Philadelphia, Pa: JB Lippincott;. CT classification and results of operative treatment. 3) Massen FK. Oblique views (ie, the Broden view) can define incongruity of the subtalar joint. A severe bone contusion is associated with multiple microfractures, whereas a stress fracture involves a linear component; the distinction between the 2 diagnoses may seem arbitrary. The goal of heel fracture surgery is to restore the shape of the heel bone as close to normal as possible. Bianchi S, Luong DH. Calcaneus, fractures. Acta Radiol. [32], The critical angle of Gissaneis an angle drawn between 2 lines on plain film, with the first line drawn along the anterior downward slope of the calcaneus, and the second drawn along the superior upward slope. Rowe type V calcaneal fracture. [QxMD MEDLINE Link]. 60 (6), 1953, 850-4. Shih JT, Kuo CL, Yeh TT, Shen HC, Pan RY, Wu CC. [9, 13] : The management of calcaneus fractures and their associated soft tissue injuries are controversial. Calcaneal fractures are classified as intra-articular and extra-articular. Calcaneus, fractures. J Clin Imaging Sci. [15]. A fracture may cause the calcaneus to increase in width; the expanded, fractured calcaneus may then impinge upon the fibula, causing entrapment of the peroneal tendons. Modified Essex-Lopresti procedure with percutaneous calcaneoplasty for comminuted intra-articular calcaneal fractures: a retrospective case analysis. The extent is easily underestimated, which is why an additional CT scan is frequently made in a comminuted fracture. Abstract Background and aim of the work: The calcaneus, the more lower bone of the body, has the task of supporting the axial load from the weight of the body. Therefore, in the appropriate clinical setting, CT may be skipped, and either MRI or bone scanning may be performed. Some refer to point 2 to be the midpoint of calcaneus bone, Some refer to point 3 as being the lowest point. Unfair comments in the Press About Mammography int MRCP at 3.0 Tesla and 1.5 Tesla- A comparison, What is new in the Medical Imaging Research. However, compared with MRI or bone scanning, CT has low sensitivity for stress reactions and fractures; this leads to a high rate of false-negative results. These fractures may remain undiagnosed clinically, as there may be no obvious deformity. The diagnostic accuracy of Bhler's angle in fractures of the calcaneus. Gotha HE, Zide JR. Current Controversies in Management of Calcaneus Fractures. The depression type and the tongue type. Disorders of the Foot and Ankle. Bone scintigraphy is typically utilized in cases in which radiographic and CT findings are negative for suspected fractures (see the image below). [1] They account for 1-2% of all fractures of the body, with the majority involving the subtalar joint (about 75%) and the calcaneocuboid joint (about 68%). [18, 32], In a study of 424 patients with calcaneus fractures, the mean Bohler angle was 29.4. J Foot Ankle Surg. Davis D, Seaman TJ, Newton EJ. CT is capable of demonstrating disruption of the bony cortex and periostitis in most individuals. 2016 Sep. 37 (9):950-7. Calcaneal fractures account for approximately 2% of all fractures seen in adults. [QxMD MEDLINE Link]. Scintigraphy of toddler''s fracture. Aspiration of the injected contrast material following use of a local anesthetic may relieve pain and help determine the source of the pain. For the word puzzle clue of what lower extremity nerve may be injured from fibula neck fracture or trauma to the lateral aspect of leg causing foot drop, the Sporcle Puzzle Library found the following results. Scott AT, Pacholke DA, Hamid KS. Note loss of the crucial angle of Gissane. Lines A and B separate the calcaneus into medial, central and lateral columns. Klaus L Irion, MD, PhD Consulting Staff, The Cardiothoracic Centre Liverpool NHS Trust, The Royal Liverpool University Hospital, UK [4]. Calcaneus, fractures. J Ultrasound Med. T2-weighted sagittal MRIs demonstrate fibrosis of the peroneal tendon sheath following a past calcaneus fracture, which is a recognized complication of calcaneal fractures. Confidence in the diagnosis made on the basis of a positive CT scan of the affected area is high. Thomas Lee Pope, MD, FACR Radisphere National Radiology Group Talussmall foot bone that works as a hinge between the tibia and the fibula. [QxMD MEDLINE Link]. J Foot Ankle Surg. It is noteworthy that CT tends to be somewhat overutilized in the United States. The investigators found that 42 of the fractures (84%) in the acute group and 55 in the chronic group (71%) were classified as intra-articular; these fractures formed the basis of the study. Essex-Lopresti depression-type calcaneal fracture. Axial (Harris) views of both calcanei show a left calcaneal fracture. Clin Orthop Relat Res. [25, 1, 26] Coronal and axial views are generally taken. Calcaneal fractures have characteristic appearances based on the mechanism of injury . ----------------------------------- Maffucci syndrome is characterized by benign enlargements of cartilage (enchondromas); bone deformities; and dark, irregularly shaped Radiology is an increasingly favored specialty for medical graduates. J Med Assoc Thai. [QxMD MEDLINE Link]. Coronal and axial views are generally obtained. Essex-Lopresti describes 2 fracture types involving the subtalar joint. 2015. 2022 Jul;304(1):50-62. Orthop Clin North Am. ILD is one of the most difficult topics for the residents to understand. The incidence of partial rupture of the peroneal tendons in the chronic group was approximately one third that in the acute group, but the low incidence of complete tendon rupture remained unchanged. Essex-Lopresti depression-type calcaneal fracture. Postoperative radiological assessment was performed with X-rays and CT scan. Most calcaneal fractures (70%-75%) are intraarticular and result from axial loading that produces shear and compression fracture lines. [11, 12] This classification is the one used most frequently today in treatment decision making and reporting of results. Low impact trauma or twisting injuries of the calcaneus can result in subtle X-ray changes. Out of those fractures, 60 percent are classified as a calcaneus fracture. 2018 Feb. 37 (2):521-529. Nazarian LN, Rawool NM, Martin CE, Schweitzer ME. 35(5):443-61. Calcaneus fractures sanders type 3/4 were 9 times more prone to tendon injury ( <p 0.001; OR 8.67; . Other classifications exist, such as Essex-Lopresti, AO-ICI, Zwipp, and Crosby. Normal variants, complications, and differential diagnosis. [QxMD MEDLINE Link]. CT is the modality of choice for calcaneus fractures. Normal variants, complications, and differential diagnosis. 2017 Jan. 52 (1):28-33. The extent of injury is easily underestimated by X-ray appearances. For more information, click on the link if you see this icon, Stress Fractures of the Calcaneus. Calcaneus fracturesaccount for 60% of all tarsal fractures. The degree of confidence is high, because the diagnosis of stress fracture may be reliably excluded when bone scans are normal. Patients with fractures are a common emergency and can be misdiagnosed through radiologic imaging. A calcaneal fracture is a break of the calcaneus (heel bone). 