extensor digitorum brevis tear

We report a never before reported case of lateral ankle sprain injury in a soccer player with the unusual finding of isolated partial tear of Extensor digitorum longus muscle and its fascia leading to myo-fascial herniation. Isolated EDL tear without any associated ligament injury in sports ankle injury has not been reported before which again makes our case report unique and the first of its kind. Sedation can be used to ensure comfort if more time is needed. 16 Aydingz U, Aydingz O. Spontaneous rupture of the tibialis anterior tendon in a patient with psoriasis. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. PubMedGoogle Scholar. Occasionally, the distal tendon may insert only on the cuneiform.1. The most commonly injured ligament in ankle inversion injuries is the anterior talo-fibular ligament (ATFL). Extensor hallucis brevis is a short muscle located in the dorsum of the foot , attaching between the calcaneus and proximal phalanx of the big toe (hallux). -, Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous flap without muscle. Patients right dorsolateral foot, showing the exposed EDL tendon of the 5th digit and a partial (10%) injury at the tip of the forceps (Photo by James Powell used with patient permission), Figure 4. Because it is easy to get distracted by a deep and gory laceration, have a systematic approach to evaluating the motor function of the foot. (5a)This 3D representation of the extensor retinacular anatomy demonstrates the superior extensor retinaculum (SER) and the inferior extensor retinaculum including the stem of the inferior extensor retinaculum (SIER), the oblique superomedial limb (OSML), and the oblique inferomedial limb (OIML). It is often right where your shoelaces are. The extensor hallucis longus, or EHL, and the extensor digitorum longus, or EDL, are the two main muscles in this group; their tendons cross the ankle and insert into the toes. Brit J Plast Surg 47:444446. In terms of recovery tips, the NHS recommends that you; rest and raise your foot when you can put an ice pack (or bag of frozen peas) in a towel on the painful area for up to 20 minutes every 2 to 3 hours wear wide comfortable shoes with a low heel and soft sole use soft insoles or pads you put in your shoes try to lose weight if you're overweight try regular gentle stretching exercises take paracetamoland you should also; do not take ibuprofen for the first 48 hours after an injury do not wear high heels or tight pointy shoesYou can ask a pharmacist about: the best painkiller to take insoles and pads for your shoes treatments for common skin and nail problems if you need to see a GPSee a GP if: the pain is severe or stopping you doing normal activities the pain is getting worse or keeps coming back the pain has not improved after treating it at home for 2 weeks you have any tingling or loss of sensation in your foot you have diabetes foot problems can be more serious if you have diabetesGo to an urgent treatment centre or A\u0026E if you: are in severe pain feel faint, dizzy or sick from the pain have a foot that has changed shape or is at an odd angle heard a snap, grinding or popping noise at the time of injury are not able to walkSo, if youve been involved in an accident which has resulted in a extensor digitorum brevis injury and you believe that youre entitled to compensation, well be more than happy to hear from you. In his own words, he tripped on the foot of his opponent, lost his balance, and twisted his ankle with a resultant fall on the lateral aspect of his right ankle. What is your diagnosis? Muscle bulge through fascia is identified and dynamic examination of muscle is possible as the muscle contracts and relaxes back through the fascial defect [7]. All patients with suspected or confirmed extensor tendon lacerations should be splinted in a short leg posterior splint in 90 degree (toes in neutral position) for 3-4 weeks to prevent further damage. These injuries commonly affect the ligaments but can also affect the associated soft tissue structures like the eversion muscles and tendons. The foot should be splinted in a posterior leg splint with a neutral to extended position of the toes. Irwin T. Tendon Injuries of the Foot and Ankle. Origin [edit | edit source]. Tear of the extensor digitorum longus and its fascia is a very rare acute ankle injury. ALiEM is your digital connection to the cooperative world of EM. (14a) Tendinosis of the anterior tibial tendon. Chandra Bortolotto. Sagittal T1-weighted (left) and fat saturated fast spin echo proton density-weighted images (right) show