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ADVANCED TRAUMA SKILL COURSE

DEPARTMENT OF TRAUMATOLOGY AND HAND SURGERY

Manual Skill Course - 2015

ADVANCED TRAUMA SKILL COURSE


DATE:
Mondays, between 03:00 04:30 pm
LOCATION / MEETING POINT:
Conference Room (1st Floor), Department of Traumatology
Akc u 1, Pcs, HU
NUMBER OF PARTICIPANTS:
limited to 12 participants of the Course
ORGANIZER:
Lszl G Nt, MD
Dept. of Traumatology & Hand Surgery
/email: laszlogn@icloud.com/

CAST FIXATION, BRACES AND TAPES

CONDITONS THAT BENEFIT FROM IMMOBILIZATION

1.Fractures
2.Sprains
3.Severe soft-tissue injuries
4.Reduced joint dislocations
5.Inflammatory conditions: arthritis,
tendinopathy, tenosynovitis
6.Deep laceration repairs across joints
7.Tendon lacerations
Boyd AS et al: Principles of Casting and Splinting.
Am Fam Physician. 2009 Jan 1;79(1):16-22.

COMPLICATIONS OF IMMOBILIZATION

1. Compartment syndrome
2. Ischemia
3. Heat injury
4. Pressure sores and skin breakdown
5. Infection
6. Dermatitis
7. Joint stiffness
8. Neurologic injury
Boyd AS et al: Principles of Casting and Splinting.
Am Fam Physician. 2009 Jan 1;79(1):16-22.

HISTORY OF CAST FIXATION


Egypt - 5th Dynasty Egypt (2465-2323 BC)
First Splinting of Fractures.

Antonius Mathysen (1852): first cast fixation

X-ray machine (1895): reduction is available

Nowadays: fluoroscope (early 1960s) and


portable extremity CT-scanner

LEGACY OF LORENZ BHLER (1885 1973)


Lorenz Bhler (practicing in Vienna) gained expertise by treating injured
soldiers during the First and Second World Wars. Written on his
experience, Bhlers Book series became the gold-standard of
conservative treatment until the operative era

INDICATIONS

non-operative fracture treatment


ligament / tendon injuries
additional temporary support following operation
septic / aseptic inflammation

Bhlers 3R principles:
I. Reduction
II. Retention
III. Rehabilitation

DIFFERENT TYPES OF CASTING MATERIALS

1. Plaster of Paris (traditional orthopedic cast)


Cotton bandage that has been impregnated with plaster of
paris, which hardens after it has been made wet.
Chemical reaction: calcined gypsum (roasted gypsum) + water
is added the more soluble form of calcium sulfate returns
to the relatively insoluble form by producing heat);
reaction: 2 (CaSO4 H2O) + 3 H2O 2 (CaSO4.2H2O) + heat (!!)
The water should be tepid, or lukewarm, with an ideal temperature
between 22 and 25 C. /AO Manual/
Note: the setting of unmodified plaster starts about 10 minutes after mixing
and is complete in about 45 minutes; however, the cast is not fully dry for
72 hours.

DIFFERENT TYPES OF CASTING MATERIALS

2. Fiberglass and polyurethane: bandages of synthetic


materials: knitted fiberglass bandages impregnated with
polyurethane

3. Thermoplastic bandages: synthetic rubber-based material


with the advantage of thermoforming condition (possibility of
readjustment)
Advantages:
- lighter & dry much faster than plaster bandages
- thin, breathable, water-resistant (limited)
Disadvantages:
- conventional plaster can be more easily moulded to
make a snug and therefore more comfortable fit.
- plaster is much smoother and does not snag clothing
or abrade the skin.

DIFFERENT TYPE OF CASTS

Splint
Circular split casting
Full circular cast /additional reduction: wedging of cast/
Upper extremity / lower extremity casts
Desault-bandage + cast fixation
Spica cast: shoulder spica, single hip spica
Body casts: Minerva cast

DIFFERENT TYPE OF CASTS

DIFFERENT TYPE OF CASTS

CAST FIXATION TOOLS

padding

tools

casting material

CAST FIXATION STEP-BY-STEP

CAST FIXATION STEP-BY-STEP

CAST FIXATION STEP-BY-STEP

CAST FIXATION STEP-BY-STEP

HOW TO AVOID MISTAKES ?

