Key words: talus, fracture, talar neck, talar head, talar body, lateral process, posterior process, talar extrusion, orthopaedic surgery, review. So sometimes a posterior process is an actual fracture, and sometimes its a natural occurrence where the bone just hasnt fully ossified, and technically you have this other thing called an Os trigonum it doesnt really matter the specifics of the terms or what that means, it just means you have a natural separation of the two pieces where it never, ever completely fused together. Verywell Health articles are reviewed by board-certified physicians and healthcare professionals. Foot Ankle 13, 453457 (1992). Scand. J. Orthop. From January 2014 to December 2018, 12 cases with displaced fracture of talar posterior process were treated in our department. Surgery is the definitive treatment, indicated especially for open or displaced fractures. 28430 - Closed treatment of talus fracture. Findings suggest that the minimally invasive fixation of posterior talar process fracture is potentially a safer and more convenient method rather than the ORIF with posteromedial approach. J. Vasc. https://doi.org/10.3109/08941939.2012.740146 (2013). Avulsion fractures of the medial tubercle of the posterior process of the talus. Provided by the Springer Nature SharedIt content-sharing initiative, Journal of Orthopaedic Surgery and Research (2022). Medicine 97, e13331. The posterior talar process fracture is an uncommon fracture and is frequently undiagnosed by orthopaedic surgeons. Foot Ankle Int. This site needs JavaScript to work properly. The talar avulsion fracture in this patient is also small with only slight displacement and is seen hovering just above the mid to anterior talus. Mao, H., Wang, H., Zhao, J. et al. This allows your surgeon to reposition the fragments and secure them with plates and screws. Crutches are advised initially. Learn how we can help. Well that thing curves right down around the back of the ankle, and if you get a fracture or a crack in that part of the talus, when you roll your ankle really, really badly, well that can cause chronic pain, because what happens is that you get a little crack there, and every time you take a step, youve got the FHL tendon (flexor hallucis longus) going right around here and it wraps around as it goes down around the bottom of your foot, and every time you take a step and you pull down with the big toe, it actually pulls on the posterior process fracture and it moves it and that causes pain. Res. To obtain TREATMENT 22. This study provided insight into our previous experience using percutaneous screw fixation and ORIF techniques for the treatment of posterior talar process fracture with clinical outcome assessment. Screw placement can be done within the safe zone, avoiding lesion of neurovascular structures, with careful preoperative planning. The neck has approximately 15 to 20 of medial deviation and is the area most vulnerable to fractures. In some other animals, it is the . https://doi.org/10.1111/j.1445-2197.1987.tb01441.x (1987). An avulsion fracture occurs when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone. - frx may also occur when ankle is forced into extreme equinus; Treatment is based on the alignment of the bones and the stability of the ankle joint. Internal fixation was designed to perform as internal fixation compression with a cannulated screw. Towson, MD 21204 A groove containing the flexor hallucis longus tendon along the posterior talus separates the medial and lateral tubercles of the posterior talus. Get the most important science stories of the day, free in your inbox. The AOFAS scores using the ORIF technique were improved from 64.5 to 83.5 at 4months postoperatively, and to 82.8 at 12months postoperatively. No patients complained of stiffness in the ankle and subtalar joint. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. Talus mobilization for ankle mobility. Haijiao Mao. Fractures of talar posterior process have three types, namely an isolated fracture of either medial or lateral tubercle and a simultaneous fracture of medial and lateral tubercles (i.e. https://doi.org/10.1097/BOT.0b013e31804ea0d9 (2007). All CT scans were performed using a 256-slice Siemens CT scan (GE, United States) with 1.0mm slices at 0.1s intervals for the foot and ankle imaging. Further-more, the fractures of the medial . If a fracture wassuspected with plain radiographs, then an urgent CT scan wasrecommended in order to identify the fracture and assess the size and fracture fragment. - lateral tubercle has an articular surface, & frx thru this tubercle is often associatted w/ arthrosis; - Frx of Medial Tubercle: It forms a joint with the talus bone, the subtalar joint. TIBIAL STRESS FRACTURE Reza Maulana Abstrak. There are few studies about this injury in the literature and most of them are case reports6,18,25. government site. Nonsurgical treatment includes restricted weight-bearing, patellar tendon-bearing braces, and extracorporeal shockwave therapy. Tucker, D. J., Feder, J. M. & Boylan, J. P. Fractures of the lateral process of the talus: two case reports and a comprehensive literature review. These medical reviewers confirm the content is thorough and accurate, reflecting the latest evidence-based research. - posterolateral ankle tenderness may be elicited; . Can. The unfused ossification center of the lateral tubercle forms the os trigonum. J. 2013 Nov;201(5):1087-92. doi: 10.2214/AJR.12.9918. TREATMENT Goals of treatment: 1. https://doi.org/10.1038/s41598-020-77151-6, DOI: https://doi.org/10.1038/s41598-020-77151-6. Use the Previous and Next buttons to navigate three slides at a time, or the slide dot buttons at the end to jump three slides at a time. Choice of optimal treatment methods depends on fragment size, degree of displacement, subtalar joint involvement and articular surface intervention. posterior process consist of medial and lateral tubercles separated by groove for FHL Navicular bone Sustenaculum tali Blood supply talar neck supplied by three sources posterior tibial artery via artery of tarsal canal (dominant supply) supplies majority of talar body deltoid branch of posterior tibial artery supplies medial portion of talar body It is considered a serious injury which is often accompanied by ligament damage and dislocation of the ankle. Fig. But in either case, if your pain is on the back of your ankle and it hurts when you do stuff with your big toe, for example, if youre doing calf raises, if you stand up on the balls of your feet and your heels are way up off the ground, then youre having to pull hard with your big toe to maintain your balance in that position. Another limitation is the validity and reliability of the AOFAS and VAS score system, which is not universally examined and accepted. Treatment of posterior ankle pain by excision of a bipartite talar fragment, Fractures of the Distal Tibial Metaphysis, Orthopaedic Specialists of North Carolina. Treatment of an avulsion fracture typically includes resting and icing the affected area, followed by controlled exercises that help restore range of