Posterior impingement can also occur if you have an enlarged bony prominence called an 'os trigonum' on the back of the foot bone or a bony anomaly in your ankle. Call us @ 7026-200-200 Medfin.in for more help The relief of pain is presumably related to both a reduction of humeral head subluxation and due to disengagement of the rotator cuff from the region of internal impingement. Facebook: http://www.facebook.com/geekymedics Robinson C & Aderinto J. Posterior Shoulder Dislocations and Fracture-Dislocations. The image on the right is rotated 90? Additionally, if the shoulder has been dislocated for 3 weeks (particularly common in debilitated elderly patients) or if the anterior humeral articular injury (reverse Hill-Sachs defect) involves >20% of the articular surface, then the closed reduction is contraindicated 2. 1. For a full list of available versions, see the Directory of published versions . Given that the most common reason a shoulder X-ray is requested is to look for dislocation or successful subsequent relocation, being familiar with alignment is arguably the most important part of shoulder X-ray interpretation. Glenoid: version and shape. CT-images in another patient show a reversed osseus Bankart in a patient with posterior dislocation. Bankart lesions with an osseus fragment are common findings in patients with an anterior dislocation and are frequently seen on the x-rays or CT-scan. DO NOT perform any examination or procedure on patients based purely on the content of these videos. CT). FMS Impingement Clearing Screen This is the exact screen the FMS uses to "clear" someone for impingement. Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. There is an osseus Bankart lesion (curved red arrow). J Bone Joint Surg Am. This causes you to have pain when raising your arm overhead or out to the side. 2 articles feature images from this case The test is positive if the patient complains of deep posterior pain. Each clinical case scenario allows you to work through history taking, investigations, diagnosis and management. Notice the distance between the humeral head and the glenoid on the AP-view, which is abnormally wide. Adapted from an original image by Jmarchn. Posterior shoulder pain in a high-level tennis player. Lateral view: the humeral head will lie posterior to the glenoid fossa. Normal radiographic measurements of the shoulder. Check for errors and try again. The ABER-view shows an absent antero-inferior labrum. 6 1707-1715. by Michel De Maeseneer et al 174 no. Dr udayan das is an orthopedic surgeon. Subacromial bursal thickening and increased fluid indicating co-existing subacromial bursitis. What are the findings What is your diagnosis? The tendon of the Infraspinatus muscle attaches on the posterior aspect of the greater tuberosity. There are several ways in which impingement can be classified. 5. Posterior view of the shoulder Infraspinatus The infraspinatus muscle is located posterior to the scapula, inferior to the scapular spine. A Bankart lesion is an injury of the anterior glenoid labrum due to anterior shoulder dislocation. This is doubly true in the context of trauma, as rib fractures and the subsequent complications may be missed by a distracting injury like a fractured humerus or dislocated shoulder. Due to these recurrent dislocations significant bone loss and erosion of the anterior glenoid rim may occur, which maintains the unstable situation. Arthroscopy 1999;15 : 253-258. There is mild thickening of the inferior glenohumeral ligament and anterior joint capsule. AJR 2005; 185:925-929. Pitchers with internal impingement typically complain of pain in the late cocking or early acceleration phase of throwing. Clayfield PhysioWorks provides excellence in the provision of Physiotherapy, Remedial Massage, Acupuncture and Nutritional services for the suburbs of Clayfield, Hendra, Ascot, Hamilton, Albion, Wooloowin, Wavell Heights, Toombul, Nundah, Northgate, Virginia, Chermside and other inner north Brisbane suburbs. Radiography. The mean posterior recess angle measured 65 (SD 27) for the controls and 94 (SD 38) for the athletes (P = .002).ConclusionsOverhead-throwing athletes with internal impingement pain and internal rotation deficit tend to have a thicker labrum and a shallower capsular recess in the posterior inferior shoulder joint than do non-overhead-throwing athletes. General Inquiries. HAGL is a Humeral Avulsion of the inferior Glenohumeral Ligament. Posterior internal impingement tes t. Starting position is supine . On CT it is easy to appreciate the osseus fragment of the anterior glenoid (arrow). 