Circular-split casts and splints:


ALL LAYERS must be accurately cut through !!
Mistakes may lead to:
- Strangulation
- Volkmanns ischemic contracture
- Contribution to Sudeck-dystrophy

HOW TO AVOID MISTAKES ?

Proper padding

HOW TO AVOID MISTAKES ?


Proper application of bandage

Proper molding of cast

Proper positioning of joints

Proper length of cast

FAILURE OF CUTTING THROUGH ALL THE LAYERS

STRANGULATION

PRESSURE TISSUE DAMAGE


VESICLE-FORM
SKIN LESION

HISTORICAL PHOTOS THOUGH THE PRINCIPLES ARE


STILL THE SAME...

Lorenz Bhler
1885.01.15.-1973.01.20.

HISTORICAL PHOTOS THOUGH THE PRINCIPLES ARE


STILL THE SAME...

HISTORICAL PHOTOS THOUGH THE PRINCIPLES ARE


STILL THE SAME...

HISTORICAL PHOTOS THOUGH THE PRINCIPLES ARE


STILL THE SAME...

ORTHOPEDIC BRACES, SUPPORTS & TAPES

SHOULDER, CLAVICLE AND HUMERUS BRACES


INDICATIONS:
After shoulder and humerus surgery
Humerus fracture (proximal and midshaft
fracture)
Clavicle fracture
AC dislocation
Shoulder dislocation
Distorsion
Inflammation

SHOULDER, CLAVICLE AND HUMERUS BRACES


INDICATIONS:
After shoulder and humerus surgery
Humerus fracture (proximal and midshaft
fracture)
AC dislocation
Clavicle fracture
Shoulder dislocation
Distorsion
Inflammation

ELBOW BRACES
INDICATIONS:

Tennis elbow
Golfer elbow
Dislocations
Ligament injuries
After elbow surgeries
Treatment of selected fracture types

HAND AND WRIST SUPPORTS


INDICATIONS:

Wrist strain
Overuse injuries
Inflammation, tendinitis
Ligament injuries
After wrist surgeries
Treatment of selected fracture types

LOWER LEG SUPPORTS

Augusto Sarmiento
Miami Brace 1964

ANKLE AND FOOT SUPPORTS


INDICATIONS:

Ankle strain
Overuse injuries
Inflammation, tendinitis
Ligament injuries: lateral ankle ligaments,
proprioceptive training!!
After ankle and foot surgeries
Treatment of selected fracture types

CERVICAL SPINE SUPPORTS


INDICATIONS:

Spondylosis, spondylarthritis, discopathy


Cervical distorsion
Degenerative disorders
Vertebral malignancy
Cervical traumas ATLS, primary care!!
Vertebral fractures
Postoperative additional support
Pain management

LUMBO-SACRAL SPINE SUPPORTS


INDICATIONS:

Spondylosis, spondylarthritis, discopathy


Lumbosacral pain
Other degenerative disorders
Vertebral malignancy
Vertebral fractures
Postoperative additional support
Pain management

KINESIOLOGY TAPES

KINESIOLOGY TAPES

Kinesiology tape: thin, stretchy, elastic cotton strip


with an acrylic adhesive.
Therapeutic kinesiology tape that can benefit a
wide variety of musculoskeletal and sports
injuries, plus inflammatory conditions.
Kinesiology tape is almost identical to human skin
in both thickness and elasticity, which allows
kinesio tape to be worn without binding,
constricting or restriction of your movement.

KINESIOLOGY TAPES

Primary purpose: to treat athletic injuries


and a variety of physical disorders.
For the first decade after its introduction
practitioners in Japan were the main users of the
therapeutic kinesiology tape. By 1988 the tape had
been adopted by Japanese Olympic and
professional athletes before spreading across the
world.
You would have noticed that more an more
professional athletes use kinesiology taping
improve their sporting performance, prevent injury
and allow them to return to sport quicker.