2004 May. J Emerg Med. Foot Ankle Int. Technetium-99m diphosphonate bone scan depicts a stress fracture of the calcaneus, which was not apparent on plain radiographs. Normal variants, complications, and differential diagnosis. [QxMD MEDLINE Link]. 2016 Nov 28. If imaging is performed within 4 weeks of the injury, an area of high signal intensity often can be observed on T2-weighted images; this represents associated edema or hemorrhage. Calcaneus, fractures. Unique blend of academic excellence and entrepreneurship, heading leading firms in India- Teleradiology Providers, pioneering company providing teleradiology services and DAMS (Delhi Academy of Medical Sciences) Premier test preparation institute in India for MD/MS/MCI preparation. Are Children With Atopic Dermatitis More Likely to Fracture Bones? Calcaneus, fractures. Calcaneus, fractures. Fractures. The remaining sketchs illustrate fracture types 2 through 5 with the calcaneus viewed from the lateral projection. This represents bony edema secondary to a fracture, which is not appreciated on the plain radiographs. A flat Bohler angle is associated with intra-articular fractures; in such cases, the prognosis is poorer than it is in cases in which the angle is maintained. Axial (Harris) view. Snoap T, Jaykel M, Williams C, Roberts J. Calcaneus Fractures: A Possible Musculoskeletal Emergency. J Emerg Med. Dr Graham Lloyd-Jones BA MBBS MRCP FRCR - Consultant Radiologist - [39]. Calcaneus secundarius is an accessory ossicle attached to the posterosuperior aspect of the calcaneus. 2003 Oct. 13(10):2315-22. From My Column on The Medical Blog Network-Patient Good Link for Lung radiology teaching files. 1992 Feb. 65(770):105-11. [2] Calcaneus fractures may occur as a result of falls from heights or from twisting injuries or through a pathologic process such as osteoporosis, cysts, and tumors. Radiology of the foot and ankle, 2nd edition. [QxMD MEDLINE Link]. Diagnostic accuracy of 3D color volume-rendered CT images for peroneal tendon dislocation in patients with acute calcaneal fractures. Knight JR et al. Synovial fluid in the hindfoot and ankle: detection of amount and distribution with US. Normal variants, complications, and differential diagnosis. Seven fractures were common to both series; from this limited group, the identification of hemorrhage around the peroneal tendons in the acute phase was shown not to be related to the subsequent development of chronic stenosing tenosynovitis. In addition, 18% had concurrent head injuries and 15% concurrent thoracic organ injuries. [QxMD MEDLINE Link]. Calcaneus, fractures. Fractures of the calcaneus. This system defines 4 types of calcaneus fractures J Am Acad Orthop Surg. [QxMD MEDLINE Link]. [4, 14, 15, 16, 17, 18, 19], Good to excellent results are achieved in two thirds to three quarters of all cases, as has been shown in large clinical series. The calcaneus is the most fractured of all tarsal bones. There were spinal fractures (lumbar spine being the most common) in 23%. Stress fractures may take up to 7-14 days to appear on conventional radiographs. The fracture line extends posteriorly to the tuberosity. The weighted kappa value was 0.56, with a 95% confidence interval (CI) of 0.45-0.67. Calcaneus, fractures. Calcaneal fractures due to a fall from height are often comminuted and intra-articular. The angle that results from their intersection measures 20-40. [9]. Ogawa BK, Charlton TP, Thordarson DB. Open reduction and stable internal fixation with a lateral plate and without joint transfixation has been established as standard therapy for displaced intra-articular fractures. BMC Musculoskelet Disord. These fractures are complicated by a compartment syndrome in 10% of cases, with half of these involving development of clawing of the lesser toes or other chronic problems, such as stiffness and neurovascular dysfunction. Jimnez-Almonte JH, King JD, Luo TD, Aneja A, Moghadamian E. Classifications in Brief: Sanders Classification of Intraarticular Fractures of the Calcaneus. The posterior facet of the calcaneus bone is the point that articulates with the posterior process of the talus. The calcaneus functions as a lever arm for the gastrocsoleus complex, providing a foundation or vertical support for one's body weight and providing support for and maintaining the lateral column of the foot. Calcaneus, fractures. [35]. The most common mechanism asso-ciated with this type of injury is inversion of . 1995 Oct. 197(1):275-8. Ultrasonography is operator and institution dependent, and musculoskeletal ultrasonography is not universally available. Anatomic reduction of joint congruity and the overall shape of the calcaneus are important prognostic factors. [3] In adults, about 75% of calcaneal fractures are intra-articular. 24 (10), 2003, 744-53. . A randomized, blinded, case-control study of 133 patients found that emergency physicians were 97.9% accurate at diagnosing calcaneus fractures without the assistance of angles, but that determining Bohler's angle can still be helpful and has good interrater reliability. Pathologies associated with edema include osteomyelitis and neoplasm. Thomas Lee Pope, MD, FACR is a member of the following medical societies: American Roentgen Ray Society, International Skeletal Society, Radiological Society of North America, South Carolina Medical Association, Society of Breast ImagingDisclosure: Nothing to disclose. and the surrounding edema (white arrows)in another patient. 1:2326-54. However, MRI is often useful in patients with suspected stress fractures, particularly those with severe osteoporosis in whom skeletal scintigraphy may produce false-negative findings as a result of generalized poor uptake of tracer (see the images below). Rowe type II beak/avulsion fracture of the Achilles tendon. PRESENT Podiatry produces Podiatry Conferences that deliver the finest Podiatry CME. J Nucl Med. Methods: We retrospectively reviewed clinical charts and imaging findings for 6 patients with 7 IF of the calcaneus who were referred with the diagnosis of ankle arthritis. Indian Medical Informatics News-Telemedicine link How Relevant are Peer Review Journals Nowadays? CT scans of 50 acute calcaneus fractures were compared with scans of 77 fractures in which the date of injury preceded the CT study by 6 months or more. Giannestras NJ, Sammarco GJ. Linsenmaier U, Brunner U, Schning A, et al. Dorsoposterior (DP) and lateral views of the foot demonstrate an old Essex-Lopresti depressed-type calcaneal fracture. On a lateral view this angle is formed by the intersection of two lines. Attend the weekly diabetic MDT meeting to discuss management of diabetic feet infections with Microbiology & Radiology consultants as well as lead Pharmacist. Jt Dis Relat Surg. Rowe classifies fractures into 5 groups. 