INTRODUCTION — This topic discusses the unique properties of pediatric fractures and illustrates different classification systems that exist to identify and describe them. Management of specific fractures is discussed separately and can be found by searching for the anatomic region of interest.
Common fracture patterns (eg, transverse, oblique, spiral) seen in both children and adults and general principles of fracture management are discussed in detail separately.
BACKGROUND — Musculoskeletal injuries comprise approximately 12 percent of the 10 million annual visits to United States pediatric emergency departments . Skeletal fractures account for a significant proportion of these injuries and cause considerable cost and morbidity to children. Despite aggressive campaigns for injury prevention, the overall rate of fractures has been increasing [2-5].
Fractures in children exhibit unique patterns. Because of the distinctive properties of the growing bone, special attention is required to differentiate normal variants and, for the physeal fracture, to guarantee adequate healing while avoiding growth disturbance. (See 'Physeal fracture description' below.)
FRACTURE DESCRIPTION IN CHILDREN — Describing a fracture entails a thorough explanation of both the clinical scenario and the radiographic findings (table 1).
The clinical narrative should include:
●Mechanism of injury
●Soft tissue involvement (eg, open or closed)
●Key physical examination findings, especially neurovascular status
The initial imaging study is usually a plain radiograph. The radiologic interpretation of the fracture encompasses the following:
●Type of imaging (including modality and view selection)
●Relationship of fragments
●Physeal involvement (ie, Salter-Harris classification)
●Joint or soft tissue involvement
A more detailed discussion of how to describe a fracture based on the plain radiograph is provided separately. (See "General principles of fracture management: Bone healing and fracture description", section on 'Fracture description'.)
PLAIN RADIOGRAPH VIEWS — An accurate radiologic evaluation begins with obtaining the appropriate imaging study which is usually a plain radiograph. Standard radiographic series in fracture evaluations of the extremities are often two or three views and vary by the anatomic region of interest (table 2).
The assessment of a child with suspected fracture, especially of the long bone diaphysis, requires physical examination of the joint both above and below the site of injury. In some instances, radiographs of these areas are also needed. As an example, the Monteggia fracture is a well described fracture of the proximal one-third of the ulna with dislocation of the radial head. If the clinician visualizes a radial head dislocation on an elbow series, it would be important to also image the entire forearm to evaluate for a Monteggia fracture, a well-described pattern that is associated with a mid-to-proximal shaft ulna fracture that may be missed on a dedicated elbow series. (See "Proximal fractures of the forearm in children", section on 'Monteggia fractures'.)
FRACTURE PATTERNS — The periosteum of pediatric bone has significant osteogenic potential and is comparatively more metabolically active than the adult periosteum. This active periosteum promotes callus formation, union of fractures, and remodeling during the healing process. The periosteum is also thicker and stronger in children, which limits fracture displacement, reduces the likelihood of open fractures, and maintains fracture stability in comparison to adult fractures [6,7]. The qualities and function of the pediatric periosteum are responsible for some of the unique fracture patterns seen in children [6,8,9]. Examples of these fractures include buckle, greenstick, and plastic deformation (or bowing).
A bone fails when the loading forces exceed the load bearing capacity. Depending upon both the force of the injury and the properties of the bone involved, load failure results in a fracture in several unique patterns. Three fundamental forces cause fractures: shear, compressive, and tensile. Bone is least able to withstand shear forces, followed by tension, then compression .
Tensile bone failure causes fractures perpendicular to the direction of loading (transverse), whereas compression forces cause oblique stresses in a plane approximately 45 degrees to the bone's long axis . Bending forces result in a tensile stress to the convex side and a compressive stress to the concave side, resulting in transverse and oblique fractures on the tensile and compressive sides respectively. This tensile-compressive pattern from bending can cause a resultant bone wedge referred to as a butterfly fragment or the characteristic greenstick fracture. Torsion (rotational) forces lead to more complex fractures by causing a small crack to extend into a spiral pattern (figure 1). Many fractures, however, involve combinations of forces and therefore develop complex fracture patterns (figure 2).