motion, improve muscle strength and promote bone healing. Trauma 32, 601606. The postoperative VAS and AOFAS scores were comparable, with no significant differences between the two techniques. Based on their description, lateral and posterior process fractures are classified into four types. Google Scholar. MeSH Intraoperative fluoroscopy photo of percutaneous screw implanted with the minimally invasive technique. Am. Foot Ankle Surg. Foot Ankle Int. The tibialis posterior muscle originates from the back of the tibia and fibula (lower leg bones), it then . This is why postoperative care will often require the ankle to be non-weight-bearing for six weeks. The https:// ensures that you are connecting to the As the bone remains aligned after the blow, it is usually easier to treat a non-displaced fracture as compared to a displaced fracture. The postoperative course of the patients was evaluated based on Visual Analog Scale (VAS). It should be noted, that the AOFAS score is currently not validated for most authors in the literature. Immediate treatment of a talus fracture includes immobilizing the foot and elevating it above the heart. Treatment usually includes a period of immobilization followed by gradual return to activity. https://doi.org/10.1177/1071100719868712 (2019). Cedell, C. A. Rupture of the posterior talotibial ligament with the avulsion of a bone fragment from the talus. Buddy Taping/6 weeks: Non displaced fracture is treated with Buddy Taping and rigit sole shoes to limit joint movements.Buddy taping is taping the fractured toe to the next. Average follow-up was 26 months (range: 18-43). Excision of ununited fractures of the posterior process of the talus: a treatment for chronic posterior ankle pain. The posterior talar process fractures present in the study were classified as lateral tubercle fracture, medial tubercle fracture and entire posterior process fracture. So sometimes a posterior process is an actual fracture, and sometimes it's a natural occurrence where the bone just hasn't fully ossified, and technically you have this other thing called an Os trigonum it doesn't really matter the specifics of the terms or what that means, it just means you have a natural separation of the two pieces . This research was approved by the Ethics Committee of the affiliated hospital of the medical school of Ningbo University. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. https://doi.org/10.1097/MD.0000000000013331 (2018). Disord. Open Orthop J. Among a total of 12 patients have undergone pre and post-operative 3D-CT. Entire posterior process fractures are easier to identify than isolated medial or lateral tubercle fractures on plain radiographs. Clinical and radiological outcomes of patients were assessed at 4 and 12months postoperatively. Kopp L, Obruba P, Riegl J, Meluzinov P, Edelmann K. Acta Chir Orthop Traumatol Cech. Your healthcare provider may recommend: Casting. Initial assessment of treatment of talar posterior process fractures with open reduction and percutaneous fixation, https://doi.org/10.1038/s41598-020-77151-6. Tibialis posterior tendonitis is a condition characterized by tissue damage and sometimes swelling of the tibialis posterior tendon, usually following overuse, resulting in pain located at the inner aspect of the lower leg and ankle. Appropriate, expedient treatment provides the patient the best chance of obtaining a good functional outcome. Six patients sustained open fractures and two had associated talar neck fractures. 128, 593598. 6). And I give lectures at medical conferences about subtle fracture patterns, Ive been doing that for about 10 years or so, lecturing at medical conferences on this topic, because I did some research on another rare fracture called a Lateral Process Fracture, and in that study we actually looked at all of these patients that came into the hospitals and clinics over a three-year period, and what we found is that if a posterior process fracture was noticed on the x-ray, there was actually a statistical probability that you would also have a Lateral Process Fracture. Talus fracture treatment. Because the ankle is vulnerable to twists and compression, the fracture of these bones is not uncommon and can sometimes be difficult to treat. Percutaneous screw fixation treatment with computer-assisted three-dimensional evaluation shortened the operation time and reduced incidences of surgical complications. 38.3, A and B shows preoperative and postoperative radiographs of a talar neck fracture, respectively. 110 West Rd., Suite 227 Thank you for visiting nature.com. In addition, the short follow-up time might have not been adequate for complications such as ankle and subtalar joint osteoarthritis to develop. The AOFAS and VAS scores were used to analyze the treatment outcomes. Most avulsion fractures heal very well without surgical intervention. Anterior process fractures result . Tape it and forget it. More often, breaks will occur when the medial and lateral malleolus are also involved. A. No complications such as screw loosening, nonunion, or malunion were reported and no patients complained about stiffness of the ankle and subtalar joint. If your fracture is stable and your joints are well-aligned, surgery may not be necessary. Normally a towel or rope works well. CT scan provides more accuracy for assessment of size, displacement, and comminution fragment of posterior talar process fracture or lateral process of the talus than plain radiographs24. Relat. Ebraheim, N. A., Skie, M. C. & Podeszwa, D. A. Medial subtalar dislocation associated with fracture of the posterior process of the talus. Complication rates were high, ranging between 6% SSI up to 64% osteoarthritis, following operative treatment of talar fractures. J. Previously, we described a case and defined a safe zone for percutaneous screw fixation8,15. PubMed The skin and subcutaneous tissue were carefully dissected when close to the posterior tibial neurovascular bundle (Fig. 1). Closed reduction of the subtalar dislocation was performed initially in this study. Talus fractures. Department of Orthopaedic Surgery, The Affiliated Hospital of Medical School, Ningbo University, No. Cedell fracture: Posterior talar process fracture with injury to the posteromedial tubercle caused by forced dorsiflexion and pronation. 27824 - Closed treatment of fracture of weight bearing articular portion of distal tibia (pilon or tibial plafond), with or without anesthesia. Orthopaedic Specialists of North Carolina. There was no evident difference between the two, according to clinical assessment. Twelve Asian patients with talar posterior process fracture were treated with two techniques and followed up in this study. Biz C, Golin N, De Cicco M, Maschio N, Fantoni I, Frizziero A, Belluzzi E, Ruggieri P. BMC Musculoskelet Disord. The statistical significance of the difference between the groups was determined at the 0.05 significance level15. Elderly patients with limited ambulatory capacity, similarly, may be best treated nonoperatively if the joint is not significantly displaced Excellent and good results were achieved in eight (66.7%) patients, fair results were achieved in three (25%), and poor results were observed (8.3%) for the last follow-up. Romeo, N. M., Hirschfeld, A. G., Githens, M., Benirschke, S. K. & Firoozabadi, R. Significance of lateral process fractures associated with talar neck and body fractures. https://doi.org/10.1177/107110079801900414 (1998). Treating complicated ankle fractures. - surgical excision of the ununited fragment thru a posterolateral ankle arthrotomy may relieve the pain. . Total recovery time is between four to six months, although it may take longer for more severe injuries. To the authors knowledge, no study in the literature described in detail the initial assessment of ORIF and percutaneous screw fixation treatments. 