KINESIOLOGY TAPES

1. Pain Relief
A) Physically, the lifting action of the kinesiology tape relieves
pressure on pain receptors directly under the skin, allowing for
both immediate and lasting relief.
B) Sensory stimulation of other types of nerve fibers. In these
circumstance, kinesiology tape may be effective for pain that
persists for a longer time.
2. Swelling Reduction
By lifting this skin, kinesiology taping provides a negative
pressure under the tape, allowing the lymphatic drainage
channels to drain swelling and other inflammatory cells away
from the injured area quickly.

KINESIOLOGY TAPES

3. Lymphoedema Reduction
Based on the same physical lifting principle, kinesiology taping
can be very effective in the reduction of lymphoedema.
4. Reduced Muscle Fatigue, Cramps and DOMS.
Exercise and repeated muscle contractions produces postexercise byproducts such as lactic acid. Lactic acid can cause
poor muscle performance, fatigue cramping and delayed onset
muscle soreness (DOMS).
Kinesiology tape can help remove lactic acid and other
exercise byproducts from the region, which can assist muscle
performance, reduce fatigue, cramps and DOMS.

KINESIOLOGY TAPES

5. Assists Weak or Injured Muscles


Kinesiology tape provides both a physical and neurological
support for your dynamic structures such as muscles
Kinesiology tapes unique elasticity provides passive support to
weak or injured muscles. This can assist everyday activities,
high level sport or even low tone children.
6. Quicker Return to Sport, Work and Play
By supporting weak or painful structures, kinesiology tape
ultimately allows injured athletes, workers and weekend
warriors to return to sport, work or play quicker that without
kinesiology tape's unique dynamic support.

KINESIOLOGY TAPES
Kinesiology tapes can be used for hundreds of common
injuries such as lower back pain, knee pain, shin splints,
carpal tunnel syndrome, and tennis elbow...

Ankle

Neck

Calf and
arch

Hamstring

Shoulder Upper knee Elbow

Hip

Lower back

Full knee

Groin

Posture

Power
strips

IMPORTANT PRE-COURSE VIDEO LECTURES

Please, watch these educational videos about the main types of


cast fixation methods.
During the course, the time will be limited only for a quick demonstration of the
manual practice (tricks and tips).
Please, copy this link to the webpage-address line of your web-browser:
http://www.aovideo.ch/catalog/
Then, search for keyword: circular cast choose the following video tutorials:
a, Foot and Ankle - Fractures and Sprains - Lower Leg Backslab Splint
b, Foot and Ankle - Fractures and Sprains - Lower Leg Circular Cast
c, Tibia, Knee and Femur - Fractures and Soft-tissue Injuries - Upper Leg Circular Cast
d, Radius and Ulna - Fractures - Basic Forearm Circular Cast
e, Metacarpal and Phalanx - Fractures and Soft-tissue Injuries Thumb Spica Leg
f, Radius and Ulna - Fractures - Above Elbow Circular Cast

WOUND HEALING. TREATMENT OF SOFT TISSUE


DEFECTS: SKIN GRAFTS AND FLAPS.

DIFFERENT TYPE OF WOUNDS

abrasion (superficial)

vulnus abrasum

cut (sharp)

vulnus scissum

cut (blunt)

vulnus caesum

contusion

vulnus contusum (ruptum)

laceration

vulnus lacerum

stab

vulnus punctum

gunshot

vulnus sclopetarium

bite

vulnus morsum

DIFFERENT TYPE OF WOUNDS

vulnus abrasum: superficial, affects only the skin


vulnus scissum: acting force is almost parallel to the
surface sharp, regular wound edges (surgical wounds)
vulnus caesum: acting force is perpendicular to the
surface sharp, a bit irregular edges, some tissue laceration
vulnus contusum (ruptum): acting force is a blunt one,
almost perpendicular to the surface irregular, lacerated
wound edges, often dirty
vulnus lacerum: acting force is a blunt one, almost parallel to
the surface irregular, lacerated wound edges, often dirty
with excessive soft tissue damage (conquassation)

DIFFERENT TYPE OF WOUNDS

vulnus punctum: acting force is almost perpendicular to the


surface, small entry point, possibly deep wound
vulnus sclopetarium: low / high velocity projectile; small entry
point, large exit point concentric tissue damage, due to the
kinetic energy of the bullet
vulnus morsum: small entry point, tissue damage, can be
deep potentially infected, conquassated wound, bad healing
potential
Note: most dangerous bite: human

DIFFERENT TYPE OF WOUNDS

Note: most dangerous bite: human

DIFFERENT TYPE OF WOUNDS

WOUND HEALING. TREATMENT OF SOFT TISSUE


DEFECTS: SKIN GRAFTS AND FLAPS.