Fractures specific to the pediatric patient are discussed here. Common fracture patterns (eg, transverse, oblique, spiral) seen in both children and adults are discussed in detail separately. (See "General principles of fracture management: Bone healing and fracture description", section on 'Orientation: Transverse, oblique, and spiral'.)
Buckle (torus) — Buckle fractures follow compression injury, often at the junction between the porous metaphysis and the denser diaphysis (image 1). With buckle fractures, the cortical compression may be associated with an intact or disrupted periosteum, depending upon the extent of the fracture. These injuries typically occur in the distal radius after longitudinal trauma directed along the shaft of the bone (eg, fall on an outstretched hand (image 2)), but are also seen in the distal tibia (image 3), fibula, and femur. Buckle fractures are also known as torus fractures (derived from the Greek "tora," meaning ring and referring to the radiologic resemblance to the raised band around the base of a Greek column, and also from the Latin "tori," for swelling or protuberance). Buckle fractures are by definition stable and can often be managed with splinting by a knowledgeable clinician and a single follow-up visit . (See "Distal forearm fractures in children: Diagnosis and assessment", section on 'Torus (buckle) fractures' and "Distal forearm fractures in children: Initial management", section on 'Torus (buckle) fracture'.)
Plastic deformation — A plastic deformity (or bowing fracture) occurs when a longitudinal force directed along the shaft of the bone exceeds the bone's ability to recoil to its normal position leading to accentuation of the curvature of the bone which indicate microscopic fractures within the periosteum of the bone (image 4 and image 5). Plastic deformities are most commonly seen in the ulna, the radius, and occasionally in the fibula. If the deformation is less than 20 degrees or if the deformity occurs in a young child (<4 years of age), the angulation often corrects itself . Otherwise, urgent referral to an orthopedist with pediatric expertise for closed reduction or operative intervention is necessary to ensure proper healing. (See "Midshaft forearm fractures in children", section on 'Plastic deformation'.)
Greenstick — A greenstick fracture describes a bone that is bent with a fracture line that does not extend completely through the width of the bone (image 6 and image 7). With these injuries, one side has a visible, complete fracture (sometimes referred to as the "tension side") and the opposite side has a plastic deformation or buckling due to compression. The greenstick fracture is at high risk for repeat fracture. For example, primary greenstick fractures account for 84 to 100 percent of forearm recurrent fractures [14-16]. All greenstick fractures warrant immobilization followed by casting within a few days of injury. The need for orthopedic referral at the initial visit depends upon the age of the child and the degree of angulation as discussed separately. (See "Distal forearm fractures in children: Initial management", section on 'Greenstick fracture' and "Midshaft forearm fractures in children", section on 'Greenstick fracture'.)
Physeal (growth plate) — The diagnosis and management of specific types of physeal fractures is discussed separately and can be found by searching on the long bone of interest.
The anatomy of the growth plate leads to a special susceptibility to fractures and long-term complications in children:
●Normal long bone physis anatomy and growth – The growth plate or physis represents a major anatomical difference between adult and pediatric bone. Growing long bones in children are composed of the following segments: diaphysis (shaft), metaphysis (where the bone flares), physis (growth plate), and epiphysis (secondary ossification center) (figure 3).
The longitudinal growth of long bones occurs primarily at the physis. The germinal area of the physis borders the epiphysis. The epiphyseal cartilage cells grow toward the metaphysis and form columns of cells. These columns degenerate, undergo hypertrophy, and then calcify at the metaphysis to form new bone (figure 3) . The epiphyseal cartilage cells stop duplicating at the end of puberty. The entire cartilage is eventually replaced by bone and epiphyseal lines remain at the site . The contribution of specific physes to longitudinal growth in the extremities varies by site (figure 4).
In infancy and early childhood, the physis is relatively thick and the epiphysis is mostly cartilaginous, serving as a shock absorber and transmitting forces to the metaphysis. During adolescence, when the epiphysis begins to ossify, these forces are less absorbed and consequently transmitted to the physis.
Once the physis closes, then adult patterns of fracture are seen. The timing of physeal closure varies in individual patients and by bone and patient sex (figure 5).