57, 643646. Any fractures that exhibited displacement larger than 2mm involving joint surface were treated with percutaneous screw fixation or ORIF. doi:10.1097/BOT.0000000000000763, Smeeing DPJ, Houwert RM, Kruyt MC, Hietbrink F. The isolated posterior malleolar fracture and syndesmotic instability: a case report and review of the literature. CAS Treatment options for talar osteonecrosis can be grouped into four categories: nonsurgical, surgical joint-sparing, surgical salvage, and joint-sacrificing treatment. entire posterior process fractures). 9 Hospital, Ningbo, Zhejiang, China, You can also search for this author in They can shatter into multiple fragments and are often difficult to diagnose. The body includes the dome of the talus, which articulates with the ankle joint above. Symptoms get worse with exercise, particularly running, and ease with rest. Serbest S, Tiftiki U, Tosun HB, Kesgin E, Karata M. Isolated posterior malleolus fracture: a rare injury mechanism. Terminology Thank you, {{form.email}}, for signing up. Fan Z, Ma J, Chen J, Yang B, Wang Y, Bai H, Sun L, Wang Y, Lu B, Dong BC, Tian A, Ma X. J Orthop Surg Res. https://doi.org/10.1097/BPB.0b013e328351419c (2012). - minimally displaced fractures are treated w/ short leg cast for 4 to 6 weeks; Immediate first aid treatment for a talus fracture, as with any painful ankle injury, is to apply a well-padded splint around the back of the foot and leg to immobilize and protect the limb. Nondisplaced fractures can be managed with a trial of nonoperative immobilization. Fracture of the entire posterior process of the talus: a case report. You'll need some form of immobilization like a splint or cast and might need surgery to . Melenevsky Y, Mackey RA, Abrahams RB, Thomson NB 3rd. Journal of Orthopaedic Trauma. Another way to do this is to go through dorsiflexion with a posterior glide on the talus. Foot Ankle Surg. & Zhang, L. Medial subtalar dislocation associated with fracture of the posterior process of the talus. Skin sutures were removed 14days postoperatively and the operated limb was immobilized with a short non-weight bearing leg cast for another 6weeks. (A) Medial ankle; (B) achilles tendon; (C) entry point of percutaneous screw. The yellow arrow is a cannulated screw. Initial assessment of short-term results in patients who underwent internal fixation using ORIF and percutaneous screw techniques for posterior talar process fracture was performed in this study. Please enable it to take advantage of the complete set of features! 2015 May-Jun;35(3):765-79. doi: 10.1148/rg.2015140156. Generally speaking, the best way to reposition the bone is through an incision in the back of the ankle. https://doi.org/10.1097/00005131-199602000-00014 (1996). Percutaneous screw fixation has also demonstrated success in certain patterns. Talus fractures have a wide variety of presentation from low-energy avulsion fractures of the lateral or posterior processes, to high-energy comminuted talar body fractures. Google Scholar. Assoc. Fracture of the posterior process of the talus is an uncommon injury that is often missed on plain X-Ray and misdiagnosed as ankle sprain. J. To evaluate the surgical outcomes of talar, posterior process displaced fractures with posteromedial approach. Talar fractures are divided by anatomic region: head, neck, and body. Addressing posterior malleolar ankle fractures. 2015;20:123. doi:10.11604/pamj.2015.20.123.6046, Duan X, Kadakia AR. This typically involves the separation of the posterior tibial insertion of the PCL to variable degrees. Safe Zone of Posterior Screw Insertion for Talar Neck Fractures on 3-Dimensional Reconstruction Model. Differential diagnosis sharing sensitive information, make sure youre on a federal & McGanity, P. L. Excision of ununited fractures of the posterior process of the talus: a treatment for chronic posterior ankle pain. The technique involved placing one or two cannulated screws to stabilize the fracture with percutaneous screw fixation. #432 3 reasons runners get black toenails, #434 Top 3 tips to avoid bruising your toenails during long runs . & Grenier, J. M. Fracture of the lateral tubercle of the posterior talar process caused by a rock-climbing fall: a case report. The talus, meanwhile, is the bone situated between the tibia, fibula, and heel which forms the primary connection between the lower leg and foot and is vital for mobility and balance. The fragment was then fixed with a self-tapping and drilling 3.0mm cannulated screw (Synthes Inc, Shanghai) directed from the posterior to the anterior through the fracture fragment into the body of the talus (Fig. Minimal displacement of fracture fragment with percutaneous screw fixation was recommended. The site is secure. If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate. Carousel with three slides shown at a time. Look-Ups. https://doi.org/10.1016/j.injury.2014.12.002 (2015). Complications include avascular necrosis , posttraumatic arthritis , and union issues (e.g., malunion, 6, 21, 23, 24. entire posterior process fractures). 5). Clinical outcome and concomitant injuries in operatively treated fractures of the lateral process of the talus. Defination: a pott's fracture is a type of ankle fracture that is characterized by a break in one or more bony prominences on the sides of the ankle known as the malleoli . This comes from a discussion I recently had with a runner during a telemedicine visit, and she called me for a second opinion. - look for tenderness and perhaps a mass just posterior to medial malleolus and pain w/ motion ofgreat toe (due to motion ofFHL); 56, 187190. The cause of injury for eight of the cases was vehicle accident and for four of the cases sport injury. Tags: talar dome fracture , ankle pain , bone problems , stress fracture Recommended Products Walking Cast - High Top Pneumatic As low as $67.96 Ankle Support - Elastic As low as $8.46 Ankle Wrap - Figure-8 As low as $8.46 Swede-O Ankle Lok Brace As low as $25.46 MalleoLoc Ankle Brace If they do that and they have pain in the back of the ankle, that can signify that you actually have inflammation of that tendon, or you have inflammation and irritation of the posterior process of the talus, so thats something to think about and check. Type 4 talus fractures include not only the dislocation of the body of the talus (the posterior portion) from the calcaneus but also the separation of the head of the talus from the other tarsal bones anterior to it. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. The average follow-up period was 13months (816months). The remaining cases were cast before preoperative examination. https://doi.org/10.1016/j.jvir.2012.09.006 (2012). A., Okereke, E. & Williams, G. R. Jr. Open medial subtalar dislocation associated with fracture of the posterior process of the talus. The percutaneous screw fixation and ORIF techniques were performed for posterior talar process fracture in accordance with fracture displacements. The majority of posterior process fractures cases are associated with concomitant subtalar dislocation. PubMed Central Disclaimer, National Library of Medicine Repeat surgical intervention after an index treatment of a talus fracture can stem from treatment of infection, reconstruction of a malunion, revision fixation of a nonunion, or fusion/joint reconstruction of post . The methodological improvement in this study was a good option depending upon the size and displacement of the fracture fragment. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Foot Ankle Surg. Whats the significance of that? Future studies should include more clinical cases or cadaveric studies can be used to validate these techniques. Naranja, R. J. Jr., Monaghan, B. Well, theres a groove right there, and the thing that sits in this groove at the back of the posterior process, it runs right through that groove, well thats the flexor hallucis longus tendon goes through there. Radiol. Chen, Y. J., Hsu, R. W., Shih, H. N. & Huang, T. J. Fracture of the entire posterior process of talus associated with subtalar dislocation: a case report. Approach is based on the fracture pattern and the need for both open reduction and fixation versus closed reduction and fixation. Tibia sebanyak 59.5% dibanding pada remaja mempunyai ujung atas yang melebar dan (16-19 tahun) sebanyak 31.8%, dan anak- ujung bawah yang lebih kecil, serta sebuah anak (1-16 tahun) 8.7%.6 Tempat paling corpus.10 sering terjadinya . Read More. However, it is apparent that . 14 As expected, there seems to be a trend of increased complication rates with a longer follow-up . also known as broken ankle , ankle fracture and malleoli fracture . Pan Afr Med J. By far the rarest foot and ankle fractures are those of the posterior process of the talus2. Surgery will often be required to ensure the fragments are correctly placed. 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. She got back to running, but shes had intermittent pain in the back of her ankle, not at the same place where she got the sprain, but shes had this pain thats been going on for a long time, and then she got an x-ray and someone told her she might have a posterior process fracture of the talus, but they didnt really explain exactly what that was, and so she was told to take some time off of running for a little while and see if it improves. Subsequently, the best surgical approach is still in controversy. Instead, surgery should be performed if the posterior malleolus fracture causes any instability of the ankle joint, irrespective of the size or location of the fracture.. In the meantime, to ensure continued support, we are displaying the site without styles Fractures of the anterior process account for approximately 15 percent of all calcaneal fractures and are commonly misdiagnosed as ankle sprains. The first phase of rehab will be focused on restoring mobility to the ankle joint, followed by weight-bearing exercises once the fracture has started to heal. Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. B 21, 439442. Implementation of the minimally invasive technique allows easy access for fracture fixation, minimization of intraoperative risk of traction lesion of neurovascular structures, and shortening of operation time and rehabilitation period. Majeed, H. & McBride, D. J. Talar process fractures: an overview and update of the literature. pott's fracture. official website and that any information you provide is encrypted This could be a subtle difference to a type 3 talus fracture and was not originally part of the classification system. Mickel TJ, Andersen R, Keeling J, McKenna P. Foot Ankle Int. The injuries can be divided anatomically into osteochondral, lateral process, posterior process, and true body (dome) fractures. This type of fracture may result in severe complications due to missed diagnosis, delayed or inappropriate treatment. Yaw Boachie-Adjei, MD, is a board-certified, double-fellowship Orthopedic Surgeon. The wound was closed and stabilized using a dry and sterile bandage, then a below-knee splint was applied, and patients were permitted non-weight bearing mobility with the use of crutches. PubMedGoogle Scholar. the posterior and the lateral. Previous reports have described that ORIF treatment leads to a different outcome9,16. The fracture was then reduced temporarily and stabilized with two guide pins and the reduction was confirmed with fluoroscopy. ( 20 tahun) paling tinggi dengan talus dan ujung distal fibula. and transmitted securely. Mao, H., Wang, H., Wang, L. & Yao, L. Definition of a safe zone for screw fixation of posterior talar process fracture by 3-dimensional technology. A closed reduction and internal fixation of the posterior process of the talus using a minimally invasive approach was performed, based on the images from the preoperational simulations (Fig. ORIF was performed in four of the cases and percutaneous screw fixation for posterior talar fracture was performed in eight of the cases. And so what does that mean? To the authors knowledge, there are few descriptions of surgical techniques for fractures of posterior talar process in the literature8,13,19. Firstly, deviation may be present in the results due to the nature of the research being retrospective and most importantly due to the limited number of cases. 58, 286290 (2014). And sometimes patients are told that they have a posterior process fracture when they really dont. Int J Surg Case Rep. 2017;41:360-365. doi:10.1016/j.ijscr.2017.10.062. The most common site of talus fractures is at the talar neck followed by the lateral process. Use of a 30-Degree External Rotation View for Posteromedial Tubercle Fractures of the Talus. . Surg. Conservative treatment is recommended for stable and nondisplaced fractures and typically involves a non-weight-bearing, short leg cast for 6-8 weeks. The talus is sandwiched in between these two, and you can see its sitting there squished right in between the tibia and the heel bone. - nonunions are uncommon: The scores using the percutaneous screw technique were improved from 63.5 to 84.1 at 4months postoperatively and to 83.9 at 12months postoperatively (Table 1). There were no significant differences for AOFAS scores and VAS scores between the two groups at 4 and 12months postoperatively (p>0.05) (Tables 1,2). Verywell Health's content is for informational and educational purposes only. Talar fractures comprise 3%-5% of all foot and an- . 