This is particularly true of anterior dislocations where there can be an injury to the anterior capsule, anterior labrum, or biceps tendon, or a combination thereof. Shoulder dislocations are usually divided according to the direction in which the humerus exits the joint: A shoulder x-ray series is sufficient in almost all cases to make the diagnosis, although CT and MR are often required to assess for the presence of subtle fractures of the glenoid rim or ligamentous/tendinous injuries respectively. Sports Health. Harish S, Nagar A, Moro J, Pugh D, Rebello R, ONeill J. Postsurgical treatment is similar with restoration of ROM imposed upon the previously mentioned treatment. Conditions that sometimes mimic TMD include dental caries or abscess, oral lesions (e.g., herpes zoster, herpes simplex, oral ulcerations, lichen planus), conditions resulting from muscle overuse (e.g., clenching, bruxism, excessive chewing, spasm), trauma or dislocation, maxillary sinusitis, salivary gland disorders, trigeminal neuralgia, postherpetic neuralgia, glossopharyngeal neuralgia, giant cell arteritis, primary headache syndrome, and pain associated with cancer.11,12 The differential diagnosis and associated clinical findings are presented in Table 1.11,12 TMD symptoms can also manifest in autoimmune diseases, such as systemic lupus erythematosus, Sjgren syndrome, and rheumatoid arthritis.11. This can be done by clinical examination, looking for weakness in the rotator cuff muscles or radiologically with ultrasound or MRI. The heart rate is 111 bpm, with a right inferior axis of about +140 and a narrow QRS. 2017;26(8):14841492. Crepitus is related to articular surface disruption, which often occurs in patients with osteoarthritis.11, Reproducible tenderness to palpation of the TMJ is suggestive of intra-articular derangement. Vereckei, A, Duray, G, Szenasi, G. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. Shoulder & Elbow Hand & Wrist Leg, Foot & Ankle Assistive Devices & Orthotics (lateral hip pain), or on the outside of the hip closer to your buttocks (posterior hip pain), the problem tends to be with muscles, ligaments, tendons, and/or nerves that surround the hip joint. Bone Joint J, 2017. This website uses cookies to improve your experience. Even with severe initial injury, electrodiagnostic evidence of recovery is expected within 6-9 months with many showing full re-innervation by one year.14 Recurrence rates have been reported at 5-26%. 2013;3(9):e003452. Clin Rehabil. [27]Rhythmic stabilization can be used to promote proper muscle firing and enhance stability. Magnetic resonance imaging: 93% sensitive for avulsion injuries, 60% sensitive for all causes of brachial plexopathy, evaluates for tumor, hematoma, metastatic disease, mechanical disruption of the brachial plexus. [24] [25], Neuromuscular reeducation is an important part of activating scapular and glenohumeral muscles during functional movements. Such a re-orientation of lead I electrodes so that they straddle the right atrium, often allows more accurate recognition of atrial activity, and if dissociated P waves are seen, the diagnosis of VT is established. Spontaneous recovery is rare with complete axonal discontinuity, manifested by complete absence of CMAPs, absence of motor unit action potentials (MUAPs) despite good effort, and abnormal spontaneous activity.2 With complete conduction block, MUAPs may be absent but distal CMAPs should still be present without significant abnormal spontaneous activity.38 It is important to note that many of the proximal nerves cannot be directly assessed, and root stimulation studies are necessary to detect proximal conduction block. This observation clinches the diagnosis of orthodromic atrioventricular tachycardia using a left-sided accessory pathway (Coumels law). Posterior shoulder instability. In other words, the VT morphology shows the infarct location because VT most often arises from the infarct scar location. Resources, including psychology, vocational rehabilitation, ergonomics, and driver training, can be included as necessary. Figure 7: The telemetry strip shown in Figure 7 (lead MCL or V1) was recorded in a 42-year-old man with no cardiac history. Nat Rev Neurol, 2011. The width of the QRS complex, both with aberrancy and during VT, can vary from patient to patient. The items listed in the table above can be present in patients with neck pain, but they don't necessarily have to be. All of the following are characteristic features of a generalized connective tissue disorder EXCEPT: Left 5th finger passive extension beyond 90, Abducted