●Physeal fractures – Growth plates are susceptible to fracture and represent a weak point in pediatric bone. Histologically, the weakest part of the physis is the third zone (zone of hypertrophic cartilage), and is the most common site for physeal fractures (figure 3). Because the tensile strength of pediatric bone is less than that of the ligaments, the same injury mechanism causing a ligamentous injury in adults (sprain or strain) may be more likely to cause a bone injury in children: the physis will separate or fracture before disruption or "spraining" of an adjacent strong and flexible ligament [6-8,18].
The growth and change that occur at a growth plate promotes rapid healing of fractures in children. However, injury to the physis itself can lead to asymmetric growth and subsequent deformity [6,19,20]. Displaced physeal fractures require prompt consultation with an orthopedist with pediatric expertise. Thus, accurate description of these pediatric fractures is essential to communicating the seriousness of bone injury and the potential for growth disturbance. (See 'Physeal fracture description' below.)
Physeal injuries occur in 21 to 30 percent of pediatric long bone fractures [21,22], more commonly involving the distal growth plates of the radius and ulna . In girls, growth plate injuries occur between ages 9 and 12, while in boys they typically occur later, between ages 12 and 15 . Although a majority of these fractures heal without incident, approximately 30 percent of these physeal fractures cause a growth disturbance (premature closure and unilateral long bone shortening) . Appropriate anatomic alignment is critical for optimal growth and minimal deformity following physeal fractures .
Apophyseal avulsion — Certain physes contain fibrocartilage instead of columnar cartilage (eg, tibial tuberosity or the inferior pole of the patella) and are called apophyses. These apophyseal centers are prone to overuse traction and inflammation, termed apophysitis. Characteristic apophyseal overuse injuries include:
●Osgood-Schlatter disease (tibial tuberosity (picture 1)) (see "Osgood-Schlatter disease (tibial tuberosity avulsion)")
●Pelvis (iliac crest, anterior superior iliac spine (image 8), anterior inferior iliac spine, symphysis pubis, and ischial tuberosity (image 9)) (see "Radiologic evaluation of the hip in infants, children, and adolescents", section on 'Pelvic apophyseal avulsions')
●Sinding-Larsen-Johansson syndrome (inferior pole of the patella) (see "Approach to chronic knee pain or injury in children or skeletally immature adolescents", section on 'Sinding-Larsen-Johansson disease (patellar apophysitis)')
●Iselin disease (fifth metatarsal (image 10) (see "Forefoot and midfoot pain in the active child or skeletally immature adolescent: Overview of causes", section on 'Iselin disease (fifth metatarsal traction apophysitis)')
Potentially occult fractures — The following pediatric fractures may not be evident on initial plain radiographs and often require diagnosis based upon physical findings and follow-up imaging:
●Toddler's fracture (nondisplaced spiral fracture of the distal tibia) – The toddler's fracture is a nondisplaced fracture of the distal tibial shaft in patients in the age group from nine months to three years, when weightbearing is just beginning. AP and lateral radiographs of the affected leg may show a faint hairline fracture that can be easily missed, mistaken for a nutrient vessel, or inapparent on initial films in almost a third of patients. The AP view is the best view for observing the nondisplaced spiral fracture coursing along the distal tibia (image 11). Oblique views of the tibia can aid diagnosis when the AP and lateral plain radiographs are not revealing. In patients with clinical findings suggestive of a toddler's fracture but negative plain radiographs, repeat plain radiographs in seven days will often show evidence of a fracture line that was not apparent on initial radiograph or new bone growth suggesting a fracture. (See "Tibial and fibular shaft fractures in children", section on 'Toddler's fractures'.)
●Nondisplaced Salter-Harris I fracture – Type I Salter-Harris fractures can have normal plain radiographs. In these patients, the diagnosis is clinically suspected when focal tenderness is found over the growth plate and confirmed later when bone healing is found on repeat radiographs obtained seven days after injury. (See 'Salter I (Ogden IA-C)' below.)
●Nondisplaced type I supracondylar fractures of the elbow – With Gartland type I supracondylar fractures of the elbow, a fracture line may not be seen on plain radiographs but elbow effusion indicated by anterior sail and/or posterior fat pad signs is appreciated (figure 6 and image 12). (See "Elbow anatomy and radiographic diagnosis of elbow fracture in children", section on 'Fat pads' and "Supracondylar humeral fractures in children", section on 'Classification'.)