1987;69(1):9-18. The dislocation of the humeral head to antero-inferior causes damage to the antero-inferior rim of the glenoid in the 3 - 6 o'clock position (marked in red). Mackenzie D & Liebmann O. Point-Of-Care Ultrasound Facilitates Diagnosing a Posterior Shoulder Dislocation. show answer. 2002;224(2):485-6. It is the impingement of the rotator cuff (muscles and tendons within the shoulder which play a large part in lifting and twisting the arm) against other structures within the shoulder which form the basis of impingement syndromes. This is a post-reduction view. an ALPSA-lesion (black arrow). Widening of the gap between the clavicle and the coracoid process may indicate pathology affecting the coracoclavicular ligament (e.g. It represents a patial tear of the anteroinferior labrum with adjacent cartilage damage. ENROLL IN OUR COURSE: http://bit.ly/PTMSKGET OUR ASSESSMENT BOOK http://bit.ly/GETPT OUR APP: iPhone/iPad: https://goo.gl/eUuF7w Android: https. The red arrow points to the absent labrum - Buford complex. Shoulder X-rays are common investigations in every Emergency Department, typically in the context of trauma, with shoulder dislocations being the most common pathology. This is a bone defect as result of the impaction of the glenoid rim on the humeral head. Although much less common, it is also important to check the lungs for malignancy, as a Pancoast tumour may be visible in the apex of the lung. The use of paramagnetic contrast has proven beneficial in the evaluation of internal impingement. - Medical Finals Question Pack: https://geekymedics.com/medical-student-finals-questions/ There is also a Hill-Sachs defect (red arrow). Thickening / increased fluid within the subacromial / subdeltoid bursa. Walch et al first described internal impingement in 1992, in a study of 17 overhead athletes.1 Walch found that in abduction and external rotation, contact occurs between the undersurface of the rotator cuff and the glenoid, and that though the contact is physiologic, it may lead to disease when performed forcefully and repetitively, as in the throwing athlete (4a,5a). The shoulder is a very mobile and therefore unstable joint. It is seen in 75-100% of patients with anterior instability. An axillary view is a preferred view for diagnosis. Shoulder pain is a common musculoskeletal medical condition affecting 7% to 26% of individuals and is the third most common musculoskeletal-related complaint in the primary care setting. J Bone Joint Surg Am. Posterior ankle impingement should always be included in the differential diagnosis when evaluating a patient with chronic, deep posterior ankle pain, particularly in the very active patient or in a patient with a previous ankle injury. Although somewhat controversial, recent work has supported the role of laxity in the pathogenesis of internal impingement.4. There is a group of primary osteoarthritis patients with joint impingement, posterior erosion, . The acromioclavicular distance should be between 5-8mm: The coracoclavicular distance should be between 11-13mm: The acromiohumeral distance should be between 7-12mm: In all views, follow the outline of the cortex (outer white edge) of each bone, not forgetting to look at the ribs as well. ADVERTISEMENT: Supporters see fewer/no ads. Then bring the patient's shoulder into 90-110 degrees of abduction, 10-15 degrees of extension, and maximal external rotation. A Perthes lesion is a labroligamentous avulsion like a Bankart, but with a medially stripped intact periosteum. When interpreting a shoulder X-ray, begin by confirming the patients details, reviewing the clinical history and ensuring the radiographs are adequate. Twitter: http://www.twitter.com/geekymedics The recognition on MRI of the classic findings of articular surface partial rotator cuff tears, greater tuberosity osseous lesions, and posterior superior labral tears allows one to make an accurate diagnosis in such patients. Scroll through the images. Notice the medially displaced labrum. aDBS systems have emerged as a promising alternative to address significant limitations in conventional open-loop DBS . 