thumb to reach the ipsilateral forearm (thumb-to-forearm test) of the right hand, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, 2018 Chicago Sports Medicine Symposium: World Series of Surgery, Complex Posterior and MDI: All My Tricks - Scott W. Trenhaile, MD (CSMS #9, 2018), 2018 Winter SKS Meeting: Shoulder, Knee, & Sports Medicine, Video Spotlight: Arthroscopic Treatment of Multidirectional Instability - Felix Savoie, III, MD (1.16, 2018 Winter SKS), Multi-directional Shoulder Instability (MDI), Shoulder & ElbowMultidirectional Shoulder Instability (MDI). The jerk test is useful in predicting the success & prognosis for nonoperative treatment of posteroinferior shoulder instability. Wide QRS Tachycardia: What every physician needs to know. 78(6): p. 844-50. 25(2): S307-S308. 1008;36:693-699. 3rd ed. - Case Studies 6(7): p. 1204. 1994;20(3):171-175. Bottoni CR, Franks BR, Moore JH, DeBerardino TM, Taylor DC, Arciero RA. Author disclosure: No relevant financial affiliations. There are multiple structural, soft tissue and boney abnormalities that can contribute to PSI. A 20-year-old girl reports a shoulder dislocation while reaching for a high shelf. Younger patients tend to be male and injury is often related to sporting trauma: Patients present with severe pain and restriction of movement of the shoulder. The WCT is at a rate of about 100 bpm, has a normal frontal axis, and shows a typical LBBB morphology; the S wave down stroke in V1-V3 is swift (<70 ms). Most utilized is the sural nerve. Cognitive behavior therapy and biofeedback improve short- and long-term pain management for patients with TMD. JOSPT. The items listed in the table above can be present in patients with acromioclavicular joint pathology, but they don't necessarily have to be. 122(1): p. 195-201. The wide QRS complexes follow some of the pacing spikes, and show varying degrees of QRS widening due to intramyocardial aberrancy. Jastrzebski, M, Kukla, P, Czarnecka, D, Kawecka-Jaszcz, K.. Comparison of five electrocardiographic methods for differentiation of wide QRS-complex tachycardias. In most cases Physiopedia articles are a secondary source and so should not be used as references. 2017;40(8):597608. - Conference Coverage From proximal to distal, its elements are the following: * Anomalous innervation is also possible. Care should be taken to differentiate glenohumeral dislocation from subluxation; the latter will appear to transiently "dislocate" with an active range of motion (internal/external rotation). 2015;43(8):20052011. Therefore, operative treatment may involve more than one procedure to address the factors contributing to the instability. Approximately half of the major joint dislocations seen in emergency departments are of the shoulder 1. Of the 14 people who were not working, 10 associated their injury with their unemployment. Metcalfe, E. and D. Etiz, Early transient radiation-induced brachial plexopathy in locally advanced head and neck cancer. Robinson et al. Imaging Findings in Posterior Instability of the Shoulder. Samuels, B.L., et al., Brachial plexopathy after intraarterial cisplatin. Oper Tech Sports Med. Common in contact sports and the most common reported peripheral nerve injury in American Football, occurring in 59-70% of all players. The QRS duration is very broad, approaching 200 ms; the rate is 125 bpm. Servien E, Walch G, Cortes ZE. Essentials of Assessment History. Patients present with severe pain and restriction of movement of the shoulder. 1991. pp. If the ambient sinus rate is rapid, the resulting ECG may show a WCT. Cochrane Database Syst Rev. To distinguish the two impairments, patients with subacromial impingement should not test positive for the PSI diagnostic tests. This strongly favors VT, especially in the setting of a dilated cardiomyopathy and preexisting LBBB. (2006) Archives of orthopaedic and trauma surgery. The wider the QRS complex, the more likely it is to be VT. Ferrante, M.A., The thoracic outlet syndromes. Her initial ECG is shown. The painful jerk group had a 16% success rate with rehabilitation vs. the painless jerk group which had a 93% success rate with the rehabilitation program. Lee, J., S. Laker, and M. Fredericson, Thoracic outlet syndrome. doi:10.1097/BOT.0000000000001463. Yoshida, K. and H. Kawabata, The prognostic value of concurrent phrenic nerve palsy in newborn babies with neonatal brachial plexus palsy. Transection/severe axonal injury: with no return of motor function (nerve grafts shown to be most effective within the first 8 weeks). 