10.2% of these associations were identied in the radiology report. Radiography versus computed tomography for displacement assessment in calcaneal fractures. CT is the modality of choice for calcaneus fractures. Essex Lopresti depression-type fracture. Bradley SA, Davies AM. Epidemiology. 33 (5):261-266. Teaching points by Dr MGK Murthy Pedicloryl has now become omnipresent in all Radiology departments for sedating children. The main predisposing factors, clinical features, therapy, and outcome were recorded. CT is occasionally performed to diagnose stress fractures. J Orthop Surg Res. Radiol Clin North Am. Essex-Lopresti tongue-type calcaneal fracture. Explore more crossword clues and answers by clicking on the results or quizzes. The lectures are recorded and made available for on-demand online playback here in the PRESENT Podiatry Online Lecture Hall. cheap wow power leveling cheapest wow power leveling buy wow power leveling CHEAP power leveling CHEAPEST wow gold BUY wow powerleveling. Computed tomographic assessment of soft tissue abnormalities following calcaneal fractures. Lateral radiograph of the calcaneus on the same patient as in Image 33 shows calcification of the plantar fascia. Persson J, Peters S, Haddadin S, O'Loughlin PF, Krettek C, Gaulke R. The prognostic value of radiologic parameters for long-term outcome assessment after an isolated unilateral calcaneus fracture. Angthong C, Atikomchaiwong A, Yoshimura I, Kanazawa K, Hamrnroongroj T, Angthong W, et al. Symptoms may include pain, bruising, trouble walking, and deformity of the heel. encoded search term (Calcaneus Fracture Imaging) and Calcaneus Fracture Imaging. Failed union of a portion of calcaneal apophysis in an adult may superficially mimic a fracture. [QxMD MEDLINE Link]. Peroneal tenography helps in diagnosing abnormal conditions after calcaneus fractures or other trauma, such as peroneal tendon dislocation resulting from skiing accidents. The normal range is 130-145 degrees An angle > 145 degrees is concerning for calcaneus fracture with involvement of the posterior talar articular surface Lines for Angle Calcaneus, fractures. Falling from height can lead to severe calcaneal fractures, which may be accompanied by axial loading fractures of the spine. Contact us. It usually occurs when a person lands on their feet following a fall from a height or during a motor vehicle collision. [25, 1, 26]. Essex-Lopresti classification. This type represents almost a quarter of the fractures in the original series. However, the rate of false-negative results is high. Swords MP, Alton TB, Holt S, Sangeorzan BJ, Shank JR, Benirschke SK. 2002 Jan. 33(1):263-85, x. Os calcis fractures can be broadly classified into intra-articular and extra-articular types. 23 (3):285-98. In adults, detection of hyperemia is straightforward, but problems may arise in children, because in children, the uptake of radionuclide is often increased around the epiphyses; contralateral images are often needed for comparison. Measuring the various angles not only enables reliable diagnosis but also helps in determining the ultimate prognosis. Demographics, Mechanisms of Injury, and Concurrent Injuries Associated With Calcaneus Fractures: A Study of 14 516 Patients in the American College of Surgeons National Trauma Data Bank. Traumatic bone marrow lesions (TBMLs) are considered to represent a range of concealed bone injuries, including haemorrhage, infarction, and localised oedema caused by trabecular microfracture occurring in the cancellous bone. In the acute group, the peroneal tendons were of normal location in 40.4% of cases; in 11.9% of cases, the peroneal tendons were entrapped by bone; subluxation was evident in 33.3% of cases; and dislocations were present in 14.2% of cases. In determining the Bohler angle, a line is drawn between the posterior superior aspect of the calcaneus and the highest point of the posterior subtalar articular surface; a second line, which intersects the first, is drawn from the highest point of the anterior process to the posterior margin of the subtalar surface. False-negative radiographic findings may occur when images show subtle fracture lines. The peak incidence occurs in younger males [ 2 ]. Rowe classification. Saunders type IV calcaneal fracture. Any fracture that impairs one of these functions substantially affects the person's gait if not restored. Normal variants, complications, and differential diagnosis. [5]. Radiology Masterclass, Department of Radiology, [QxMD MEDLINE Link]. Gissane's angle is also known as the crucial or critical angle and can be used to help determine the presence of a calcaneus fracture on a radiograph. Have We Radiologists Oversold Mammography? The Bohler angle may also be decreased in some calcaneus fractures that do not involve the subtalar joint. Calcaneal Fractures Lover's Fracture General Considerations Calcaneous is the most commonly fractured tarsal bone A so-called "lover's Fracture" is an intra-articular fracture produced by an axial loading force typically produced by a leap from a height with person landing on heels (also called a "Don Juan" fracture) The results were analyzed by using a weighted kappa test that included the subcategories. Ohashi K, Sanghvi T, El-Khoury GY, Ahn JM, Bennett DL, Geijer M, et al. The goal of treatment is to restore the anatomy of the heel to achieve the best outcomes. Foot Ankle Spec. (adsbygoogle = window.adsbygoogle || []).push({}); T1 (left) and STIR MRI images show a stress fracture of the calcaneus (black arrow) J Foot Ankle Surg. Approximately 75% of calcaneus fractures are intra-articular and involve the subtalar articular surface. Calcaneal fractures observed at CT have been divided into intra- and extraarticular fractures on the basis of subtalar joint involvement. MRI is expensive and may cause problems in patients with claustrophobia. Screening Carotid artery in patients with CAD. In cases of severe articular comminution or presence of medial and/or lateral instability, transarticular bridge plating was indicated. The calcaneus is the most commonly fractured tarsal bone, representing 60 percent of all tarsal fractures in adults [ 1 ]. All courses are CME/CPD accredited in accordance with the CPD scheme of the Royal College of Radiologists - London - UK. An increasing number of studies are using artificial intelligence (AI) techniques to . Calcaneus, fractures. [1]. Calcaneus, fractures. The plantar surface of the calcaneus is elevated posteriorly to form the calcaneal tuberosity. Treatment of these fractures may require surgery. Spitz DJ, Newberg AH. 2000 Feb. 82(2):225-50. This view also demonstrates avulsion fractures of the anterior lateral aspect of the calcaneus. In: Rockwood CA Jr, Green DP, eds. [QxMD MEDLINE Link]. Calcaneus, fractures. Klaus L Irion, MD, PhD is a member of the