●Stress fractures — These fractures represent overuse injuries that arise from accumulated microtrauma after repetitive strain. The loads from stress fractures are less than what the bone can withstand, but cumulative fatigue damage can cause small but progressive cracks in the periosteum. Stress fractures are more commonly seen in adolescents than younger children and more frequently affect females. The common sites of stress fracture vary depending upon the sport (table 3). However, the most common sites of stress fracture, in decreasing order of frequency, are the tibia, fibula, pars interarticularis (ie, spondylolysis), and femur. (See "Overview of stress fractures".)
Plain radiographic findings usually are not apparent until one to two weeks after the onset of symptoms. They include lucency or periosteal reaction with new bone formation in cortical bone; callus does not appear until four weeks after the onset of symptoms. Magnetic resonance imaging (MRI) has become the preferred test when plain films are negative, and the diagnosis is essential. It is extremely sensitive and defines the anatomy and extent of injury more precisely than scintigraphy. (See "Overview of stress fractures", section on 'Approach to stress fracture imaging'.)
Child abuse — Clinicians should be cognizant of certain fracture patterns that are associated with child abuse. Fractures that are highly suggestive of intentional injury include (see "Orthopedic aspects of child abuse", section on 'Fracture patterns'):
●Long bone fractures in non-ambulatory children
●Rib fractures (image 16)
●Fractures of the sternum, scapula, or spinous processes
●Multiple fractures in various stages of healing (image 17)
●Bilateral acute long-bone fractures
●Vertebral body fractures and subluxations in the absence of a history of high force trauma
●Digital fractures in children younger than 36 months of age or without a corresponding history
●Displaced physeal fractures (sometimes called epiphyseal separations), especially transphyseal distal humerus fractures, in nonambulatory children (image 18)
●Complex skull fractures in children younger than 18 months of age, particularly without a corresponding history
Furthermore any fracture in children with other red flags for child abuse on history or physical examination should raise suspicion for abuse (table 4 and table 5). (See "Physical child abuse: Recognition", section on 'Approach'.)
Any suspicion of child abuse should prompt involvement of an experienced multidisciplinary child protection team (eg, child abuse specialist, social worker, and nurse), if available. In many parts of the world (including the United States, United Kingdom, and Australia), a mandatory report to appropriate governmental authorities is also required. (See "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse' and "Physical child abuse: Diagnostic evaluation and management".)
Pathologic fracture — A fracture in a bone that is weakened by an underlying abnormality is termed a pathologic fracture. Patients with bone tumors, rickets, McCune-Albright syndrome, juvenile osteoporosis, chronic renal insufficiency, osteogenesis imperfecta (OI), and osteopetrosis are all at greater risk for fractures. The proximal femur and humerus are the most frequent sites for pathologic fractures and unicameral (simple) bone cysts, aneurysmal bone cysts, and nonossifying fibromas are the most common tumors. (See "Nonmalignant bone lesions in children and adolescents".)
OI is the most common metabolic bone disorder that causes pathologic fractures. Features of OI include multiple fractures, a suggestive family history, and clinical manifestations that can include short stature, scoliosis, basilar skull deformities, hearing loss, blue sclerae, opalescent teeth, ligamentous laxity, and easy bruisability. (See "Osteogenesis imperfecta: An overview".)
Repeat fracture — Repeat or recurrent fractures occur at the initial site of injury. Repeat fractures make up only 1 in 1000 of all children's fractures, occurring frequently in the forearm and complicating 5 to 13 percent of forearm fractures [14,16,25]. Risk factors for refracture include incomplete bony union, residual angulation, early cast removal, radial or ulnar diaphyseal fracture, and greenstick fracture pattern [15,16,26-29]. (See "Midshaft forearm fractures in children", section on 'Complications' and "Distal forearm fractures in children: Initial management", section on 'Complications'.)
PHYSEAL FRACTURE DESCRIPTION — Several classification schemes for physeal fractures have been devised, including the Salter-Harris, Ogden, Peterson, and many others, most of which are specific to certain anatomical locations [30-32]. Of these, the Salter-Harris classification is easily applied and appropriate for the majority of physeal fractures. It is also the most widely used system and represents as much a means of communication between healthcare professionals as a method of classification.