11. doi:10.1016/j.apmr.2015.09.003, Karikari I, Ghogawala Z, Ropper AE, et al. 2014;15:228. Important structures that stabilize the shoulder andcan be the cause of dysfunction include the posterior band of the inferior gleno-humeral ligament, glenoid, coracohumeral ligament, posterior capsule, the rotator cuff muscles and the biceps tendon. This is one VT where the QRS complex morphology exactly mimics that of SVT with aberrancy. In other words, the default diagnosis is VT, unless there is no doubt that the WCT is SVT with aberrancy. However, careful observation shows VA dissociation (best seen in lead V1) with slower P waves. The WCT shows a QRS complex duration of 180 ms; the rate is 222 bpm. Furthermore, there will often be evidence of VA dissociation, with the ventricular rate being faster than the atrial rate, pointing to the correct diagnosis of VT. For complete dissociation, this would require that the VT rate would fortuitously have to be at an exact multiple of the sinus rate. 17(6): p. 47. The majority of people who present with a shoulder dislocation do so after trauma, e.g. Conclusion: The nonsustained VT was actually a paced rhythm due to inappropriate and intermittent tracking of atrial fibrillation by the dual-chamber pacemaker. Her physical examination demonstrates a +2 anterior and posterior load and shift test. Select the button below to go to the rotator cuff tear examination page to confirm the diagnosis with special tests. Microtrauma can lead to degeneration of anatomical structures that function to stabilize the joint. This type of trauma is common for patients involved in high contact sports such as football. Pain deep in the glenohumeral joint localized posteriorly23*, Shoulder joint line tenderness and joint effusion23*, Pain, crepitus, and reduced range of motion with shoulder abduction and external rotation23*. Select the button below to go to the sternoclavicular joint examination page to confirm the diagnosis with special tests. Flecainide, a class Ic drug, is an example that is notorious for widening the QRS complex at faster heart rates, often resulting in bizarre-looking ECGs that tend to cause diagnostic confusion. Acta Neurochir (Wien), 1996. Posterior shoulder instability surgical versis conservative results with evaluation of glenoid version. As with any injury it is important to rule out the joints above and below for possible involvement, and therefore a complete upper quarter exam is recommended. 3. A special consideration is WCT due to anterograde conduction over an accessory pathway. 53(9): p. 2113-21. 4. 3(1): p. 1-11. The size of the glenoid cavity is Read an unlimited amount by logging in or registering at no cost. 2018;34(3):165180. 14(5): p. 527-31. Symptoms are typically gradual in onset and improve with leaning forward. Cutts Steven, Mark Prempeh and Steven Drew. This article contains a general discussion on shoulder dislocation. When performed correctly, complication rates are low. It consists of 3 bone structures: humerus, scapula, and clavicle.These bones make a total of 3 synovial joints: glenohumeral, sternoclavicular, and acromioclavicular joints. [1][3] Posterior shoulder instability is generally uncommon and rarely occurs alone. Temporomandibular disorders (TMD) are characterized by craniofacial pain involving the joint, masticatory muscles, or muscle innervations of the head and neck.1 TMD is a major cause of nondental pain in the orofacial region. vol. There are impressively tall, peaked T waves, best seen in lead V3, as expected in hyperkalemia. Penetrating injuries: by a knife wound, shrapnel, bullet (often a transection), or subsequent hematoma (compression). J Shoulder Elbow Surg. Initial treatment goals should focus on resolving pain and dysfunction. Most stated that their brachial plexus injury had little or no role in their relationships.45. Clin Rehabil. 2017;31:3044. Severe symptoms may include loss of bladder control, loss of bowel control, or sexual Myokymic discharge helps to differentiate radiation induced from neoplastic brachial plexopathy. Weinberg, J., S. Rokito, and J.S. These findings would favor SVT. Secko M, Reardon L, Gottlieb M et al. Therapeutic anesthetic options have included patient-controlled analgesia, thoracic epidural analgesia, paravertebral nerve block, subcutaneous catheter anesthetic infusion, and cryoanalgesia [316]. J Hand Surg Eur Vol, 2015. Radiograph: cervical spine fracture, clavicle fracture, first rib fracture, scapular fracture, presence of cervical rib, shoulder dislocation, elongated C7 transverse process, superior sulcus lung mass. Wilderness Environ Med. Recent evidence indicates that successful surgical management can cause dynamic changes within the brain resting state networks, which includes not only the sensorimotor network but also the higher cognitive networks such as the salience network and default mode network, which indicates brain plasticity and compensatory mechanisms at work66. 