- German surgeon and bacteriologist


- Studied microbiology with Robert
Koch
- Experimental contaminated wound
model in guinea pigs to study wound
infection
- Thoracic surgery to treat tuberculosis
- Described the principles of primary
wound care
Paul Leopold Friedrich
1864 - 1916

PRINCIPLES OF WOUND MANAGEMENT

1. Disinfection, Anesthesia, Careful Debridement (cleaning,


necrectomia): remove all foreign materials and devitalized
tissues
2. Proper Drainage (prevent retention)
3. Opening of Body Cavities - Penetrating injuries
4. Question of Wound Closure: usually within 6 hours
- Primary Closure
- Secondary Closure
- Delayed primary closure,
5. Tetanus prophylaxis: active immunization: AT
passive immunization: TETIG
(human immunoglobulin)
important date: 01/01/1941

PRINCIPLES OF WOUND MANAGEMENT

Never close primarily: punctum / sclopetarium / morsum


+ contaminated, infected wounds

MANAGEMENT OF STABBED WOUND

MANAGEMENT OF STABBED WOUND

MANAGEMENT OF GUNSHOT WOUND

MANAGEMENT OF GUNSHOT WOUND

MANAGEMENT OF GUNSHOT WOUND

PHASES OF WOUND HEALING

I. Inflammatory phase

II. Proliferative phase

III. Remodeling phase

TYPES OF WOUND HEALING

1. Primary wound healing (sanatio per primam


intentionem): no gap (diasthasis), minimal
connective tissue, minimal scar
2. Secondary wound healing (sanatio per
secundam intentionem): aseptic or steril
inflammation accumulation of connective
tissue, scar formation

INDICATIONS OF TISSUE GRAFTS

Extensive wounding or trauma


Burns
Areas of extensive skin loss due to septic complication
Specific surgeries that may require skin grafts for healing
to occur - most commonly removal of skin cancers

SKIN GRAFTS

Autologous: The donor skin is taken from a different site


on the same individual's body (also known as an
autograft)
Isogeneic: The donor and recipient individuals are
genetically identical (e.g., monozygotic twins, animals of
a single inbred strain; isograft or syngraft)
Allogeneic: The donor and recipient are of the same
species (humanhuman, dogdog; allograft)
Xenogeneic: The donor and recipient are of different
species (e.g., bovine cartilage; xenograft or heterograft)
Prosthetic: Lost tissue is replaced with synthetic
materials such as metal, plastic, or ceramic (prosthetic
implants)

SKIN GRAFTS

I.

Split-thickness: skin graft including the epidermis and


part of the dermis. Its thickness depends on the donor
site and the needs of the patient. It can be processed
through a skin mesher which makes apentures onto the
graft, allowing it to expand up to nine times its size:
`mesh-graft`. Split-thickness grafts are frequently used
as they can cover large areas and the rate of auto
rejection is low. The donor site heals by re-epitheliasation
from the dermis and surrounding skin and requires
dressings.
II. Full-thickness: consists of the epidermis and the entire
thickness of the dermis. The donor site is either sutured
closed directly or covered by a split-thickness skin graft.
III. Composite graft: small graft containing skin and
underlying cartilage or other tissue.

NEGATIVE PRESSURE WOUND THERAPY (NPWT)

Indication: pre-operative wound maintenance and postoperative graft healing is the use of negative pressure
wound therapy (NPWT)
Mechanism: NPWT system works by placing a section of
foam cut to size over the wound, then laying a perforated
tube onto the foam. The arrangement is then secured
with bandages.
A vacuum unit creates negative pressure, sealing the
edges of the wound to the foam, and drawing out excess
blood and fluids.
Advantages: helps to maintain cleanliness, promotes the
development of new blood vessels, and induces fibroblast
proliferation.
Indication in trauma care: soft tissue defects, especially
after septic complications or major traumas

NEGATIVE PRESSURE WOUND THERAPY (NPWT)

Uses of Negative Pressure


Wound Therapy i n
O r t h o p e d i c Tr a u m a
Mark J. Gage, MDa, Richard S. Yoon, MDa,
Kenneth A. Egol, MDa, Frank A. Liporace, MDa,b,*
KEYWORDS
! Negative pressure wound therapy ! VAC ! Infection ! Trauma ! Open wound ! Wound dehiscence
! Limb salvage ! Open fracture

KEY POINTS

INTRODUCTION

WHAT IS IT?