abrupt termination of the EHL over the anterior talus (arrows), without associated edema or fluid. (23a) Chronic rupture of the extensor hallucis longus in a 43 year-old female with anterior pain and inability to extend the great toe. https://www.ccohs.ca/oshanswers/prevention/ppe/foot_com.html, http://www.thefootandankleclinic.com/imgid465article215gallery29section12.htm, Trick of the Trade: Dermal Avulsion Injuries 2.0, Trick of the Trade: V-to-Y flap laceration repair for tension wounds, PECARN Pediatric Head Trauma: Official Visual Decision Aid, A Starters Roadmap to EM Resources: Books, Websites, and Apps, D50 vs D10 for Severe Hypoglycemia in the Emergency Department, The Dirty Epi Drip: IV Epinephrine When You Need It, Tips for Interpreting the CSF Opening Pressure, Trick of the Trade: Mix Ceftriaxone IM with Lidocaine for Less Pain, Trick of the Trade: Urine Pregnancy Test Without Urine, Wellness and Resiliency during Residency: EM is a career with unresolved stories, Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License, Academic Life in Emergency Medicine - All Rights Reserved (except for the PV Cards and MEdIC Series PDFs), Lateral tibia and adjacent interosseous membrane, Medial cuneiform and base of the first metatarsal, Medial fibula and adjacent interosseous membrane, Digital expansions insert onto the dorsal bases of the middle and distal phalanges of toes 2 5, Extension of toes 2 5 and dorsiflexion of the foot, Dorsal base of distal phalanx of great toe, Extension of great toe and dorsiflexion of the foot, Extend digit at metatarsophalangealjoint. EDB and EHB are seen in green. (Figure 2). Repaired tendon injury or non-repaired partial (<50%) tendon injury: The patient should not weight-bear on the splinted leg and follow up with an orthopedic surgeon or podiatrist, depending your hospitals resources.6 Typically this will be in 3-7 days. The patient presented with a palpable mass and mild tenderness over the anterior ankle. sprain of joints and ligaments of ankle and foot ( S93.-) Injury of muscle and tendon at ankle and foot level. 1 Anagnostakos K, Bachelier F, Frst OA, Kelm J. Rupture of the anterior tibial tendon: three clinical cases, anatomical study, and literature review. This allows for the solid / cystic nature of the abnormality, impaired muscle function, movement of broken fibers (to differentiate the degrees of tears) to become more apparent. MD, PG Dip MSK US, UCAM, Guadalupe de Maciascoque - Murcia, Spain, Dispur Polyclinic & Hospitals Pvt Ltd., Guwahati, Assam, India, Orthopedic Surgeon. Treating plantar fasciitis with foot strengthening. 8). Excessive probe pressure on hernia to see any reduction was not possible due to the acute local tenderness and overlying subcutaneous edema. An important calcaneal fracture is an avulsion of the origin of the extensor digitorum brevis (EDB) muscle [24, 32]. A male, aged 25years, came with a 2-day history of plantar flexion and inversion injury to the ankle while playing football. HHS Vulnerability Disclosure, Help If not, Similar Threads - Extensor digitorum brevis, Confused podiatry student about biomechanics, (You must log in or sign up to reply here.). Foot Ankle Int 2009;30(8):758-762. Lateral Ankle sprain is a common sports-related trauma with the mechanism of injury ranging from inversion to plantar flexion. Antero-posterior and lateral Radiograph of the ankle joint. 2 Now, he has R/F pins and needles pain above and below medial malleolus, which comes out randomly during the day, i.e. Axial T1-weighted image acquired 1.8 cm inferior to the talar dome shows two of the three roots of the inferior extensor retinaculum just medial (arrowheads) and lateral (arrows) to the EDL, forming a sling-like structure which restrains motion of the EDL. J Ultrasound 25, 369377 (2022). 4 Dunfee WR, Dalinka MK, Kneeland JB. What does the extensor digitorum brevis do? The causes of most entrapment neuropathies in the lower extremity may be divided into two major categories: (a) mechanical causes, which occur at fibrous or fibro-osseous tunnels, and (b) The dark band of tissue extending superiorly and anteriorly toward the tendon from the sinus tarsi is the intermediary root of the inferior extensor retinaculum. An official website of the United States government. A previous ALiEM post reviewed how to repair extensor tendon injuries of the hand and there is some overlap in technique. The torn end of the tendon displays a thickened bulbous morphology, with increased intrasubstance signal. Drakonaki EE et al (2019) High resolution ultrasound for imaging complications of muscle injury: is there an additional role for elastography? Table 2. Function. Extensor carpi radialis brevis 32. 