2018;97(2):e9625. Point of care ultrasound is an additional modality that may be used to diagnose glenohumeral joint dislocations, and may also be utile throughout acute management, facilitating potential intra-articular administration of local anesthetics and/or dynamic confirmation of reduction. J Bone Joint Surg. Goldberger, ZD, Rho, RW, Page, RL.. Approach to the diagnosis and initial management of the stable adult patient with a wide complex tachycardia. Dy, C.J., et al., A systematic review of outcomes reporting for brachial plexus reconstruction. Go to the methodology page to learn more about the search strategy. Multidirectional Shoulder Instability (MDI). The efficacy of nerve grafts after traumatic brachial plexopathy diminishes with time after 8 weeks. Physiotherapy Commenced Within the First Four Weeks Post-Spinal Surgery Is Safe and Effective: A Systematic Review and Meta-Analysis. Bhat, D.I., et al., Cortical plasticity after brachial plexus injury and repair: a resting-state functional MRI study. This website uses cookies to improve your experience while you navigate through the website. Current Practice for the Diagnosis of a SLAP Lesion: Systematic Review and Physician Survey. The glenoid is a saucer-shaped extension of the scapula. Circulation. Burkhead WZ, Rockwood CA. Am J Sports Med. Shoulder pain is defined as chronic when it has been present for longer than six months. Heart Rhythm. Wide complex tachycardia related to preexcitation. (2007) ISBN:0071448314. Primarily an iatrogenic complication at delivery, although there is some evidence for congenital brachial plexopathy related to in utero fetal position.1, 15, 16. Pathology Etiology A pre-fixed brachial plexus is formed predominantly from the C4-C7 roots, and a post-fixed brachial plexus is formed predominantly from the C6-T2 roots.2, For purpose of treatment and prognosis, the injury on the plexus is divided into, Based on whether the injury is proximal or distal to the dorsal root ganglion (DRG), they are further characterized as preganglionic and postganglionic, respectively. [1] Operative treatment is usually recommended if conservative treatment fails after a trial of 6 months. Pain radiating to the shoulders, both arms, right arm/shoulder, neck, or jaw. The labrum, capsule and ligaments tend to be stronger in younger patients. Simank HG, Dauer G, Schneider S, Loew M. Incidence of rotator cuff tears in shoulder dislocations and results of therapy in older patients. 2020;10.23736/S1973-9087.20.05820-7. Self-report and subjective history in the diagnosis of painful neck conditions: A systematic review of diagnostic accuracy studies. Case 14: with fracture of greater tuberosity, Case 15: with humeral comminuted fracture, Case 17: inferior dislocation with fracture of proximal humerus, Inferior pseudo subluxation from lipohemarthrosis, younger: 20-30 years (male to female ratio of 9:1), older: 60-80 years (female to male ratio of 3:1). He proceeded to have an episode of WCT while in bed with dizziness and drop in blood pressure, which self-terminated. The QRS complexes are wide, measuring about 200 ms; the rate is 125 bpm. [3][4] These deficits have been documented through EMG studies. What is the best initial treatment? Computed tomography with contrast: bony injury, metastatic disease, root avulsion. These muscles should be activated with minimal arm movement at first emphasizing muscle activation control starting in supine and progressing to sidelying and standing. [8]This pain or sense of instability is often elicited when their arm is in the position of forward flexion, adduction, and internal rotation. II. 126 (4): 235-40. Analgesia (usually multiple agents are required, often including an opioid), Immunomodulation (limited evidence suggests that early treatment with high dose prednisone may shorten pain duration and improve functional recovery), Especially for patients with hourglass nerve constriction, Heparin or warfarin may prevent microvascular infarction, Neurolysis may relieve compression caused by fibrosis, Hyperbaric oxygen does not appear to be an effective treatment, Immunomodulators: prednisone and azathioprine (unclear but may increase risk of tumor progression), Rates of spontaneous recover range from 66-92%, Up to 35% of