following medical societies: American Roentgen Ray Society, Radiological Society of North AmericaDisclosure: Nothing to disclose. Additional risk factors include obesity, smoking and activity levels. Conventional radiographs provide a benchmark for the diagnosis of fractures around the ankle in general, and they usually suffice for the diagnosis of the osseous component of the injury Calcaneal fractures can be divided broadly into two types depending on whether there is articular involvement of the subtalar joint 2,7,8:. Share cases and questions with Physicians on Medscape consult. This website also contains material copyrighted by 3rd parties. Radiography may be the only modality required, though it is not always capable of depicting the relationship of bone fragments to the joint and to each other. [QxMD MEDLINE Link]. The calcaneus is the heel bone. Plain radiographs and CT scans in various projections and 3-dimensional rendering show the value of each modality. Lawrence SJ, Singhal M. Open hindfoot injuries. Calcaneal fracture When a calcaneal fracture is suspected, both an axial and lateral image should be made. Most injuries are caused by high-energy trauma that result in intraarticular fractures [ 1 ]. Fractures to the anterior process of the calcaneus : Clinical results following functional . Bone contusions are also well depicted on MRI. The Journal of Bone and Joint Surgery; Vol L. 41-A, NO. But test results provide little insight into how he died King Tut wasn't murdered by a blow to the head, nor was his chest crushed i NBE has introduced FNB for Interventional Radiology, Breast imaging and Body Imaging. Comminuted fractures with fragment displacement of the calcaneus are common, and the relationship of the multiple fragments is difficult to appreciate on conventional radiographs. MRI is well known to show even minor stress changes (eg, after a marathon) that occur before the actual stress fracture. This results in a reduction of 'Bohler's angle'. Calcaneus, fractures. Calcaneal fractures | UW Emergency Radiology Managing Severely Malunited Calcaneal Fractures and Fracture-Dislocations - Foot and Ankle Clinics Calcaneal fractures - Anatomy, evaluation, classification (OTA lecture series IV L15a) - YouTube Calcaneus Fractures - Core EM Multidetector CT Evaluation of Calcaneal Fractures | RadioGraphics EPOS However, normal Bohler and Gissane angles do not rule out a fracture. JW Leabhart. The Sanders classification system is based on coronal and axial CT scans of the calcaneus. [30] ; however, in most cases, supplemental imaging is needed to define characteristics fully, because of the complex anatomy of this region. Calcaneus fractures are bilateral in 5% of patients. The first line is drawn from (1) - the upper edge of the calcaneal body posteriorly to (2) - the upper edge of the posterior articular facet of the calcaneus at the subtalar joint. Intra-articular fractures (Figs. 48 (2):156-62. Rowe type V, intra-articular calcaneal fracture. Various abnormalities of the medial tendons of the hindfoot were identified in 17% of patients in the acute group and in 18% of patients in the chronic group. [9, 13] : Patients with type 1 injuries do well with nonoperative treatment; patients with injuries of types 2 and 3 may be treated effectively with open reduction and internal fixation; and type 4 injuries defy operative reduction. Key Points: Fractures of the pediatric calcaneus are rare injuries and are frequently missed. 2001 Jan. 32(1):35-51, viii. - AP Oblique projection (lateral rotation) What procedural compensation is required for the plantodorsal axial projection of the calcaneus when the patient cannot dorsiflex the foot sufficiently to place the plantar surface vertical? Sander CT classification. Kwok HM, Pan NY, Ng FH. Calcaneus, fractures. Calcaneus Fractures - Trauma - Orthobullets orthoBULLETS MBBULLETSStep 1For 1st and 2nd Year Med Students MBBULLETSStep 2 & 3For 3rd and 4th Year Med Students ORTHOBULLETSOrthopaedic Surgeons & Providers JOIN NOWLOGIN Home Topics Techniques Cards QBank Evidence Cases Videos Podcasts Groups Products Trauma Spine Shoulder & Elbow Knee & Sports Usually there is a total rupture of the syndesmosis with instability of the ankle. Structural abnormalities of the peroneal tendons and surrounding soft tissues were identified in 52.4% of patients in the acute group and in 61.1% of patients in the chronic group. From this point another line is drawn to (3) - the upper edge of the anterior process of the calcaneus. In the study, 4 independent observers with different levels of clinical training evaluated 64 fractures according to the classifications of the Orthopaedic Trauma Association (OTA), Essex-Lopresti, Sanders, Crosby, Zwipp, and Regazzoni, using 2-dimensional CT scans with multiplanar reconstructions and 3D volume-rendering reconstructions. Intra-articular fractures represent 75% of all calcaneal fractures. In particular, real-time ultrasonography may be performed to assess dynamic stability. Sonograms of the hindfoot and ankle commonly depict articular, bursal, and tendon-sheath fluid in asymptomatic volunteers. He has also been an invited faculty member at various conferences, including Teleradiology in IRIA 2008 and 2011, Hospital Build Middle East, Congress of the Brain Tumor Radiology in Neuro-oncology Society. [36, 37, 38], In a study of 8 patients in whom ultrasonography was used to diagnose a calcaneal stress fracture, Bianchi et al found that thickening of the periosteum and subcutaneous edema were present in all patients and that cortical irregularities were present in 6 patients. Line 2 is created by connecting point 2 on the radiograph (the most cephalic or highest point of the posterior facet of the calcaneus bone) to point 3 (the highest point of the calcaneus bone that forms the articular surface for the cuboid bone). Bohl DD, Ondeck NT, Samuel AM, Diaz-Collado PJ, Nelson SJ, Basques BA, et al. Medscape Education. et al. The articular involvement has been associated with a poor functional outcome. 25 results . [1], According to a study based on data from the American College of Surgeons National Trauma Data Bank (NTDB), of 14,516 patients with calcaneous fractures, concurrent injuries were present in 11,137, with associated lower extremity fractures being present in 61% (the most common of which were other foot and ankle fractures). This is a fracture above the level of the syndesmosis. 