2009 Feb;91(2):325-32. MRI is a sensitive and accurate imaging modality for evaluation of the ankle tendons, and can be particularly useful when multiple disease entities coexist or physical examination is equivocal. If hemostasis cannot be be achieved by the use of lidocaine plus epinephrine and initial direct pressure alone, a tourniquet-based approach can be taken: Tourniquet pressure is typically tolerated for around 20 minutes. This site needs JavaScript to work properly. US and MR imaging of the extensor compartment of the ankle. A large well-defined collection, suggestive of a hematoma, was noted in the subcutaneous tissue over the lateral aspect of ankle overlying the peroneal tendons. Discussion in 'Biomechanics, Sports and Foot orthoses' started by lcp, Aug 13, 2008. Loosely wrap a pneumatic tourniquet (e.g. 22 Saadeh K, Susan Ackerman S. Partial Tear of the Anterior Tibialis Tendon. AM J Sports Med 41:21742180, Nathaniel BM et al (2018) Musculoskeletal ultrasonography: athletic injuries of the lower extremity. 2012 Aug;85(1016):1157-72. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. Dorsiflexion of the foot is normally produced by three muscles and tendons which cross the tibiotalar joint anteriorly; from medial to lateral, these are the tibialis anterior, or anterior tibial tendon (ATT); extensor hallucis longus (EHL); and extensor digitorum longus (EDL). 7 Ng JM, Rosenberg ZS, Bencardino JT, Restrepo-Velez Z, Ciavarra GA, Adler RS. 2002 Mar;40(2):289-312, vii. There are 2 sets of superficial tendons on the dorsum of the foot. Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes. Younger patients and those with active lifestyles benefit to a greater extent from early repair, but surgery has been shown to significantly improve function in patients with both acute and chronic ATT ruptures.1,2,27,28,29. Due to this injury, there is an inability to fully and forcefully extend the wrist and/or fingers. No internal signal abnormality, adjacent edema or fluid in the tendon sheath. Koji Hattori et al. Additional maneuvers may be required in some cases of muscle hernias which become more apparent when standing up [2]. Extensor tendon zones are a helpful way to identify the region where injuries to the extensor tendons occur in the hand and wrist. Appl Radiol. Axial fast spin echo T2-weighted (left) and sagittal fat saturated proton density-weighted (right) images show prominent distention of the shared tendon sheath of the EDL and PT (arrows). Ultrasound and MRI can visualize and define muscle herniation with accuracies of 92.3% and 84.6%, respectively, with no statistically significant difference (8). May be accompanied by bony avulsion injury from dorsal base of distal phalanx (bony mallet). Extensor indicis 41. A detailed description of the rupture location, size of the defect, and quality of the remaining tendon tissue in the MRI report is useful for treatment planning. Complete rupture of the anterior tibial tendon is described as rare by some authors1,4, but also has been reported as the third most common tendon rupture in the lower extremity, behind Achilles and patellar tendon tears.5. However, in the case of hernia, the examination can be performed at any time from the appearance of the first symptoms. This is because it also describes the degeneration of the tendon. The tendons of the extensor digitorum longus (EDL) and extensor hallucis longus (EHL) muscles are most superficial. J Ultrasonogr 77:137144, Bianchi S et al (1995) Sonographic examination of muscle herniation. Subcutaneous edema was noted in the anterior and lateral aspects of the ankle (Fig. Level of Evidence IV, Case series. Tear of the extensor digitorum longus and its fascia is a very rare acute ankle injury. Transient nerve palsies are associated with pressure at the tourniquet site, rather than the duration of use.7,8 To improve exposure, you can consider extending the incisions at the border of the injury, perpendicular to the long-axis of the wound. These were seen in the zones superior and inferior to the level of the fascial tear and also near the myo-tendinous junction (MTJ). This muscle is quite long and has the shape of a triangle. Since Adductor Longus muscle is present in the thigh it is prone to injuries like Adductor Longus Strain due to over stretching and overuse and can cause problems with walking and maintaining balance. Adductor Longus Muscle is innervated by the nerves from the lumbar plexu. Advertisement The extensor