Since its inception more than 20 years ago, negative pressure wound therapy (NPWT) has had a
major impact in the management of orthopedic
injuries. NPWT has been widely adopted for use
in a variety of clinical scenarios, and has had reported success in the setting of high-energy
trauma, open fractures, infections, and excessive
soft tissue damage. However, although its success has led to widespread use in orthopedic
trauma, a deeper understanding of its mechanism
of action, along with the ideal clinical scenarios
for use, is required. This article reviews the nuances of NPWT application, including its mechanism of action, clinical indications, and specific
strategies used in order to achieve desired clinical
outcomes.

To administer NPWT, there are 3 main components


that create a subatmospheric pressure environment: a porous dressing sealed via an occlusive
adhesive, a vacuum device, and a connector that
allows communication (Fig. 1). In orthopedic
trauma, the dressing of choice is a dry, black, hydrophobic, reticulated polyurethane-ether foam
with a pore size of 400 to 600 mm (KCI, San Antonio,
TX). A polyvinyl alcohol (PVA) foam is also available
(KCI, San Antonio, TX). It differs from the large-pore
foam because it has a smaller pore size
(60270 mm) and comes premoistened with sterile
water. The hydrophilic nature and smaller pore
size of the PVA foam offers a less-adherent application and has significantly less granulation and
perfusion than the large-pore dressing.1 Thus, for

Conflicts of interest: The authors report no conflict of interest.


a
Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New
York, NY, USA; b Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Jersey
City Medical Center, 377 Jersey Avenue, Suite 220, Jersey City, NJ 07302, USA
* Corresponding author. Orthopaedic Trauma Research, Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY.
E-mail address: liporace33@gmail.com
Orthop Clin N Am 46 (2015) 227234
http://dx.doi.org/10.1016/j.ocl.2014.11.002
0030-5898/15/$ see front matter ! 2015 Elsevier Inc. All rights reserved.

orthopedic.theclinics.com

! Negative pressure wound therapy (NPWT) is ideal for soft tissue defects that can heal through secondary intention or require skin grafting.
! NPWT prevents desiccation, reduces edema, limits hematoma, and facilitates wound drainage.
! NPWT is an effective way to downscale the complexity of soft tissue reconstruction.
! NPWT can decreases the risk of wound complication when applied to high-risk incisions after fracture surgery.

NEGATIVE PRESSURE WOUND THERAPY (NPWT)

FLAPS

Definition: flap is a unit of tissue that is transferred from


one site (donor site) to another (recipient site) while
maintaining its own blood supply.
Flaps come in many different shapes and forms. They
range from simple advancements of skin to composites of
many different types of tissue. These composites need
not consist only of soft tissue. They may include skin,
muscle, bone, fat, or fascia.
How does a flap differ from a graft? A flap is transferred
with its blood supply intact, and a graft is a transfer of
tissue without its own blood supply. Therefore, survival of
the graft depends entirely on the blood supply from the
recipient site.

FLAPS

Classifications:
type of blood supply
type of tissue to be transferred
location of donor site.

FLAPS

A, Type of blood supply:


If the blood supply is not derived from a recognized artery
but, rather, comes from many little unnamed vessels, the
flap is referred to as a random flap. (Many local
cutaneous (skin) flaps fall into this category)
If the blood supply comes from a recognized artery or
group of arteries, it is referred to as an axial flap. (Most
muscle flaps have axial blood supplies.)

FLAPS

Axial flaps: (Mathes and Nahai classification)


One vascular pedicle (eg, tensor fascia lata)
Dominant pedicle(s) and minor pedicle(s) (eg, gracilis)
Two dominant pedicles (eg, gluteus maximus)
Segmental vascular pedicles (eg, sartorius)
One dominant pedicle and secondary segmental pedicles
(eg, latissimus dorsi)

FLAPS

B, Tissue to be transferred:
In general, flaps may comprise in part or in whole almost
any component of the human body, as long as an
adequate blood supply to the flap can be ensured
once the tissue has been transferred.