2,8 . They can shatter into multiple fragments and are often difficult to diagnose. doi: 10.1016/j.cpm.2012.01.005. Posterior cruciate ligament (PCL) avulsion fractures are a type of avulsion fracture of the knee that represent the most common isolated PCL lesion. And so when I look at a patient and they tell me that theres pain on the back of the ankle here and I suspect maybe thats the flexor hallucis longus tendon where it rubs around the posterior process, what I do is I basically take them and I just push up on their big toe, I put my thumb under the big toe, and then Ill tell him to push down as hard as they can. A shift>2mm indicated significant displacement with surgical treatment. Though uncommon, in some cases, people may need to undergo surgery to have the surgical hardware removed later on down the road. The talus is shaped like a truncated cone and is wider anteriorly than posteriorly,which creates greater ankle stability in dorsiflexion. Blanchette, M. A. Incidentally, it is the middle facets of the subtalar joint which are most commonly involved in talocalcaneal coalition accounting for 45% of tarsal coalitions. In our study, anatomical observation and classification of the posterior process of the talus were carried out, and related imaging and finite element methods were combined. Answer From Edward R. Laskowski, M.D. Ankle fractures (broken ankle). HHS Vulnerability Disclosure, Help 18, 219228. 20, 219. https://doi.org/10.1186/s12891-019-2603-3 (2019). A surgical technique for treatment of posteromedial talus fractures involving both the ankle and subtalar articulations is described in detail and results in 10 patients treated successfully with this technique are reviewed. 28445 Open treatment of talus fracture, includes internal fixation, when performed 28465 Open treatment of tarsal bone . The types of fractures that the patients exhibited were one lateral tubercle fracture, three medial tubercle fractures and eight entire posterior process fractures. BMC Musculoskelet. One or two screws were positioned for fixation of the medial and lateral tubercle of the posterior talar process (Fig. Telephone: 410.494.4994. Orthop. Bone Joint Surg. Well, the back of your ankle is the posterior aspect of your ankle, and the back of the talus is where the posterior process is. Invest. This is a small canal where nerves pass . 28400 - Closed treatment of calcaneal fracture. Nasser, S. & Manoli, A., 2nd. Cite this article. https://doi.org/10.1053/j.jfas.2012.02.007 (2012). Displacement greater than 2 mm requires operative treatment for most talar head, body, and process fractures ( Sanders 2010 ). Chirop. Fractures of the talar dome may be further classified into coronal . 226230 (1994). Eisenstein N, Hillier D, Ahmad S: Medial subtalar dislocation with navicular and posterior talar process fracture: the first report in the literature. Surgical treatment of lateral and posterior process fractures of the talus: Mid-term results of 15 cases after 7 years. TREATMENT 35. The appropriate 7th character for initial encounter should also be . Bookshelf All patients were treated with the same postoperative procedures, casted with below knee splints for six weeks. The main manuscript text was written by H.M. The purpose of this study was to provide an initial assessment of treatment for talar posterior process fractures using open reduction and internal fixation (ORIF) through posteromedial approach and percutaneous screw fixation. - active flexion of great toe may also produce pain as FHL moves over fracture site (between medial & lateral tubercles;) https://doi.org/10.1016/j.injury.2007.04.025 (2007). Thus, adequate access to the fracture fragments and using lag screws for fixation is achieved and for the neurovascular bundle to remain unharmed. in posterior impingement is believed to be the result of bone impaction and thus represents bone contusions or occult fractures. Acta Orthop. Fractures of the posterior process of the talus are rarely seen and frequently overlooked. Trauma 10, 142144. Clin Podiatr Med Surg. Am. Update on talar fracture patterns: a large level I trauma center study. Early diagnosis and timely determination of the displacement of the fracture are necessary for the choice between the using of percutaneous screw or ORIF technique. 2). The posterolateral approach involves a longitudinal incision between the lateral border of the fibula and the Achilles tendon26. The .gov means its official. Fractures that are often not out of place and in patients who are not active, can be managed well with conservative or non-surgical treatment. How your fracture is treated depends on which type it is and what caused it. The ankle joint is a complex junction of three bones known as the fibula, tibia, and talus. 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17 In a . 47, 11701175 (1965). The study provided valuable information for the minimally invasive technique of posterior talar process fracture and contributed to the accuracy of this highly demanding technique. Considerable improvements were observed in the AOFAS and VAS scores at 4 and 12months postoperatively in both fixation techniques during clinical assessment. 2022 Dotdash Media, Inc. All rights reserved. Data Trace is the publisher of Podiatry Today. Wheeless' Textbook of Orthopaedics. A talus fracture is a condition characterized by a break in one of the small bones of the ankle, known as the talus (figure 1). Interv. Avulsion fractures of the medial tubercle of the posterior process of the talus. A posterior talar process fracture is a significant foot injury that can lead to a long road to recovery. This project was supported by the medical and health science and technology project of Zhejiang Province (2015KYB339) and Ningbo Natural Science Foundation (2018A610266). von Winning, D. et al. K. Ramachandra Kamath, Sharan Mallya & Atmananda Hegde, Zhongzheng Wang, Yuchuan Wang, Yingze Zhang, Leon-Gordian Koepke, Annika Heuer, Lennart Viezens, Scientific Reports Posterior malleolus fractures can be challenging to an orthopedist since the fracture pattern is often irregular. In total 35 cases of posterior talus fractures have been reported. A bone fracture is the medical term for breaking a bone. Fractures of talar posterior process involve an isolated fracture of either medial or lateral tubercle and simultaneous fracture of the medial and lateral tubercles (entire posterior process fractures)4,6. The raw data were acquired in DICOM format and reconstructed into 3D models using the software MIMICS 15.01 (Materialise's interactive medical image control system, Leuven, Belgium, https://www.materialise.com/mis)15. Google Scholar. This is due to attachments of ligaments between the two bones. (A, B, C) for each encounter where the patient is receiving active treatment for the fracture. First, you'll be placed in a splint to keep your foot and ankle from moving. The study was performed by H.W. Skin incision was performed from the medial malleolus proximally to the calcaneal tuberosity distally and then the incision was continued along the middle line between the anterior edge of the Achilles tendon and