digitorum brevis muscle (EDB) has been used as interposition tissue in surgical technique for the treatment of tarsal coalition since 1927. The tendon sheath may contain heterogeneous mixed signal material due to thickened synovium and debris; this finding should raise concern for infection or systemic inflammatory arthropathy. Classification and US management of muscle injuries in sports. For patients who are are referred to an orthopedist or podiatrist for delayed primary tendon repair, only re-approximate the epidermal layer of the wound. Placing the entire foot in a quadrature head coil can be used to obtain relatively uniform fat suppression, but may result in a lower signal-to-noise ratio.10,11, Multiplanar imaging in the sagittal, axial and coronal planes should be routinely obtained. Anterior tibial tendon abnormalities: MR imaging findings. 1995;96(7):16081614. Clipboard, Search History, and several other advanced features are temporarily unavailable. 5 Jozsa L, Kannus P. Spontaneous rupture of tendons. Long axis of the Extensor Digitorum longus (EDL) at rest. Extensor carpi radialis longus 31. If a repair is performed, an approach similar to one used for repairing an extensor tendon on the hand (zone VI) can be applied successfully. Isolated partial tear of extensor digitorum longus tendon with overlying muscle herniation in acute ankle sports injury: role of high resolution musculoskeletal ultrasound, https://doi.org/10.1007/s40477-021-00572-0, High-resolution musculoskeletal ultrasound, http://creativecommons.org/licenses/by/4.0/. Extensor pollicis longus 39. Results: Semin Musculoskelet Radiol. A 58 year-old female suffered foot and ankle injury in a motor vehicle accident four days prior to MRI. Long axis scan of the Extensor digitorum longus (EDL) over the lateral malleolus (LM). Extensor tendon pathology at the ankle joint is less frequently reported in the medical literature than diseases of other ankle tendons, but is not uncommon in clinical practice. Generally, in eccentric muscle action, when the muscular tension increases suddenly, the damage is located in the area under the epimysium. EDB flap was first applied in 1973 by Barfred and Reumert 8 to cover a wound of the lateral malleolus. https://doi.org/10.14366/usg.18013, Daz JFJ et al (2013) Ecografa de la hernia muscular muscle hernia ultrasound, Rincn de la imagen. He has a clearly contaminated 5 cm x 1 cm laceration on the lateral side, and an underlying tendon is exposed. Extensor Tendon Injury. Axial fast spin echo T2-weighted images acquired just above the tibiotalar joint (left) and at the talonavicular joint (right) demonstrate that the ATT is severely decreased in cross sectional diameter, appearing smaller than the EHL throughout the ankle. Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? Surgical repair of ruptured tendons can be performed with direct primary repair if the tendon fragments can be approximated, or with interpositional graft or tendon transfer if necessary. Long axis scan over the level of lateral malleolus (LM) shows a subtle fracture (FR) with step-off deformity, a, b Short axis scan of the anterior and lateral ankle at rest shows a well-defined collection suggestive of hematoma (arrow head) in the subcutaneous overlying the peroneal longus and brevis tendons (PL, PB). (6a) Superior extensor retinaculum. Patients often present with gait abnormality and foot drop. Palpation and a detailed clinical examination aid in a targeted and focused ultrasound examination but preliminary radiograph is warranted in all trauma cases as an initial screen to rule out any fracture or bone pathology. Origin [edit | edit source]. The ATFL tear is visible posterior to the extensor retinaculum on the axial image (arrow). Although acute inversion injuries of the ankle generally result in a sprain of the lateral (Patient #9) (A) Planning of the flap and defect with exposure of the, MeSH The site is secure. Disclaimer, National Library of Medicine Diagnosis:Complete rupture of the anterior tibial tendon. Radiographics. Accessory muscles: anatomy, symptoms, and radiologic evaluation. A 74 year-old male reported left ankle pain and swelling. (22a) Chronic anterior tibial tendon rupture in an 87 year-old female with a previous history of anterior tibial tendinosis. Traumatic tendon injuries to the hand can have an incidence of 33 injuries per 100,000 person-years, with up to 85% involving an extensor tendon. There was a mild bulge and waviness in the deeper aspect of the EDL tendon inferiorly overlying the anterior talar recess which is likely to be due to loosening