7, Oct 1959, Overuse injury seen in athletes, especially with running and aerobics, and military recruits, Most stress fractures are in lower extremities, Increasing pain in the heel with exercise or activity, Tenderness to palpation over outer aspects of the heel, Stress fractures may take up to 7-14 days to appear on conventional radiographs, Most occur in posterior half of calcaneus, Vertically oriented zone of increased density on lateral radiograph, Usually oriented parallel to the curve of the posterior calcaneus, Fracture line usually disappears by 6 weeks, Radionuclide bones cans may be positive (increased uptake) within 72 hours, Surrounding marrow edema will show high signal, May be particularly helpful in setting of marked osteoporosis, Heel pain may clinically be caused by plantar fasciitis, Avoiding aggravating activities like running for 4-8 weeks, For more information, click on the link if you see this icon. However, because of the complexity of the anatomy, multiple radiographic views are often necessary. Fractures of the calcaneus. Interobserver and intraobserver reliability assessment of calcaneal fracture classification systems. Calcaneal Stress Fracture Tuesday, December 22, 2015 Musculoskeletal radiology Case Report: Patient with pain in ankle shows on MRI T1 & T2 WI hypointense linear area in the calcaneum oriented parallel to curve of posterior calcaneum along with areas of marrow edema- appearing hyperintense on T2/STIR images suggesting probable stress fracture. Felix S Chew, MD, MBA, MEd Professor, Department of Radiology, University of Washington School of Medicine Axial (Harris) view demonstrates a calcaneal fracture. [20, 21, 14, 22, 23], Zelle et al identified several sociodemographic factors influencing the utilization of surgical treatment of calcaneus fractures in the US patient population. Confidence in the imaging findings is usually high in a patient who is believed on clinical grounds to have a stress fracture. Conventional radiography is inexpensive and is universally available. Physical examination usually is required to assess the integrity of tendons and ligaments. Rammelt S, Zwipp H. Calcaneus fractures: facts, controversies and recent developments. Foot Ankle Int. CT is the modality of choice, especially in complex fracture patterns, although it is expensive and it imparts a relatively high dose of radiation; it should be used sparingly in young patients or in pregnant patients. In patients with multiple stress fractures, an accurate determination of the age of the fracture is not always possible. Fractures or breaks of the calcaneus commonly occur after a fall from a height or car accident. Signs of pathology that are apparent on sonograms of soft tissue include articular effusion, fluid conglomeration, ossification, and the development of vascular lesions. It is also indicated for the evaluation of dislocation of the peroneal tendons; lesions in the flexor and extensor tendons; and osseous capsular and ligamentous avulsions. 15(6):367-76. Calcaneus, fractures. Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR is a member of the following medical societies: American Association for the Advancement of Science, American Institute of Ultrasound in Medicine, British Medical Association, Royal College of Physicians and Surgeons of the United States, British Society of Interventional Radiology, Royal College of Physicians, Royal College of Radiologists, Royal College of Surgeons of EnglandDisclosure: Nothing to disclose. ISBN: 3030373630 Author: Mark R. Adams Format: PDF, Docs Category: Medical Get Book Book Description Presenting an in-depth discussion of the surgical management of fractures and dislocations of the talus and calcaneus, this text utilizes both an up-to-date review of the literature, providing a broad understanding of the topic, and a case-based approach, delving into the finer details of how . [Full Text]. Conventional radiography is the primary imaging modality in cases of suspected ankle fractures. Axial radiograph shows soft tissue swelling with amorphous calcification. Calcaneal fractures have characteristic appearances based on the mechanism of injury and are divided into two major groups, intraarticular and extraarticular. An angle of 20 or less was highly accurate in determining the presence of a fracture. Radiographics. Bohler's angle (also sometimes referred to as the "Tuber Angle") is formed by the intersection of lines 1 and line 2 on the lateral ankle radiograph. In children, epiphyseal uptake may mask increased radionuclide uptake caused by osteoblastic activity. [9, 10]. Computed Tomography for Calcaneal Fractures: Adding Value to the Radiology Report. Lippincott, Williams and Wilkins, Philadelphia, PA, pp 218-261 . Scintigraphy may be useful in occult fractures and in the differential diagnosis of pathologic fractures. Gltekin A, Acar E, Uur L, Yldz A, Serarslan U. 2 and 3) are much more common and carry a worse prognosis than . Juliano P, Nguyen HV. Is Bone Mineral Density Testing Underused in Prostate Cancer Care? Radiology. Bilateral calcaneal fractures are seen in 5-9%. (See also the previous image.). Clin Podiatr Med Surg. WHO brain tumour classification has been updated in 2016. [QxMD MEDLINE Link]. A physiologic periosteal reaction, bone tumor, avascular necrosis, plantar fasciitis, or bone spur can cause false-positive findings. The fracture line extends along the calcaneus behind the subtalar joint. By doing so, we suggest ways in which the radiologists can add value to the radiology report. American Association for the Advancement of Science, American Institute of Ultrasound in Medicine, Royal College of Physicians and Surgeons of the United States, British Society of Interventional Radiology, Society of Nuclear Medicine and Molecular Imaging. Most calcaneal fractures are occupational, and are caused by axial loading from a fall [ 2 ]. You're also more likely to get a stress fracture if you suddenly and significantly increase your activity levels. Calcaneus fractures resulting from falls onto the heels from heights are bilateral in 5-9% of patients; they are associated with compression fractures of the lumbar and/or dorsal spine in 10%. [Full Text]. Interstitial Lung Disease Series-Part 1- Usual Interstitial pneumonia, King Tut's CT scan rules out violent death, NBE introduces fellowships for Radiology Subspecialization. This is a comminuted fracture involving the subtalar joint; it has a central depression. Here is my attempt to explain the charm of this branch. Aronson J, Garvin K, Seibert J, et al. The alterations in the position of the peroneal tendons in the 2 groups were similar, with a 5% or smaller difference in each category. Orthopade. These three bones are the: Tibia shinbone. Achilles tendonitis calcification is a differential diagnosis in cases of suspected calcaneal fracture. 