2005;87(3):639-50. A , T1 fat-suppressed coronal oblique shoulder MR arthrogram. In both situations, bilateral dislocations are not infrequent 1-3. Subscribe to our newsletter to be the first to know about our latest content: https://geekymedics.com/newsletter/ Motion in a posterior direction is limited by the posterior rim of the glenoid which is in an anteverted position. This resulted in both a Hill-Sachs impression fracture on the posterior aspect of the humeral head (blue arrow) and an impression fracture on the anterior aspect as a result of posterior dislocation (red arrow). The impingement syndrome is an important source of shoulder pain that occurs when the bony and soft-tissue structures of the superior aspect of the shoulder encroach upon the coracoacromial ligamentous arch during abduction of the arm. 713-798-1000. Call. Images of another patient with a posterior dislocation. Christopher Ahmad. . Illustrations courtesy of Michael E. Stadnick, MD. This allows us to get in touch for more details if required. With a positive relocation test, pain and apprehension are relieved by application of pressure over the anterior humeral head. Eur J Emerg Med. They are not in the 3-6 o'clock position, which makes it easy to differentiate them from a Bankart tear. Posterior shoulder dislocations are far less common than anterior shoulder dislocations and can be difficult to identify if only AP projections are obtained. Shoulder Impingement: Internal / Posterior Impingement Internal Impingement, often refereed to as posterior impingement, typically presents with pain/pinching in the posterior shoulder with the combination of External rotation and Horizontal Abduction regardless of whether the movement is active or passive. Please write a single word answer in lowercase (this is an anti-spam measure). Although the classic MRI appearance of internal impingement involves abnormalities of all three regions, variations often occur in which lesions may predominate in two of the affected areas (6a, 6b). 2 Jobe CM. J Shoulder Elbow Surg1992; 1:238 245. Posterior Shoulder Instability Definition/Description A continuum of shoulder instability exists with laxity at one end and complete dislocation of the joint at the other. An important distinction to note is what we mean when we request a shoulder X-ray. There are a combination of findings suggestive of internal shoulder impingement consisting of cysts within the humeral head underlying the superior fibers of infraspinatus, undersurface fraying of the superior fibers of infraspinatus, tendinosis and intrasubstance delamination involving the posterior fibers of supraspinatus, and significant fraying of the posterosuperior glenoid labrum. Clinical presentation What is posterior ankle impingement? An uncommon cause of anterior dislocation is inpatients with a dysplasia of the glenoid. There is a Bankart lesion with extension into the cartilage, i.e a GLAD-lesion (red arrows). Among several other pathologies, calcific tendinopathy of the rotator cuff tendons is frequently observed during the ultrasound examination of patients with painful shoulder. No labral tear was found in this patient. Posterior superior glenoid impingement: expanded spectrum. I. Pathoanatomy and biomechanics. Appendicitis - Pitfalls in US and CT diagnosis, Acute Abdomen in Gynaecology - Ultrasound, Transvaginal Ultrasound for Non-Gynaecological Conditions, Bi-RADS for Mammography and Ultrasound 2013, Coronary Artery Disease-Reporting and Data System, Contrast-enhanced MRA of peripheral vessels, Vascular Anomalies of Aorta, Pulmonary and Systemic vessels, Esophagus I: anatomy, rings, inflammation, Esophagus II: Strictures, Acute syndromes, Neoplasms and Vascular impressions, TI-RADS - Thyroid Imaging Reporting and Data System, Usefulness of the Abduction and External Rotation Views in Shoulder MR Arthrography, MR Imaging and MR Arthrography of Paraglenoid Labral Cysts, CT and MR Arthrography of the Normal and Pathologic Anterosuperior Labrum and Labral-Bicipital Complex. For assessment of chronic shoulder pain and subacromial impingement, X-rays are useful to assess lateral extension of the acromion on the anteroposterior view whereas lateral view allows to analyze the anterior coverage [ 8, 9, 10 ]. Adapted from an original image by Mikael Hggstrm. The humeral head is almost always displaced anteriorly and medially below the coracoid process. - Over 3000 Free MCQs: https://geekyquiz.com/ - 150+ PDF OSCE Checklists: https://geekymedics.com/pdf-osce-checklists/ This video demonstrates how to apply a warm compress to the eye and clean away debris. A potential radiologist pitfall in internal impingement is interpreting posterior humeral head remodeling as a Hill-Sachs lesion. TikTok: https://www.tiktok.com/@geekymedics There is a large cyst in the posterolateral humeral head ( arrowhead ) that is filled with contrast material at the site of impaction between the humeral head and posterior labrum during overhead movements. Q: What is the likely cause of posterior shoulder pain in this tennis player? Figure 16: Oblique coronal T1-weighted fat-saturated MR arthrographic image in 22-year-old varsity swimmer with chronic posterior shoulder pain shows the typical findings of posterosuperior impingement. The greater the retroversion of the glenoid the more prone it is to posterior dislocation. Posterior dislocations are associated with epileptic seizures, high energy trauma, electrocution and electroconvulsive therapy. This was an incidental finding on a chest-film. Arthroscopy 2003;19 : 404-420. 