the posterior border of the medial malleolus. It is necessary to avoid complications of pain, nonunion and tarsal tunnel syndrome for the treatment of these fractures3,4,5. Knowledge of the exact fracture fragment and safe zone of fracture fixation can help reduce the risk of joint penetration and neurovascular bundle damage. Posterior talar process fractures may involve the medial or lateral tubercle of the posterior process of the talus. It will be this fragment where fixation efforts will be focused. & Schepers, T. Functional outcome and quality of life after nonoperative treatment of posterior process fractures of the talus. The approach of the ORIF surgical technique was modified according to the method described in Shi et al19. The goal is to have the bones heal as closely to perfect as possible so as to prevent any residual instability or malalignment of the bone. The experiment was conducted in accordance with the Declaration of Helsinki (World Medical Association). Epub 2012 Feb 21. Article The AOFAS scores were categorized as excellent (90100 points), good (8089points), fair (7079 points), and poor (69 points)13. You are using a browser version with limited support for CSS. A lateral talus fracture (snowboarders fracture) occurs when your ankle is forced outward while a stress fracture to the Talus bone is a less common type of talus fracture, that usually occurs due to repetitive impact. Injury 46, 759762. So unfortunately, if you have an injury and we go looking for your trouble, as soon as we find something, well, a lot of times doctors see it and they think, well, thats the problem, and they make the diagnosis of that thing, but then they miss the other thing sometimes. S92.1 Fracture of talus. Copyright 2015. ORIF was performed in four of the cases and percutaneous screw fixation was performed in eight of the cases. Jonathan Cluett, MD, is a board-certified orthopedic surgeon with subspecialty training in sports medicine and arthroscopic surgery. You can break your talus in a trauma like a fall or car accident. He served as assistant team physician to Chivas USA (Major League Soccer) and the United States men's and women's national soccer teams. A CT scan is recommended in order to reveal the fracture type and assess the displacement of the fracture fragment12,29. The calcaneus forms the bony part of the heel. Bethesda, MD 20894, Web Policies Orthopaed. Talar stress fracture symptoms. Therefore, adoption of the surgical option depends on the degree of joint involvement and the degree of displacement of the posterior process fragment. Occult talar neck fracture associated with talar avulsion diagnosed by MRI: a case report. Treatment of posterior ankle pain by excision of a bipartite talar fragment, Clifford R. Wheeless, III, M.D. Aust. The talar posterior process consists of the lateral and medial tubercles, which serve as attachments for the posterior talofibular and talotibial ligaments, respectively. anteroposterior, mortise and lateral views). Operative treatment of posterior malleolar fractures. Informed consent was obtained from the patients who participated in this study. The fracture fragments were reduced and fixed temporally with Kirschner wires. The minimally invasive surgical technique of fracture fixation was modified according to the method described in Mao et al.8,15. Mehrpour, S. R., Aghamirsalim, M. R., Sheshvan, M. K. & Sorbi, R. Entire posterior process talus fracture: a report of two cases. The posterior facet is the larger of the two making up the posterior subtalar joint while the middle facet articulates with the sustentaculum tali (medial process from the calcaneus). . The limitations in this study are several. The clinical data was offered by K.W.. talar body fractures were studied retrospectively to assess outcome after operative treatment. Traditionally, surgeons have long recommended surgery if more than 25% of the malleoli is involved. Injury 38, 13131317. Now she rolled her ankle and went to the emergency room, they gave her a brace, they gave her an ACE wrap to compress it, she was told to do some exercises, and frankly she improved a lot. J. Surg. The authors declare no competing interests. (A) Lateral tubercle of posterior talar process; (B) medial tubercle of posterior talar process; (C) groove of the flexor hallucis longus tendon. Fractures of both tubercles will usually be treated conservatively if there is minimal displacement. If the symptoms persist; an additional period of immobilization (4 to 6 weeks) might be required. The 3D model with medial and lateral virtual screw path of the posterior talar process. There are only a few reports about cases of entire posterior process fractures, according to previous literatures6,18. Subtalar dislocation accounts for 12% of all dislocations which makes treatment methods of talar posterior process fracture extremely rare10. AP: avulsion fracture, joint >2mm wide. Article - Frx of Lateral Tubercle of Posterior Process (Sheppard's Frx): Diagnosing and Treating Posterior Malleolus Fractures. From January 2008 to December 2010, 18 patients with displaced fracture of talar poste. PubMed Talus fractures have a wide variety of presentation from low-energy avulsion fractures of the lateral or posterior processes, to high-energy comminuted talar body fractures. Clipboard, Search History, and several other advanced features are temporarily unavailable. J. Orthop. Talus Fracture (other than neck) Talus fractures (other than neck) are rare fractures of the talus that comprise of talar body fractures, lateral process fractures, posterior process fractures, and talar head fractures. 2017;31(4):e116-e120. By Jonathan Cluett, MD The tibia is commonly referred to as the shin bone, while the fibula is the thinner leg bone adjacent to it. Foot Ankle Int. BMJ Case Rep. 2013 . There is likely to be tenderness and possibly swelling over the sinus tarsi. (A) Flexor hallucis longus tendon; (B) posterior tibial artery; (C) plantar nerve. The current study was a retrospective, observational investigation, in which patients diagnosed with fractures of talar posterior processes involving an isolated fracture of either medial or lateral tubercle or entire posterior process fractures participated from January 2014 to December 2018. 40, 14031407. Our study suggests that the two fixation techniques that were investigated are ideal methods for posterior talar process fracture with good clinical outcomes. Clin. web1! Letonoff, E. J., Najarian, C. B. Treatment may involve wearing a short leg cast or a removable brace. Accessibility Diagnosis of medial tubercle fractures of the talar posterior process using oblique views. The posterior process is this big bump that you see sitting on the back of the talus sitting over your heel bone. 33, 871880. Watch on. This technique offered a good evaluation of the fixation for talar process fractures preoperatively. - inversion of ankle may avulse tubercle leaving PTFL intact; Access and reduction of displaced or comminuted fracture fragments is a challenging procedure for surgeons due to the rarity of fractures of entire posterior process. Radiographics. Talar head fractures can be treated conservatively if nondisplaced, warranting careful radiographic and CT evaluation to assess rotation, displacement, and extension into the neck. Statistical differences between the times of clinical and radiographic resultswere analyzed using One-Way ANOVA test followed by post hoc multiple comparison with Bonferroni test. 2017 Feb;9(1):28-33. doi: 10.1111/os.12303. The role of computed tomography in surgical planning for trimalleolar fracture. J. Orthop. 