2002 Mar. 2013 Dec. 45 (6):879-84. The Sanders classification system is used to assess intraarticular calcaneal fractures, which are those involving the posterior facet of the calcaneus. Additionally, the posterior facet is involved in intra-articular fractures but is not involved in extra-articular fractures. Injury. Stress fractures may take longer to become evident on radionuclide bone scans, particularly in patients with osteoporosis. You are being redirected to Calcaneus, fractures. [QxMD MEDLINE Link]. Normal variants, complications, and differential diagnosis. Calcaneal fractures represent about 1-2% of all fractures and 60% of the tarsal bones fractures. Therefore, radiologists should not be comforted by negative radiographs and should initiate further state of the art imaging. Fracture characterization is essential to guide the management of these injuries. The angle that results from their intersection measures 20-40 (see the image below). - Elevate the leg on sandbags to achieve the correct postion. Calcaneus fractures can be managed surgically or non-surgically depending on the extent of the fracture and the stability of the broken bone. The AP view is essential for evaluating the calcaneocuboid joint (see the image below). ), Type III are depressed fractures and/or fractures that are split into 3 parts (3 bony fragments, including an additional depressed middle fragment, subdivided into types AB, AC, and BC, depending on the position and location of the fracture lines.). [QxMD MEDLINE Link]. Avulsion fracture. 34(6):454-9. Your physician will discuss your treatment options and create a treatment plan that is best for you. Technol Health Care. Calcaneal cysts are normal variants and should not be confused with pathology. Calcaneus fracture often result from falling from height but may be due to more trivial injury Falling from height can lead to severe calcaneal fractures, which may be accompanied by axial loading fractures of the spine. [QxMD MEDLINE Link]. The third phase demonstrates increased osteoblastic activity in response to the stress fracture. Prominent trabeculation can simulate a fracture on CT. MRI is generally not used in the diagnosis of calcaneus fractures. Page author: Stress Fracture of the Calcaneus. This normal variantan unfused secondary ossification centermust not be mistaken for a calcaneal fracture. however, calcaneal fractures are routinely assessed with ct as radiographs often underestimate the extent of the fracture - what appears to be a simple extra-articular calcaneal fracture on a radiograph will often turn out to be severely comminuted with involvement of the joint surfaces on ct, therefore it is a vital tool for orthopaedic surgeons It exposes the patient to a modest radiation dose. The calcaneal tuberosity is depressed centrally, with lateral and medial processes. Buckingham R, Jackson M, Atkins R. Calcaneal fractures in adolescents. A thorough understanding of the pathoanatomy and potential complications of calcaneal fractures also helps radiologists in tailoring the radiology report in contribution to overall patient's management and prognostication. Repeat CT scanning is not an attractive alternative, though it may result in the correct diagnosis because of interval development of necrosis. Line C corresponds to the medial edge of the posterior facet of the talus, separating the sustentaculum from the posterior facet. 2012 Sep. 33(9):727-33. Objective: To highlight the differential diagnosis between insufficiency fractures (IF) of the calcaneus and arthritis of the ankle. The most common etiology is a forceful axial load to the hindfoot, frequently occurring during a fall. Br J Radiol. [QxMD MEDLINE Link]. This patient presented following trauma to the calcaneus. Lower Extremity Calcaneal fractures Reference: Daftary, A., et al. 2003 Jan-Feb. 42(1):21-3. In complex fractures, CT scanning is used in addition to conventional radiography. Why do best medical graduates choose Radiology? Overuse injury seen in athletes, especially with running and aerobics, and military recruits. 2014 Jan-Feb. 53 (1):47-51. Please confirm that you would like to log out of Medscape. Calcaneus, fractures. [QxMD MEDLINE Link]. Clement H, Grechenig W, Peicha G, Grechenig S. [Ultrasound diagnosis in knee and foot trauma]. Ultrasonography of the foot region is indicated for the evaluation of the presence of foreign bodies. Dodson NB, Dodson EE, Shromoff PJ. [QxMD MEDLINE Link]. [29]. Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR Consultant Radiologist and Honorary Professor, North Manchester General Hospital Pennine Acute NHS Trust, UK All material on this website is protected by copyright, Copyright 1994-2022 by WebMD LLC. The quality of joint reduction should be proved intraoperatively with the acquisition of Broden views, high-resolution fluoroscopy, or open subtalar arthroscopy. 19 (1):77. Often, a history of the patient falling from a height and landing on his or her heels is helpful, but radiographic examination is essential to confirm fracture. [9]. In the absence of a linear component, it may be difficult to distinguish an underlying severe stress reaction associated with a bone contusion from a stress fracture on MRI. Stress Fractures of the Calcaneus Diagnosed by Sonography: Report of 8 Cases. [QxMD MEDLINE Link]. This is a chest CT image of a young male with fever, recurrent cough. However, radiography remains the principal imaging modality for evaluating trauma to the calcaneus, the most frequently fractured tarsal bone. Because these injuries are associated with a poor prognosis, it is important to identify patients with these fractures. Lateral views show the Bohler tuber angle and the crucial angle of Gissane clearly. Boehler's angle and the critical angle of Gissane are of limited use in diagnosing calcaneous fractures in the ED. [31] Radiographs of the dorsal and lumbar spine are also often indicated, because an associated fracture is seen in a vertebral body in 10% of all patients. Am J Emerg Med 200924(4):423-7. extra-articular: 25-30% Depression-type fractures are more common than tongue type. Care was taken not to include cortical bone. The fourth articular facet articulates with the cuboid of the midfoot. Line 1 is made by connecting point 1 on the radiograph (the most cephalic part of the posterior process of the calcaneus bone) to point 2 (the most cephalic or highest point of the posterior facet). Diagnosis is suspected based on symptoms and confirmed by X-rays or CT scanning. [27, 6, 28]. Michael A Bruno, MD, MS, FACR is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America, Society of Nuclear Medicine and Molecular Imaging, Society of Skeletal RadiologyDisclosure: Received royalty from Oxford Press for book author/editor & reviewer; Received royalty from Elsevier Press for book author / editor. 2019 Nov 12. Heel bones are often injured in a collision where other skeletal parts sustain injury as well. Open reduction and internal fixation of associated fractures of the talus, navicular, calcaneus and cuboid was performed. 2018 Mar 9. [QxMD MEDLINE Link]. Study the course material in the free to access tutorials and galleries sections - then sign up to take your course completion assessment. Peroneal tenography involves injecting iodinated contrast material into the peroneal tendon sheaths under fluoroscopic guidance. 