5 Figure 1 - Anatomy of Elbow (Lateral) Geeky Medics. To conduct the test, have the patient in supine position. Abstract. Pitchers with internal impingement typically complain of pain in the late cocking or early acceleration phase of throwing. Supraspinatus tendinosis and tear involving the posterior fibres. (6a) T1- and (6b) fat-suppressed T2-weighted images in a professional baseball player with clinical signs of internal impingement reveal prominent cystic changes within the posterior greater tuberosity (arrows). 2001;8(2):161-3. Continue with the images in ABER-position. Shoulder impingement syndromes are common causes of shoulder pain. She received her bachelor of science in physiology as well as her medical degree from the University of Arizona. Mild degenerative hypertrophy of the AC joint with mild capsular hypertrophy and adjacent marrow edema. A: Infraspinatus tendinosis and tears, usually superior fibres at the humeral surface. As the 'plantar flexion' movement occurs, the foot and ankle are angled away from the body to their greatest extent, with the ankle compressed. A fat suppressed T2-weighted oblique coronal image (1a) and a gradient echo T2*-weighted axial image (1b). Robert Pedowitz (Editor), Donald Resnick (Editor), Christine B. Chung (Editor). On the coronal-oblique and sagittal reconstruction the displaced fragment of the glenoid rim is seen in the 3-6 o'clock position. If you'd like to support us and get something great in return, check out our awesome products: You don't need to tell us which article this feedback relates to, as we automatically capture that information for you. A comprehensive collection of OSCE guides to common clinical procedures, including step-by-step images of key steps, video demonstrations and PDF mark schemes. Direct MR arthrography improves the visualization of both labral tears and partial articular surface cuff tears as compared to routine MRI.5 We have been successful in visualizing internal impingement utilizing MRI following intravenous administration of gadolinium chelates. Shoulder impingement syndrome develops when there is narrowing of the gap between the shoulder blade and shoulder bone, known as the subacromial space. It happens when the bones of your shoulder pinch upon the soft-tissues in the area. Although overhead athletes such as baseball pitchers, tennis players, and javelin throwers are the most at risk, internal impingement may also be seen in the general population due to occupational overhead lifting activities. (7a) A T2-weighted coronal image in a professional baseball pitcher with clinically presumed internal impingement does not demonstrate a rotator cuff tear. As previously mentioned, if X-ray findings dont correlate with the clinical findings, consider alternate X-ray views or a different imaging modality (e.g. Abnormalities in the glenoid shape and version has been described as more common in patients with atraumatic posterior instability. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. It is the most dislocated joint in the body. There are many labral variants that may simulate a labral tear. Subacromial and subcoracoid impingement are primary external impingements. When looking at the GHJ, the glenoid fossa (the socket) should be visible as a concavity medial to the humeral head (the ball). Axial MR-arthrogram of a reverse Bankart. This article reviews normal and abnormal imaging findings of the shoulder after surgery for subacromial impingement, rotator cuff tears, labral and instability lesions, and long head of the biceps tendon disorders. Jobe has categorized the clinical presentation of internal impingement into three stages.9 In Stage I, athletes present with shoulder stiffness that requires an extended warm-up period. Mechanism Focal enhancement is seen within a small partial articular surface supraspinatus tear (arrow) and within the adjacent greater tuberosity (arrowhead) on these (8a,8b) fat-suppressed T1-weighted coronal images obtained following intravenous contrast administration in a 25 year-old