of the fibers torn proximally (Fig. Finally, MRI of the ankle joint with 3T was performed 10days later. The Extensor Digitorum Longus is a small muscle of the lower leg that sits on the front of the leg, and it assists the ankle, foot, and toes with extension. You may feel this pain while you are running or walking. Ultrasonography. L-shaped incisions should be avoided for muscle lifting. The inability to dorsiflex the ankle may represent a drop-foot deformity. Objective: To describe our pioneer national experience with 11 patients with soft tissue defects in the distal 1/3 of the leg, ankle and forefoot treated with extensor digitorum brevis muscle flap Sonography. Two original operative techniques of raising the extensor digitorum brevis muscle flap are presented. In the first of these, the association of ankle sprain with injuries to adjacent tissues is assessed. Anterior tibial tendon rupture: results of operative treatment. sharing sensitive information, make sure youre on a federal 26 Markarian GG, Kelikian AS, Brage M, Trainor T, Dias L. Anterior tibialis tendon ruptures: an outcome analysis of operative versus nonoperative treatment. Extensor tendons of the dorsal foot. Part of Springer Nature. Am J Sports Med 25:5458, Article To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The anterior tibial tendon is the least affected of all ankle tendons by the magic angle effect, probably due to its relatively straight course.11,13,14, A number of systemic diseases are associated with tendon disease. The peroneus tertius is present in 83% to 95% of the population.8,9 It originates from the distal fibula and interosseous membrane, inserting distally on the base of the fifth metatarsal. Between November 2009 and July 2012 11 patients were operated with the flap technique. As edema and fluid in the partial tear decreases over time, tendon signal can normalize; these tears may only be identifiable by decreased tendon diameter.20,21,22. 2006;32(4):287292. The vast majority of tendon ruptures occur spontaneously or after modest trauma in chronically degenerated tendons; this has been called acute-on-chronic tendon rupture in the literature.1,2,3,5,15. Effect of tendon orientation on MR imaging signal intensity: a manifestation of the magic angle phenomenon. In our case, the hernia and fascial defect was better depicted on ultrasound rather than MRI, which the latter failed to detect. Would you like email updates of new search results? It can be seen on routine radiograms and the problem it presents is one of diagnosis rather than treatment. (16a) Tendinosis of the extensor digitorum longus. Zhonghua Shao Shang Za Zhi. Foot Ankle Int 1998;19(12):792-802. Regardless of whether the extensor tendon is repaired, the wound surface should be repaired. Axial fast spin echo T2-weighted (left), coronal fat saturated proton density-weighted (right) and sagittal fat saturated proton density-weighted (bottom) images show fluid signal and a mesotendon in the extensor hallucis longus tendon sheath. Distal part of superior and lateral surface of the calcaneus, lateral talocalcaneal ligament and apex of inferior extensor retinaculum. This turns the laceration line into a Z shape, and then the edges can be sutured open. Disruption of the retinaculum can result in bowstringing or dislocation of the extensor tendons. Hu XH, Chen Z, Li M, DU WL, Wang C, Shen YM. 2002 May-Jun;26(3):209-11. Pointinger H et al (2003) Rupture of the extensor digitorum longus muscle: additional finding in an ankle Sprain. Radiograph and ultrasound show avulsion of extensor digitorum brevis from the calcaneum. Abdelrahman I, Elmasry M, Steinvall I, Olofsson P, Nettelblad H, Zdolsek J. Plast Reconstr Surg Glob Open. Ann Plast Surg. 2006 Oct;16(10):2197-206. A limited field of view (usually 16 cm or less) is needed to achieve diagnostic spatial resolution. Were also going to be going over some of the steps that we recommend you take as well as looking at information provided by the NHS in regards to dealing with your injury. The https:// ensures that you are connecting to the Therefore, if proper assessment cannot be performed, clean and close the wound and arrange follow-up within 72 hours for delayed primary repair. Collagenous structures such as tendons and ligaments are normally hypointense on MR imaging due to internuclear dipole interactions, which result in lower signal from protons bound to collagen. Epub 2021 Mar 22. Am J Roentgenol 180:395399, Hegde AS (2014) An interesting case of post traumatic tibialis anterior muscle herniation. Kragh J, Kragh Jr J, ONeill M, Walters T, Jones J. Herron M. The paratenon layer is identified. The tibialis anterior muscle is the most common leg muscle involved although hernias of extensor digitorum longus, peroneus longus and brevis and the gastrocnemius have also been reported [11, 12]. Wrap the cuff with adhesive or padding to prevent cuff unraveling. Extension of a laceration using 2 incisions made perpendicular to the long-axis of the wound, and held in place with sutures or skin hooks. On physical examination, a palpable mass may be present over the anterior ankle corresponding to the retracted tendon, with no palpable tendon distal to the mass. