRACTURE). • TYPE II – THE WOUND IS MORE THAN 1 CM LONG, BUT THERE IS NO SKIN FLAP. THERE IS NOT MUCH SOFT-TISSUE DAMAGE AND NO MORE THAN MODERATE CRUSHING OR COMMINUTION OF THE FRACTURE (ALSO A LOW- TO MODERATE- ENERGY FRACTURE). • TYPE III – THERE IS A LARGE LACERATION, EXTENSIVE DAMAGE TO SKIN AND
  40. 40. CLASSIFYING THE INJURY • THERE ARE THREE GRADES OF SEVERITY: • TYPE III A  THE FRACTURED BONE CAN BE ADEQUATELY COVERED BY SOFT TISSUE DESPITE THE LACERATION. • TYPE III B  THERE IS EXTENSIVE PERIOSTEAL STRIPPING AND FRACTURE COVER IS NOT POSSIBLE WITHOUT USE OF LOCAL OR DISTANT FLAPS. • TYPE III C  THERE IS AN ARTERIAL INJURY THAT NEEDS TO BE REPAIRED, REGARDLESS OF THE AMOUNT OF OTHER SOFT-TISSUE DAMAGE
  41. 41. PRINCIPLES OF TREATMENT • ALL OPEN FRACTURES, NO MATTER HOW TRIVIAL THEY MAY SEEM, MUST BE ASSUMED TO BE CONTAMINATED • THE FOUR ESSENTIALS ARE: 1. ANTIBIOTIC PROPHYLAXIS. 2. URGENT WOUND AND FRACTURE DEBRIDEMENT. 3. STABILIZATION OF THE FRACTURE. 4. EARLY DEFINITIVE WOUND COVER.
  42. 42. WOUND EXTENSIONS FOR ACCESS IN OPEN FRACTURES OF THE TIBIA WOUND INCISIONS (EXTENSIONS) FOR ADEQUATE ACCESS TO AN OPEN TIBIAL FRACTURE ARE MADE ALONG STANDARD FASCIOTOMY INCISIONS: 1 CM BEHIND THE POSTEROMEDIAL BORDER OF THE TIBIA AND 2–3 CM LATERAL TO THE CREST OF THE TIBIA AS SHOWN IN THIS EXAMPLE OF A TWO-INCISION FASCIOTOMY. THE DOTTED LINES MARK OUT THE CREST (C) AND POSTEROMEDIAL CORNER (PM) OF THE TIBIA THESE INCISIONS AVOID INJURY TO THE PERFORATING BRANCHES THAT SUPPLY AREAS OF SKIN THAT CAN BE USED AS FLAPS TO COVER THE EXPOSED FRACTURE THIS CLINICAL EXAMPLE SHOWS HOW LOCAL SKIN NECROSIS AROUND AN OPEN FRACTURE IS EXCISED AND THE WOUND EXTENDED PROXIMALLY ALONG A
  43. 43. • THE EXTERNAL FIXATOR MAY BE EXCHANGED FOR INTERNAL FIXATION AT THE TIME OF DEFINITIVE WOUND COVER AS LONG AS: 1. THE DELAY TO WOUND COVER IS LESS THAN 7 DAYS 2. WOUND CONTAMINATION IS NOT VISIBLE 3. INTERNAL FIXATION CAN CONTROL THE FRACTURE AS WELL AS THE EXTERNAL FIXATOR
  44. 44. AFTERCARE • IN THE WARD, THE LIMB IS ELEVATED AND ITS CIRCULATION CAREFULLY WATCHED. • ANTIBIOTIC COVER IS CONTINUED BUT ONLY FOR A MAXIMUM OF 72 HOURS IN THE MORE SEVERE GRADES OF INJURY • WOUND CULTURES ARE SELDOM HELPFUL, IF IT WERE TO ENSUE, IS OFTEN CAUSED BY HOSPITAL-DERIVED ORGANISMS
  45. 45. REFERENCES 1. SOLOMON L, WARWICK DJ, NAYAGAM S. APLEY’S SYSTEM OF ORTHOPAEDICS AND FRACTURES. CRC PRESS; 2010. 2. F. CHARLES BRUNICARDI, DANA K. ANDERSEN, TIMOTHY R. BILLIAR, DAVID L. DUNN, JOHN G. HUNTER, RAPHAEL E. POLLOCK, ET AL. SCHWARTZ’S PRINCIPLES OF SURGERY. 9TH ED. NEW YORK/US: MCGRAW-HILL EDUCATION - EUROPE; 2009.
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