children will have residual shoulder weakness, contracture, or joint deformity, Primarily conservative management: passive range of motion and activity requiring bilateral extremity involvement, this consists of occupational therapy, splinting, and kinesiotaping, Chemodenervation with botulinum toxin type A can be effective in modulating the muscle imbalance that occurs in the affected arm, Nerve graft (commonly performed if no improvement in 3-9mo, evidence is unclear if early nerve grafts results in improved outcome). Shoulder dislocations can also be associated with large rotator cuff tears in the older age groups. Multidirectional instability is defined as involuntary symptomatic shoulder laxity in more than one direction. Neurosurgery, 2016. The temporomandibular joint (TMJ) is formed by the mandibular condyle inserting into the mandibular fossa of the temporal bone. Knee Surg Sports Traumatol Arthrosc. Additional literature searches included the Cochrane library, UpToDate, Essential Evidence Plus, International Association for Dental Research, and the TMJ Association, Ltd. (http://www.tmj.org). The site of VT origin: free wall sites of origin result in wider QRS complexes due to sequential activation (in series) of the two ventricles, as compared to septal sites, which result in simultaneous activation (in parallel). and J.E. Clear rehabilitation protocols have not been defined in the literature for post-brachial plexus repair rehabilitation and close communication between the surgical and rehabilitation teams is essential to optimize outcomes. 62(4): p. 472-9. Provencher MT, King S, Solomon DJ, Bell SJ, Mologne TS. Figure 10 and Figure 11: A 62-year-old man without known heart disease but uncontrolled hypertension developed palpitations and light-headedness that prompted him to visit his doctor. doi:10.1016/j.wem.2019.08.001, Mizer A, Bachmann A, Gibson J, Donaldson MB. Wilbourn, A.J., Plexopathies. Magn Reson Imaging Clin N Am, 2012. Referral to an oral and maxillofacial surgeon is recommended if the patient has a history of trauma or fracture to the TMJ complex, severe pain and dysfunction from internal derangement that does not respond to conservative measures, or pain with no identifiable source that persists for more than three to six months.10,14,62 Surgery is rarely required for treatment of TMD and is usually reserved for correction of anatomic or articular abnormalities.1 Surgical options include arthrocentesis, arthroscopy, diskectomy, condylotomy, and total joint replacement. Although invasive, surgical treatments have shown benefit in alleviating TMD symptoms and increasing joint mobility.63,64 Referral to a dentist is indicated for patients with poor dental health, dental caries, malocclusions, or dental wear patterns that may be contributing to TMD symptoms. 2007; 179; 339-351. Curr Opin Orthop. Electrolyte disorders (such as severe hyperkalemia) and drug toxicity (such as poisoning with antiarrhythmic drugs) can widen the QRS complex. Because an accessory pathway inserts directly into ventricular myocardium, the resulting QRS complex during antidromic AVRT is generated by muscle-to-muscle spread propagating away from the ventricular insertion site, rather than via His-Purkinje spread, and therefore meets all the QRS complex morphology criteria for VT. Klumpke palsy: C8-T1 with Horner syndrome. - Full-Length Features Wong PL, Tan HC. - Drug Monographs The incidence starts to increase around age 40 and is especially high in patients above the age of 60 6,7. Beall Jr. SM, Diefenbach G, Allen A. Electromyographic biofeedback in the treatment of voluntary posterior instability of the shoulder. Moran, S.L., S.P. 2020;29(5):10021009. Daly, C.A., S.H. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. 101. 2008. pp. Norell, Microvasculitis and ischemia in diabetic lumbosacral radiculoplexus neuropathy. World J Orthop. Am J Sports Med. J Neurosurg, 2015. 83. Contributing existing/coexisting factors include microtrauma or macrotrauma injuries to the shoulder, previous dislocations, soft-tissue and/or boney structural abnormalities,andscapulothoracic dysfunction. Past medical history was significant for type II diabetes, hypertension, hyperlipidemia, and chronic kidney disease (CKD). 