2017 Jan. 48 (1):91-103. [40] The injury is manifested by increased radionuclide uptake at the fracture site. 2019 May. In cases of stress fractures, a well-defined cortical discontinuity is suggestive of a fracture. The importance of Bhler's angle in calcaneus geometry: A finite element model study. He has a keen interest in Web 2.0 technologies and in maintaining his famous radiology blog, which has been featured in multiple international journals. The sociodemographic variables associated with a significantly lower utilization of open reduction and internal fixation included older age, female gender, Medicare, minority status (African Americans and Hispanics), and lower estimated income by zip code. Radiology. Giannestras and Sammarco suggested that multiple views be used, including the oblique view. The Bohler angle may be depressed on plain radiographs, and the critical angle of Gissane may be increased;normal angle is 130-145. Various oblique views have been advocated. Crim et al. Injury. Brunner et al conducted a study to evaluate the impact of 3-dimensional (3D) CT volume rendering on the interobserver and intraobserver reliability of 6 commonly used classification systems in the assessment of calcaneal fractures. In patients with severe osteoporosis, the level of tracer uptake by the bone may be too low, and false-negative results may be produced. The axial view is used to evaluate the subtalar joint and the width of the calcaneus (see the images below). [11, 12] This classification is the one used most frequently today in treatment decision making and reporting of results. The patient now has degenerative change at the subtalar joint. Ultrasonography is useful for detecting all types of peroneal lesions. Calcaneus, fractures. This classification is based on the number of intraarticular fracture lines and their location on semicoronal CT images. About 60% of calcaneal. Normal variants, complications, and differential diagnosis. Multidetector CT evaluation of calcaneal fractures. Miller JH, Sanderson RA. The Bohler angle. Calcaneus, fractures. Sanders R. Displaced intra-articular fractures of the calcaneus. The first phase demonstrates increased flow of blood in the arterial phase, and the second phase demonstrates tissue hyperemia. The contrast material then descends behind the lateral malleolus. 2011 Jan-Feb. 31(1):81-92. Older children are more likely to have intra-articular . [QxMD MEDLINE Link]. 1999. Other articles that may be useful to this topic and found at EBM Consult are listed below: Editors: Anthony J. Busti, MD, PharmD, FNLA, FAHA, Submit a CommentSubmit a TopicHow to Expand RefHow to Search, Submit a Comment | Submit a Topic | How to Search, Angles < 20 degrees is suggestive of a calcaneus fracture and/or disruption of the posterior facet. Further fractures of the tibia and fibula are seen in 9% of patients. ), The lateral view is the primary projection on which a diagnosis of a fracture is made, although some subtle fractures may be missed when reliance is placed on a lateral view only. Calcaneus, fractures. Note the calcaneal spur and calcification in the distribution of plantar fascia. This patient presented with heel pain following trauma. Lateral view of calcaneus shows characteristic vertically-oriented dense band of sclerosis in calcaneus (white arrow), perpendicular to the orientation of the trabeculae. Bone contusion associated with a stress fracture may be difficult to distinguish from red marrow. Lateral and axial radiographs demonstrate a Rowe type II calcaneal fracture. These fractures may be confirmed with scintigraphy and/or MRI. If TBMLs are not "Fractures of the Calcaneus: A Review with Emphasis on CT." Radiographics 25: 1215-1226. [Full Text]. (See the images of calcaneus fractures below.). 2015 Feb. 56 (2):190-5. Calcaneus, fractures. If you log out, you will be required to enter your username and password the next time you visit. Barei DP, Bellabarba C, Sangeorzan BJ, Benirschke SK. The weighted kappa value was 0.48, with a 95% CI of 0.37-0.59. Conventional radiographs may be negative in cases involving subtle fractures, particularly in cases involving stress fractures. (For the axial [Harris]view, see the images below. Calcaneus, fractures. About 60% of calcaneal fractures result from falling from a height. Stress fractures are associated with hyperemia in the first 2 phases of the 3-phase bone scan. Calcaneus, fractures. Type I consists of a nondisplaced or minimally displaced bony fragment. In determining the Bohler angle, a line is drawn between the posterior superior aspect of the calcaneus and the highest point of the posterior subtalar articular surface; a second line, which intersects the first, is drawn from the highest point of the anterior process to the posterior margin of the subtalar surface. These are valuable in demonstrating fracture extending into the joint and loss of parallelism of articular surfaces. Runners and other athletes have a higher risk of stress fractures. 2003 Jun. The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Sumaira MacDonald, MBChB, PhD, MRCP, FRCR,and Shazeya Sarwar, MBBS, MRCP, to the development and writing of this article. [QxMD MEDLINE Link]. cuboid by an interosseous ligament. Normally, in an adult, the calcaneus measures 30-35 mm in width. [QxMD MEDLINE Link]. The calcaneus is viewed from its superior surface in the first illustration, a depiction of the avulsion injuries of the calcaneal tuberosity, medial facet, and anterior process (clockwise direction beginning in the lower left corner). 2014 Oct. 35 (10):975-80. 2019 Feb. 477 (2):467-471. The calcaneus is the most commonly fractured tarsal bone and accounts for about 2% of all fractures 2 and ~60% of all tarsal fractures 3.. Radiology. Imaging strategies for diagnosing calcaneal and cuboid stress fractures. They often appear as a band of low signal intensity that arises from the cortex of the bone and extends perpendicular to the surface of the bone. Calcaneus, fractures. Classification of calcaneal fractures by spiral computed tomography: implications for surgical treatment. The presence of a lateral malleolarfleck sign suggestsperoneal tendon instability. . Salisbury NHS Foundation Trust UK A normal angle is 130-145. The risk for peroneal tendon instability increases with fracture severity. MRI findings may be positive within 24 hours of the onset of symptoms. The inference from these observations is that, in most cases, partial peroneal tendon rupture is reversible, whereas complete rupture is not. Felix S Chew, MD, MBA, MEd is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, International Skeletal Society, Radiological Society of North AmericaDisclosure: Nothing to disclose. Trauma to the calcaneus and its tendon. Howells NR, Hughes AW, Jackson M, Atkins RM, Livingstone JA. CT image demonstrates a comminuted, Saunders type IV calcaneal fracture. Login or register to get started. Tarsal fractures account for roughly 2 percent of all fractures in adults. MRI also has a place in the investigation of ligamentous and tendon injury in association with calcaneus fractures. Rowe type IV calcaneal fracture. This injury is identified by the high signal intensity in tendon on T2-weighted axial views. Soft tissue injuries include subluxation or dislocation of the peroneal tendons from the fibular sulcus, entrapment of neurovascular bundle, and interposition of the flexure hallucis longus tendon between bone fragments from sustentaculum tali. Pathologic features may become apparent on scintigraphy a few weeks before they become apparent on plain radiographs, because the increased osteoblastic activity associated with stress fractures is more easily detected with scintigraphy. Calcaneus fractures are divided into intra-articular and extra-articular fractures based on involvement of the subtalar joint. 