FLAPS

B, Tissue to be transferred:
Flaps may be composed of just one type of tissue or
several different types of tissue.
Flaps composed of one type of tissue include skin
(cutaneous), fascia, muscle, bone, and visceral (eg,
colon, small intestine, omentum) flaps.
Composite flaps include fasciocutaneous (eg, radial
forearm flap), myocutaneous (eg, transverse rectus
abdominis muscle [TRAM] flap), osseocutaneous (eg,
fibula flap), tendocutaneous (eg, dorsalis pedis flap), and
sensory/innervated flaps (eg, dorsalis pedis flap with
deep peroneal nerve).

FLAPS

C, Location of donor site:


Tissue may be transferred from an area adjacent to the
defect. This is known as a local flap. It may be described
based on its geometric design, be advanced, or both.
Pivotal (geometric) flaps include rotation, transposition,
and interpolation. Advancement flaps include single
pedicle, bipedicle, and V-Y flaps.
Tissue transferred from an noncontiguous anatomic site
(ie, from a different part of the body) is referred to as a
distant flap.

FLAPS

C, Location of donor site:


Distant flaps: may be either pedicled (transferred while
still attached to their original blood supply) or free. Free
flaps are physically detached from their native blood
supply and then reattached to vessels at the recipient
site. This anastomosis typically is performed using a
microscope, thus is known as a microsurgical
anastomosis.

REVERSED CHINESE FLAP


radial forearm free flap

LATISSIMUS DORSI FLAP


latissimus dorsi myocutaneous flap (LDMF)

History: The earliest application of the latissimus flap for


head and neck reconstruction was described by Quillen in
1978, and microvascular free tissue transfer of the flap
was described by Watson in 1979.
One of the most reliable and versatile flaps used in
reconstructive surgery
The latissimus dorsi may be transferred as a myofascial
flap, a myocutaneous flap, or as a composite
osteomyocutaneous flap when harvested with underlying
serratus anterior muscle and rib.

LATISSIMUS DORSI FLAP


latissimus dorsi myocutaneous flap (LDMF)

Large volume of tissue is available for reconstruction.


Long vascular pedicle offers excellent range for pedicled
flaps.
High caliber pedicle makes free flap vascular
anastomoses technically more feasible, even in patients
with significant atherosclerotic disease.
The possibility of independent skin paddles being able to
address complex defects (eg, through-and-through oral
cavity defects)
Rib or scapula bone is available.
Minimal donor site morbidity occurs.
It can be combined with other subscapular flaps, when
indicated.

LATISSIMUS DORSI FLAP


latissimus dorsi myocutaneous flap (LDMF)

LATISSIMUS DORSI FLAP


latissimus dorsi myocutaneous flap (LDMF)

LATISSIMUS DORSI FLAP


latissimus dorsi myocutaneous flap (LDMF)

LATISSIMUS DORSI FLAP


latissimus dorsi myocutaneous flap (LDMF)

LATISSIMUS DORSI FLAP


latissimus dorsi myocutaneous flap (LDMF)

TREATMENT OF DOG BITE CASE REVIEW

TREATMENT OF DOG BITE CASE REVIEW

TREATMENT OF DOG BITE CASE REVIEW

TREATMENT OF DOG BITE CASE REVIEW

TREATMENT OF DOG BITE CASE REVIEW

TREATMENT OF DOG BITE CASE REVIEW

TREATMENT OF DOG BITE CASE REVIEW

TREATMENT OF DOG BITE CASE REVIEW

TREATMENT OF DOG BITE CASE REVIEW

TREATMENT OF DOG BITE CASE REVIEW

USEFUL LINKS TO FOLLOW:

If you are interested in, please, check the following links for
further information:
1. AO / ASIF
www.aotrauma.org: AO Surgery Reference & Online Education
2. Orthopaedic Trauma Association (OTA)
http://ota.org/about/
3. trauma.org
http://www.trauma.org/archive/traumabank.html
4. AAOS: www.aaos.org

THANKS FOR YOUR


ATTENTION!

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