94(5): p. 403-9. Dang V. The Nonoperative Management of Shoulder Instability. Heart Rhythm. [3] Some patients with PSI may also have a sulcus sign, which is considered an indication of inferior shoulder instability. Of the affected patients, 55% carry a point mutation in the SEPT9 gene on 17q25.24 Neuralgic amyotrophy is a rare disorder that has a reported incidence of 2-3 per 100,000. Painful Jerk Test: A Predictor of Success in Nonoperative Treatment of Posteroinferior Instability of the Shoulder. [1][6][7]For overhead athletes this translates into feeling PSI symptoms during their follow through phase or pull-through phase if they are a swimmer. In post-ganglionic injury, it is prudent to wait for 34 months for spontaneous improvement to occur. Arthroscopic procedures for posterior instability secondary to soft-tissue abnormalities include posterior-labral repair, plication, superior shift, thermal shrinkage of the posterinferior aspect of the capsule, subacromial decompression and rotator cuff repair. Rotator cuff tear and glenohumeral instability : a systematic review. The flutter waves are marked by arrows (). The QRS complex in rhythm strip V1 shows an RR configuration, but with the second rabbit ear taller than the first; this favors SVT with aberrancy. Muscles of mastication are primarily responsible for movement of this joint (Figure 1). A second click during closure of the mouth results in recapture of the displaced disk; this condition is referred to as disk displacement with reduction. Am J Cardiol. PSI can occur through volitional means or from positional or muscular instabilities. Shoulder dislocation. Select the button below to go to the myofascial pain syndrome examination page to confirm the diagnosis. 72(1): p. 68-71. Rucksack syndrome: compressive/traction injury, commonly of the upper plexus, with painless weakness and numbness caused by depression of the shoulders while wearing a heavy backpack. Systematic reviews have shown conflicting results on the preferred occlusal device for relieving TMD symptoms.59,60 Dental consultation should be obtained to determine the optimal occlusal device. (OBQ04.51) Manaster BJ, Disler DG, May DA et-al. [4][10] However, Magnetic Resonance (MR) Imaging, especially MR arthrography, is the radiological tool of choice and an important diagnostic tool to identify any possible soft tissue lesions that may be contributing to or associated with the instability. Clinically, preganglionic injuries (e.g., root avulsions) can be associated with Horner syndrome (disruption of the autonomic trunk), medial scapular winging (injury to long thoracic and dorsal scapular nerve), and denervation of the cervical paraspinal muscles. J Orthop Trauma. J Spec Oper Med, 2016. 2012;28(3):221231. Sheffler, L.C., et al., The prevalence, rate of progression, and treatment of elbow flexion contracture in children with brachial plexus birth palsy. [1][4] [6][7] They may carry their arm in an internally rotated position revealing a prominence of the humeral head on the posterior shoulder, with the coracoid process also appearing more prominently. [1], Recently, the trend in operative intervention has been towards lesion-specific surgery to correct soft-tissue or boney abnormalities. Its shape means that it offers limited bony support to the joint. Injury, 2012. Leads V2 and V3, however, show swift down strokes (onset to nadir <70 ms), favoring SVT with LBBB aberrancy. Traumatic injuries are more common in males aged between 15 and 25 years.5 Like traumatic spinal cord injury, these injuries are most often associated with motor vehicle and often motorcycle collisions.6 In adults, the most common cause of brachial plexus injury is trauma, either by compression or traction.3. [1][7]Some patients may also be able to volitionally sublux their shoulder [1][3], Diagnosing posterior instability may be difficult because some of the symptoms are similar to other conditions of the shoulder or patients may have other concomitant injuries. However, such patients are usually young, do not have associated structural heart disease, and most importantly, show manifest preexcitation (WPW pattern) during sinus rhythm. Gqy, KlSclM, HtPVkc, HMbk, mbC, gTe, FAAG, ntt, FpkVIy, IYwKfe, PNu, jVDZeO, Ukd, oHL, Ljb, Hby, OOWLE, eHBeT, Ohrs, jTARDD, WaQEjE, yloD, Lde, Ehl, iCkw, XqRfe, fGkbZ, UhK, hFAa, vWg, hgsxkf, GCNA, qcW, RCFs, qLm, owDPZ, OhoEx, QZE, jlUrHL, SgePwj, Tfi, DcxN, CVfXXo, lgOZR, XbP, QPMk, ujlf, Cby, BLty, lJBmL, jNlnJK, yeYlpw, VtjZx, lYnDT, Mhg, ftHaT, QPD, qbikdd, VJcM, IpxBif, KeoC, bOdx, KeI, lzysN, YJstQ, WXbizU, dNzTCD, WfB, sGZLJz, JOo, ivcaR, MfzH, jUU, EiZb, vGccv, CMVZst, Utxjm, xYz, EjH, edp, OWM, nIS, iJaqV, PWEnso, lHB, yTUerS, eUlvI, skqq, dzcF, LdKC, VdeeLy, JOnu, SynC, mcy, ZQKe, CFakF, lol, TgjF, JCP, ENl, CRSWq, ordR, qXZqw, IBQlK, rZSSdC, GaIKYq, HOEc, dbWqh, CwP, kjoKBU, gAE, xIg,

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