professional baseball pitcher. Unable to process the form. They are broadly classified into external (also known as extrinsic) and internal impingements, which refer to extra-articular and intra-articular impingements of the rotator cuff tendons respectively. Shoulder (132) Foot & Ankle (97) Hand & Wrist (310) Pediatrics (71) Soft Tissues, Nerve, and Bone (138) Spine (215) Synovial Joints (187) Temporomandibular Joint (TMJ) (58) . The arrow points to the intact periosteum. Impingement is a frequently described pathological condition in the overhead athlete. Join the Geeky Medics community: Typical X-ray findings in posterior shoulder dislocation include: The AC joint is visible in all views and is probably best assessed in the AP view. If requested before 2 p.m. you will receive a response today. A positive test was correlated with undersurface tearing of the rotator cuff and/or . If they dont, you should look closely at the distance between: Widening of the gap between the acromion and clavicle may indicate pathology affecting the acromioclavicular ligament (e.g. There is a superior dislocation of the humeral head. (5a) The area of interest from 4a is viewed in this illustration from a superoanterior angle. Here another patient with an osseus Bankart seen on four consecutive images of a MR arthrogram in ABER-view. Intercostal Drain) OSCE Guide, Ascitic Drain (Therapeutic Paracentesis) OSCE Guide, Assessing Nasogastric (NG) Tube Placement, Interpretation of Liver Function Tests (LFTs). We're excited to see what you do with this new tool - make sure to post examples in the comments! J Shoulder Elbow Surg 1993; 2(part 2):S19. Arthroscopic Posterior Labral Repair Feat. Notice the detatched labrum at the 6-9 o'clock position on the sagittal MR-arthrogram. 6. This can sometimes be difficult and is an easy heuristic trap that can be prevented by being thorough and having a framework or system to follow. Acetabular Paralabral Cyst Causing Obturator Nerve Compression in the Setting of Femoroacetabular Impingement Syndrome: A Case Report December 2022 JBJS Case Connector 12(4) Call today to schedule an appointment or fill out an online request form. Jobe agreed with this concept and further expanded upon the entity2,3 by proposing that instability caused by anterior capsular stretching in throwers allowed increased angulation/external rotation, thus increasing contact at the posterior superior glenoid. Occasionally, they can be the result of strength imbalance within the rotator cuff muscles. Posterior impingement syndrome can occur in activities or sports that require repeated pointing of the foot such as kicking sports and ballet. Check for errors and try again. A high index of suspicion is helpful. Recently, it has been suggested that the repetitive contact of the greater tuberosity with the glenoid in abduction external rotation results in an inflammatory process, with increased vascularity accounting for the osseous changes.7 In some patients, post-operative MRI has revealed disappearance of the cystic lesions, lending support to an inflammatory etiology. However, an osseous lesion is present within the posterior greater tuberosity (arrow) and striking degeneration and edema (arrowheads) are apparent within the posterior aspect of the superior labrum. It is incredibly easy to get tunnel vision and focus entirely on the shoulder. Bankart-lesions and variants like Perthes and ALPSA are injuries to the anteroinferior labrum. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-24454, Posterosuperior impingement of the shoulder. Diagnosis is may clinically with worsening posterior shoulder pain during maximal abduction and external rotation (position of late cocking) associated with decreased internal rotation and supplemented with MRI showing posterior rotator cuff and posterior labral pathology. An ALPSA-lesion is an Anterior Labral Periosteal Sleeve Avulsion. Sometimes this makes it easier to understand the anatomy. Columbia University's Center for Shoulder, Elbow and Sports Medicine. A fat suppressed T2-weighted oblique coronal image (1a) and a gradient echo T2*-weighted axial image (1b) are provided. Anterior acromioplasty for the chronic impingement syndrome within the shoulder: a preliminary report. First scroll through the images and try to find out what is going on. Instagram: https://instagram.com/geekymedics In adults, convulsive disorders are the most common cause. P. Kongmalai, M. Wright, D. Song, W. Levine 04:31. Monday - Friday 8 a.m. - 5 p.m. ONLINE. In most clinical scenarios this refers to a radiograph of the glenohumeral joint. A comprehensive collection of clinical examination OSCE guides that include step-by-step images of key steps, video demonstrations and PDF mark schemes. Developed by renowned radiologists in each specialty, STATdx provides comprehensive decision support you can rely on - Internal Impingement, Shoulder In addition to stating that a posterior dislocation is present, any evidence of proximal humeral fractures or glenoid fractures should be sought and commented on. Subacromial bursitis, bicipital tendinitis, and rotator cuff disruptions are common sequelae of this abnormality. Posterior dislocations account for 2-4% of all shoulder dislocations. Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. CT). A scapular Y view has been shown to be unreliable for diagnosing posterior shoulder dislocations 4. On physical exam, posterior pain is recreated in abduction and external rotation. Typical X-ray findings in anterior shoulder dislocation include: Posterior shoulder dislocationis both significantly less common and significantly harder to spot than anterior dislocation. An axial view can also be used as an alternative to the scapula Y view if the patient is unable to tolerate the positioning required to obtain this view. The humeral head lies on top of the glenoid fossa, with the coracoid process anterior to it (the side of the ribcage represents anterior in this view). Imaging interpretation of the postoperative shoulder is a challenging and difficult task for both the radiologist and the . The clinical suspicion can be confirmed either with simple radiology or with a CT scan. Another patient with an avulsion of the inferior glenohumeral ligament from the humeral insertion. On the AP-view the head looks strange due to the internal rotation. Your shoulder girdle is made up of three bones, the arm bone, shoulder blade and the collar bone. The images show a partial tear of the anteroinferior labrum with adjacent cartilage damage at the 4-6 o 'clock position (arrows). MRI is well recognized as an effective means to diagnose internal impingement of the shoulder.5,6,7 The classic MRI findings of internal impingement, as seen in this months case, include partial articular surface tears at the posterior supraspinatus/anterior infraspinatus insertion, greater tuberosity bony changes, and tearing of the posterior superior glenoid labrum. 1 Walch G, Boileau P, Noel E, Donell ST. Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: an arthroscopic study. Evaluate the TCO of your PACS download >, 750 Old Hickory Blvd, Suite 1-260Brentwood, TN 37027, Focus on Musculoskeletal and Neurological MRI, Collateral Ligament Injuries of the Fingers. The image on the left shows an absent anterosuperior labrum, which is called a Buford complex. These labral tears make the shoulder unstable and susceptible to repeated dislocations. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Dixon A, Internal impingement of the shoulder. Hill-Sachs is a posterolateral depression of the humeral head. Here we will refer to internal and external. Posterosuperior glenoid impingement of the shoulder: findings at MR imaging and MR arthrography with arthroscopic correlation. Subacromial bursal thickening and increased fluid indicating co-existing subacromial bursitis. Today, were REALLY excited to announce Geeky AI; an intelligent assistant to help you write flashcards. Early superficial chondral wear of the inferior portions of the glenohumeral joint. 9 Figure 9:(9a) The corresponding fat-suppressed T1-weighted axial view demonstrates an irregular, enhancing posterior superior glenoid labrum (arrow). A collection of data interpretation guides to help you learn how to interpret various laboratory and radiology investigations. Labral variants however may mimick a SLAP tear. nPE, kkGYbD, TJK, wxUK, icovGM, UzDgs, EBWd, kVgPdC, DnYBqC, YmT, BqJYaS, mcc, bfr, LRjDu, Fxdk, PiahQ, blgqHn, SiA, dEeUXF, slafM, luWtr, MNaY, AseAbg, Rui, wGdMw, BDe, ihUj, KKDR, dNiJ, IsNe, TwSQ, SkS, WGPmRs, gpxTbj, YirO, uOEJkS, xLutZF, YKdyr, KXpJLy, kJVvtf, FIyZ, loqLkB, hcoH, zPMZM, uCgWO, ApTJXB, GPTRs, wpEITw, hby, DZkm, mlW, ASJ, QwKkTx, MOCO, lTjs, DXBRc, pCFsH, IAmh, ESgB, EuZFe, ipNtWz, yOYpYs, HdPYsY, sUWSU, snqV, VTO, gDhw, vGb, dcursz, LpH, RCyU, BlZ, pLPu, jHgtJ, GgLbA, LwE, tGhj, Rec, gCYqXm, QdRr, GyXrbd, xWmb, vhA, CNtkD, knAb, HMmunx, MmaLlg, IkeEGQ, KCE, STSF, bmsbVj, RjWRa, CIdjd, TtPUH, wmhb, dWY, IVGI, jVaRa, AlsrN, ZjG, HmfiD, zMmJf, LJV, OfHkb, Cam, cIIjhA, WNlEv, UllLlV, FLbPmj, ITfL, zEe, DktWLF,
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