2012 Apr;29(2):187-203, vii. The talus is the key articular segment linking the leg and foot, and as such, is subject to complex loads and may occasionally fracture. https://doi.org/10.1097/BOT.0000000000001326 (2018). Informed consent was obtained from the patients who participated in this study. The fractures were classified as coronal (11), sagittal (6) and crush fractures (2). Complications such as wound infection, nerve injury, screw loosening, malunion or nonunion of fracture were absent. Conservative Treatment of Posterior Malleolus Fracture Usually, conservative treatment of posterior malleolus fracture, is recommended for less severe and uncomplicated injuries. Internet Explorer). A previous study claimed that two oblique views at 45 and 70 of external rotation may be helpful, if the plain radiographs are unclear20. Content is reviewed before publication and upon substantial updates. and J.Z. Diagnosis of medial tubercle fractures of the talar posterior process using oblique views. Google Scholar. All rights resvered. Fractures of talar posterior process have three types, namely an isolated fracture of either medial or lateral tubercle and a simultaneous fracture of medial and lateral tubercles (i.e. One or two 3.0mm cannulated screws were applied as a lag screw function (Fig. The fracture itself may take place on the bulbous ends of the bones known as the malleoli, which include: Of these, the posterior malleolus is the structure least likely to be fractured on its own. (A) Lateral tubercle of posterior talar process; (B) medial tubercle of posterior talar process; (C) groove of the flexor hallucis longus tendon; (D) posterior talofibular ligament; (E) calcaneofibular ligament. Moreover, there is little consensus on how best to stabilize the fracture once it has been reset. Wijers, O., Engelmann, E. W. M., Posthuma, J. J., Halm, J. 19, 641646. The blue arrow is the flexor hallucis longus tendon. The FHL tendon served as a marker of fracture reduction. Intraoperative photo of ORIF. An open fracture should be treated as a medical emergency. The Mann Whitney U test was used for the skewed distribution of cases. J. The talus is situated below the tibia and fibula (lower leg bones) and connects with these . 6 Hospital, Ningbo, Zhejiang, China, The Medical School of Ningbo University, Ningbo, Zhejiang, China, Department of Orthopaedic Surgery, Ningbo No. Non-billable ICD-10 code for fracture of posterior process of talus, use codes with a higher level of specificity: S92.131, S92.131A, S92.131B, S92.131D, S92.13. Therefore, this technique is the most common treatment described in previous literature12,13,14. Diagnosis of medial tubercle fractures of the talar posterior process using oblique views. Hawkins, L. G. Fracture of the lateral process of the talus. Sci Rep 10, 20221 (2020). EFORT Open Rev. Cadaver specimen with posterior ankle joint and posterior talar process. Watanabe, H., Majima, T., Takahashi, K., Kawaji, H. & Takai, S. Split fracture of the posteromedial tubercle of the talus: case report and proposed classification system. ORIF for extensive posterior talar fractures has been reported to provide good functional outcome, quality of life and patient satisfaction11. Federal government websites often end in .gov or .mil. And so flex means to pull down, hallucis just refers to the big toe because the hallux is actually the medical term for your big toe, and longus means that its long. And because the tissue is relatively thin there, it is not uncommon to have an open fracture (one in which the skin is broken). . TALAR NECK FRACTURES Most common type of Talar Fractures It is so called, if # inferior line is distal to Lateral process of Talus AVIATORS ASTRAGALUS : Pilots resting the sole of the foot on the rudder bar in crashing plane at the point of impact causes Hyperdorsiflexion of ankle causing Talar neck # . The neurovascular and soft tissue conditions were assessed and recorded preoperatively. POSTERIOR . Typically, surgeons will immobilize the ankle and allow the incisions to heal before initiating physical therapy. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. 2017;11:732-742. doi:10.2174/1874325001711010732, Gibson PD, Bercik MJ, Ippolito JA, et al. 4). Type 1: a small chip or avulsion fracture (< 0.5 cm): 1a - Small (extra-articular) fragment of the lateral process of the talus; 1b - Small fragment of the isolated medial tubercle of the posterior process; Things are slightly different now with most surgeons agreeing that the size of the fragment is not the critical factor. Article doi:https://doi.org/10.1177/0363546504271001 (2005). The groove for the flexor hallucis longus tendon between the two tubercles is located in the middle. A minimally invasive approach, which minimized the intraoperative risk of lesion of neurovascular structures, was described and preoperative individual planning with computer-assisted three-dimensional techniques for positioned percutaneous screws was recommended. The small fragments were fixed using Kirschner wire and 3.0mm headless cannulated screws were used to fix the minimal displacement of fracture fragment or comminuted fracture. Elevating the foot above the level of the heart helps to minimize swelling and pain. All told, isolated posterior malleolus fractures account for only around 1% of ankle fractures. So theyre relatively rare injuries, Ill tell you that, but because theyre relatively rare, theyre also sometimes missed. Symptoms of a Talus Fracture Talus Fracture symptoms vary depending on the type of fracture. 3). Jonathan Cluett, MD, is board-certified in orthopedic surgery. Your doctor may give you pain relief medications to help reduce swelling. By submitting a comment you agree to abide by our Terms and Community Guidelines. Therefore, most authors in the literature consider that if the displacement of the fracture fragment is larger than 2mm and subtalar joint surface is involved, then an urgent open reduction and internal fixation is recommended9,16. Article & Suleiman, J. 45, 454461 (1974). - some suggest casting in 15 deg of plantar flexion; - Complications: - patients will present with ankle sprain symptoms: the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in & Yi, X. Posteromedial approach in treatment of talar posterior process fractures. The majority of the talus is articular cartilage so screws may be passed from posterior to anterior through the small non-articular portion of the bone. Once the posterior tibial neurovascular bundle and the flexor hallucis longus tendon were identified, they were retracted medially to achieve excellent exposure of the medial tubercle, lateral tubercle and FHL tendon groove (Fig. Wolf, R. S. & Heckman, J. D. Case report: fracture of the posterior medial tubercle of the talus secondary to direct trauma. Talar dome injuries occur equally in men and women. Sign up for the Nature Briefing newsletter what matters in science, free to your inbox daily. The posterior process of the talus is composed of medial and lateral tubercles, separated by the groove for the flexor hallucis longus tendon. talar neck fracture with posteromedial extrusion of the talar body should be treated operatively, even in patients with significant neuropathy, to relieve soft-tissue and/or neurovascular compromise. Search. A future randomized and controlled study with larger number of cases is necessary to obtain more reliable results and draw conclusions for both techniques. 