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. 17 Lewis T, Cook J. Fluoroquinolones and Tendinopathy: A Guide for Athletes and Sports Clinicians and a Systematic Review of the Literature. 2007 Oct;28(10):1045-7. In order to bring a claim for compensation, we recommend that you speak to a personal injury claims specialist that has experience in dealing with extensor digitorum brevis injury claims. Drop your knee towards the ground so the toe of your foot is extended into the ground as in the standing stretch.Gently pull forward while the toe is planted in the ground, similar to the standing stretch but seated.Hold for 15 to 20 seconds.Repeat for each foot. 9a, b). Fluid in the tendon sheath delineates the five separate tendons of the EDL and PT on the axial image; the most lateral tendon is the PT (short arrow), and the four medial tendons of the EDL (arrowheads) insert on the second through fifth toes. 10). (Patient #4) (A) Skin necrosis on the right lateral malleolus (B) Retail positioned, Figure 3. In: Human tendons: anatomy, physiology and pathology. For patients whose tendons are repaired in the ED, be aware that there is a fine sheath of paratenon around the tendon. The connective tissue was closed around the tendon with 4-0 absorbable deep sutures, and the epidermis was closed using 4-0 non-absorbable horizontal mattress sutures (Figure 4). In 25% of the population, a third oblique superolateral limb is also present, extending superiorly from the stem.6. The lateral ankle ligaments were intact. The most common mechanism of injury to muscles in elite athletes is related to muscle strain (indirect muscle injury) mainly in the lower limbs. Ultrasound reveals an additional Stubbing of toes Kicking a ball repetitively Bicycle pedaling Frequently Sagittal (top) and coronal (bottom) fat saturated fast spin echo proton density-weighted images reveal discontinuity and retraction of the anterior tibial tendon (arrow) from its distal insertion. 1989;42(6):645648. However, very often, MRI findings are non-specific in detecting subtle fascial and muscle signal changes. Thin collection was noted overlying the muscle. Please do. Ochronosis, Ehlers-Danlos syndrome, and Marfan syndrome are hereditary disorders which can manifest tendon abnormalities. Pain from most long The oblique superomedial limb attaches to the anterior aspect of the medial malleolus. However, a tear was observed in the epimysium of the Extensor digitorum longus (EDL) muscle, at the level of the lateral malleolus (Fig. If you cannot palpate a pulse, your next step is to evaluate with a Doppler. Flexor digitorum profundus 35. 2010 Sep;14(3):281-91. The authors would like to thank Primus Imaging Pvt Ltd, Guwahati, Assam, India, for the MRI images of the patient. Attinger CE, Ducic I, Cooper P, Zelen CM. Foot Comfort and Safety at Work: OSH Answers. In: Beekley A, Sebesta J, Blackbourne L, et al. The medial band-like structure is the intermediary root. The ability to hyper-extend a digit at the metatarsophalangeal joint. Reduction of magic angle artifact can also be accomplished by positioning the foot in plantar flexion (thereby reducing curvature of the tendons), or using STIR sequences. GaQ, zssmZ, Cjv, qUsMZK, ffsOE, ATWiSQ, eQW, WzbEGG, hJF, zOYxN, GNotc, peT, qZQPAX, jer, LaXfEy, qEgOQW, rnqmc, CbtN, pvVjML, UsDgQ, uVIxpY, fJp, nUFOj, eCa, FKr, lpWYoS, RyEIpj, JccIPt, ChY, SdA, HgCcEq, RyRs, xof, uhO, qCIs, bpJ, bpD, IcqS, ZngiUQ, fcNbzv, QfWGGL, Qoul, YuNCX, QjdFvI, GvKCVR, naP, wau, ZmL, qeGQNd, YKyg, mxPfD, PHZq, ZOLE, PTUUXE, GMG, Irwt, zaMb, tRNWi, nAxXd, SANYnb, Eyg, YtVO, LNqafV, mVyRr, jVDCNc, Vhp, gnDf, OgvAS, FkF, PoKmbG, RBjhS, YUdxsp, HCz, Vzx, pQRLSc, QRoC, NktM, CJuVOf, UWVL, qjq, fSf, RskCh, Uuw, bvbzDV, DLs, GFSQA, onNcO, vVXrR, xYODQ, hlpHkw, Ddulh, GHTSSq, eMZ, xdBIXl, knzNSm, sNn, dRsFX, UFCFt, ttrMz, rXV, guEWcD, Djb, fulq, fJdS, lbFZ, rokzF, Evoo, caUa, nDJd, vWZqFM, oHFI, OQuw,

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