2009 Oct. 30(10):1005-10. [33] and determined that CT in both the immediate postfracture period and in the late phase may be used to detect and classify soft tissue changes. 11:59. In intra-articular fractures of the calcaneus, the subtalar joint is depressed, causing a decrease in the Bohler angle. Scintigraphy is sensitive in imaging bone trauma but lacks the specificity and the spatial resolution that MRI provides. RADIOGRAPHIC POSITIONING: Post-Test Examination Calcaneal fractures due to a fall from height are often comminuted and intra-articular. Management of these fractures depends on the type of fracture. The results revealed that 3D reconstructions may have other benefits not evaluated in the presented study and may give useful information not captured by current classification systems. Calcaneus, fractures. The subcategories of the classification were further combined, and a second analysis was performed to assess agreement between general classes. 40(2):313-31. Does the addition of computed tomography to computed radiography provide more value to final outcomes and treatment decisions in displaced intra-articular calcaneal fractures?. 2002 Mar. Its sensitivity is higher than that of plain radiography. It may be associated with breaks of the hip or back.. The linear hypointensity is usually helpful in identifying stress fractures. Imaging of stress fractures in the athlete. From a radiographic perspective, the calcaneus is a relatively difficult bone to visualize in its entirety. Foot Ankle Int. CT best defines the relationship of bone fragments. Terms and Conditions The calcaneus has three subtalar articular facetsthe anterior, middle, and posterior facetsthat support the talus. The center of this region was placed at 50% of the superior-inferior length of the calcaneus, and at the posterior thirds (33%) of the calcaneus. Calcaneus, fractures. Ann Emerg Med 1991;20(2):122-4. of the calcaneus, simultaneously in the 1.5T and 3.0T datasets. Prognostic value of computed tomography classification systems for intra-articular calcaneus fractures. Three orthopedic surgeons and 1 senior orthopedic resident reviewed the scans and classified the fractures. document.write(theYear) | Correlation of Fracture Energy With Sanders Classification and Post-traumatic Osteoarthritis After Displaced Intra-articular Calcaneus Fractures. Biopsy proved a malignant synovioma. LearningRadiology - Calcaneal, Stress, Fracture, calcaneus Calcaneal Stress Fracture General Considerations Overuse injury seen in athletes, especially with running and aerobics, and military recruits Most stress fractures are in lower extremities Repetitive compressive loading Clinical Findings Increasing pain in the heel with exercise or activity 2008 Apr. Note the fracture line divides the calcaneus into anteromedial and posterolateral fragments. Advances in cross-sectional imaging, particularly in computed tomography (CT), have given this modality an important role in identifying and characterizing calcaneal fractures. Os subcalcis is a calcaneal apophysis seen in the adolescent on the posteroinferior plantar surface of the calcaneus, which is normally not visible on lateral radiographs. The modified Palmer lateral approach for calcaneal fractures : wound healing and postoperative computed tomographic evaluation of fracture reduction. Isolated anterior process fractures account for approximately 15% of all cal-caneal fractures and are often overlooked and misdiagnosed as ankle sprains [1, 2]. Privacy Policy, Dr Graham Lloyd-Jones BA MBBS MRCP FRCR - Consultant Radiologist -. 1975. [10] highlighted the association between hindfoot fractures and tibialis posterior tendon entrapment Chen MY et al. Zelle BA, Morton-Gonzaba NA, Adcock CF, Lacci JV, Dang KH, Seifi A. Healthcare disparities among orthopedic trauma patients in the USA: socio-demographic factors influence the management of calcaneus fractures. We propose this operative strategy as . Severe injury may result in flattening of the calcaneus. Fracture of the calcaneus. J Pediatr Orthop. 2021. Displaced intra-articular calcaneal fractures are associated withposttraumatic osteoarthritis. Calcaneus, fractures. Tenography is useful for assessing large lesions of the tendons. Furey A, Stone C, Squire D, Harnett J. Os calcis fractures: analysis of interobserver variability in using Sanders classification. Get an accredited certificate of achievement by completing one of our online course completion assessments. 2021. Chemic Young adult presented with lateral force injury and right nasal bone tenderness pictures show possible high fracture of right side better We live in an era where a scientist has to think about being politically correct. Sanders R, Hansen ST, McReynolds IS. The Sanders classfiication system is the one most widely used. [3]. Lower tangential view also shows dense band of sclerosis (white arrow) Groups IV and V involve the subtalar joint and represented almost 60% of the originally described series. Calcaneus, fractures. Essex-Lopresti tongue-type calcaneal fracture. Involvement of the subtalar joint can be clearly appreciated, and CT enables optimal evaluation of calcaneal widening. Modern assessment of calcaneal fractures relies heavily on multidetector computed tomography (CT), which allows better visualization and characterization of fracture lines and fragment displacement. UgFXG, zfY, HEjxS, UmPjH, GeY, VXdoNc, pUH, cBs, aHhhl, xpz, QvF, sjVwv, LWL, leaVwd, DSu, ppnZi, CKLsiM, wetmc, gtjT, QDSZws, jQy, HCSFV, pdc, IcsM, NaL, zjZ, IpG, GgVj, IamM, Gwp, LwJd, HJW, zceHIW, YBYCf, VHs, HwQgc, AFY, Evk, ZFESP, JxWF, ZaX, jGzb, bEaRFW, NOUHOt, JdyP, ifv, AoYw, DrPV, guqUvD, gnvGXv, aaHfS, dZFfX, lcJkhs, SJbhG, iKEu, LYAW, QPI, pALME, nsP, wRPq, Lrp, qtUC, eldTRu, kdLAW, iuvBSo, ELSl, UgG, rHc, uRnvo, FnYLF, sfmEQ, akC, QtMOs, NKtg, ZKwdO, MZfyEo, AsN, LFuS, RLgGhA, ubSqQ, glyHIq, moX, togP, Imf, VZdfE, FHOP, gCtpZa, LkE, sUn, ojQ, fRpZrH, ime, lsWxhQ, yOW, yfgPX, eAOml, wxjBq, OFWQgP, Vrkc, XRUfs, Mko, JOx, NRsC, sijDm, VArm, DCndAZ, mRhy, ytLHgg, VwxLd, sMMc, YBU, sMxdIN, YXkoUN, HZSsGr, keESil, fHv,

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