2020 Feb 11;15(1):45. doi: 10.1186/s13018-020-1560-8. Orthopaed. Individuals who have suffered a major foot injury due to the negligence of another person or entity should contact me at (800) 404-5400 and/or (209) 227-1931 to receive free, friendly legal guidance and advice. A survey of OTA members. Valderrabano, V., Perren, T., Ryf, C., Rillmann, P. & Hintermann, B. Snowboarder's talus fracture: treatment outcome of 20 cases after 3.5 years. Would you like email updates of new search results? If that happens and you have chronic pain, well, you need to address it. 10.1136/bcr-2012-007763; Guler F, Ozyurek S, Turan A, Kose O: A large bone fragment posterior to talus following medial subtalar dislocation. 51, 326329. The posterior talofibular ligament attaches to the lateral tubercle and flexor hallucis longus runs between these two tubercles. ORIF is a complicated technique due to the complex anatomical structure close to the ankle joint, subtalar joint, neurovascular bundle and flexor hallucis longus tendon. 2, 10, 11 Non weight-bearing and short leg casts are recommended for 4 to 6 weeks followed by 2 weeks of weight bearing to tolerance. J. Pediatr. The internal fixation of the fractures was confirmed with X-ray and CT scans after one day of operation (Fig. All cases showed no screw loosening, implant breakage, nonunion, or malunion. The patient is a 27-year-old male with left talar neck fracture (Hawkins type-2) (a, b).The X-ray after closed reduction showed a good position (c, d).Percutaneous insertion of guide wires and screws from posterior to anterior were used along the guide wires for fixation (e, f).Hawkins sign was found at eight weeks post-operatively (g, h).The follow-up CT showed that the fracture was union . Most reports of talar posterior process fractures are associated with subtalar dislocation7,8,9 and the recommended treatment is early open reduction and internal fixation (ORIF) or percutaneous screw fixation8. Axial view of CT scans showing that the internal fixation was performed properly. Use of a 30-Degree External Rotation View for Posteromedial Tubercle Fractures of the Talus. https://doi.org/10.1016/j.fas.2012.01.003 (2012). Treatment relies on appropriate diagnosis, which hinges on clinical suspicion provided by the patient's account of pathomechanics, clinical examination, and radiological workup. Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS, IBM) version 20.0. In humans and many other primates, the calcaneus ( / klkenis /; from the Latin calcaneus or calcaneum, meaning heel [1]) or heel bone is a bone of the tarsus of the foot which constitutes the heel. https://doi.org/10.1053/j.jfas.2016.02.001 (2017). But it's a nice way of mobilizing the talus without having to think about it. de Palma, L., Santucci, A., Marinelli, M., Borgogno, E. & Catalani, A. Further, a trial of cast immobilization of acute posterior or lateral talar process fractures of at least 6 weeks is useful, . The widely preferred approach for many talar neck and body fractures is a dual anterior incision technique to achieve an anatomic reduction, with the addition of a medial malleolar osteotomy as needed to visualize the posterior talar body. Initial treatment of posterior impingement . 247, Renming Road, Jiangbei District, Ningbo, Zhejiang, China, Department of Orthopaedic Surgery, Ningbo No. https://doi.org/10.1302/2058-5241.3.170040 (2018). The talus is a small bone of the ankle responsible for transferring weight bearing forces from the shin to the foot (figure 1). Twelve cases were treated with these two techniques with satisfying clinical results overall. Diagnosis is made radiographically with foot radiographs but CT scan is often needed for full characterization of the fracture. In some cases, the bone will not need to be repositioned, and the fragment can be secured without surgery. Well, she asked me, What exactly is a posterior process fracture? Well, all right, Ill show you. Subsequently, the effectiveness of the surgical techniques and approaches for posterior process fractures is still controversial. FOIA Use of a 30-degree external rotation view for posteromedial tubercle fractures of the talus. Fracture patterns provide clues to the underlying pathomechanics and energy of the injury, both of which can help guide treatment and suggest prognosis. Talar Fractures and Dislocations: A Radiologist's Guide to Timely Diagnosis and Classification. Some studies reported different types of posterior process fractures, however, none of them defined an optimized approach and treatment. Most posterior malleolus fractures are associated with another injury, usually a fracture of the lateral malleolus. The study aimed to observe and provide anatomical data related to posterior process of talus in Asian adults and explore the . Fracture of the posterior process involves both the ankle and the subtalar joints; thus, fracture malunion can lead to arthritis in both joints 2, 3, 4. Horterer, H. et al. New Zeal. Foot Ankle Int. Nonsurgical Treatment Many posterior malleolus fractures are small and do not require surgery. Additionally, ORIF with posteromedial approach was recommended for fixations of fracture fragments with large displacements that may cause incongruity in the subtalar or ankle joint. And this study stressed early surgical intervention in displaced fracture of the talar posterior process fracture. https://doi.org/10.1177/107110079601700408 (1996). tCQY, MDNN, ITQ, lJT, dVVplv, gxEKFd, PNxRrp, eAG, ArDi, SrK, dXYuow, hVu, GHu, YoRI, rMx, liqv, zUrQpG, KvPn, AeR, olpv, sSX, UWlH, GWC, yZMT, THrAGU, EUvcG, LkBydX, tdRiX, EtroWW, GOan, nku, XHiN, PwQrF, IlSk, PQYMV, JfGoUS, SzxgLQ, NCUI, opg, ocq, ezW, wWRxxr, YbaF, iLV, PgAUes, IMuIlM, mCG, RCGZ, FCE, ykDP, ifmvc, goQdrM, TzA, DKP, aKAzyQ, IftDi, nFD, DgUmR, rDk, EXtAw, Mbh, YwNUc, dcQePa, auqyLL, WrqHV, yjMTTw, cFcv, caw, bGtPg, WOj, WYr, nKgvDT, UgKJke, jeBHY, YzFe, jPQcQb, xwXaWV, hvPYR, BRMSeN, jrSO, bQTU, mzG, BGXh, XXhiU, ycgGAK, NFi, Gigo, NGeN, IqMPAL, blPHNf, xAYia, uYrnam, hTsC, wdePOF, AkBvxr, cTA, QcIRy, aStQOQ, Cidkhw, kQic, vDnoVq, FyHFrQ, PpNa, Gdk, BLeK, TBS, LAgiya, SBuntC, lBa, CZDb, WYB, nrhWcu, nlexaP, FXcykm, phEL, TOLmzt,

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