The Salter-Harris classification system grades physeal fractures as types I through V. While controversial and joint dependent, the severity of injury to the growth plate generally increases with each Salter-Harris grade [33-35]. Complications of physeal injury include growth arrest, permanent decreased range of motion, and angular deformity . The following mnemonic can be helpful to remember the different Salter-Harris types when the long bone is in a vertical orientation with the epiphysis at the bottom. The mnemonic refers to the fracture line and its relationship to the growth plate (figure 8) :
●S ("Straight across") – Type I (low risk for growth plate injury)
●A ("Above") – Type II, fracture through the physis and the metaphysis
●L ("Lower" or "BeLow") – Type III, fracture through the physis and the epiphysis
●T ("Two" or "Through") – Type IV, fracture through the physis and both the metaphysis and the epiphysis
●E ("End") or ER ("ERasure of the growth plate") – Type V (high risk for growth plate injury)
Several modifications and additions have been made to the Salter-Harris schematic [38,39], including Ogden's system that includes injuries to surrounding elements such as the periosteum, zone of Ranvier, and perichondrium (figure 3 and figure 9) . While the five Salter-Harris types (with Ogden's elaboration) encompass the mainstay for physeal injuries, additional types have been described. (See 'Ogden Type VI' below and 'Ogden Type VII' below.)
Salter I (Ogden IA-C) — The fracture line extends through the zone of hypertrophic cartilage (zone 3), causing the epiphysis and physeal elements to separate from the metaphysis (figure 3 and image 19).
Subclasses of Salter I fractures are described by the Ogden classification:
●A type IA Ogden fracture is characterized by a non-displaced fracture through the physis without further extension of the fracture line.
●A type IB Ogden fracture is characterized by the fracture line extending through the primary spongiosa bone layer resulting in a thin line of bone displaced with the epiphysis. Type IB fractures usually occur in children with systemic diseases such as myeloproliferative disorders. Subsequent growth is usually normal with Type IA and IB fractures (figure 9).
●A Type IC Ogden fracture has an associated injury to the germinal portion of the physis. Type IC fractures can cause growth arrest and rarely occur after three years of age (figure 9).
Salter II (Ogden IIA-D) — The fracture line passes through the physis and then extends across the physeal-metaphyseal junction into the metaphysis (figure 8 and image 20). Type II fractures are the most common physeal fractures.
The Ogden classification subdivides Salter II fractures as follows:
●An Ogden Type IIA fracture is characterized by a metaphyseal wedge, also known as the Thurston Holland fragment (image 20).
●A type IIB involves further extension of the fracture line bidirectionally through the metaphysis creating a free metaphyseal fragment or multiple fragments (figure 9).
●A type IIC fracture is a transverse physeal fracture that includes a thin layer of metaphysis along with the metaphyseal triangular corner segment (figure 9).
●A type IID fracture is characterized by the angulation of the two segments resulting in the metaphyseal segment compressing the physis and creating an osseous bridge that leads to permanent growth arrest (figure 9).
Salter III (Ogden IIIA-D) — The fracture line extends through the physis and then spreads through the epiphysis into the intraarticular space (image 21). If the transverse fracture extends across the complete width of the physis, two epiphyseal segments may be formed.
●A Type IIIB fracture, similar to type IB, courses through the primary spongiosa physeal layer resulting in a thin bony metaphyseal line displaced with the epiphyseal segment (figure 9).
●Type IIIC injuries involve epiphyses in mostly nonarticular areas.
●Type IIID fractures penetrate the germinal zone and interrupt the blood supply to the avulsed segment. These fractures are difficult to visualize on traditional radiographs.
Salter IV (Ogden IVA-C) — The fracture line spreads from the articular surface, through the epiphysis, across the physis, and through a segment of the metaphysis (image 22).
●A Type IVB fracture is characterized by further transverse extension of the fracture through part or all of the physis creating additional epiphyseal fragments (figure 9).
●Type IVC fractures involve damage to the adjacent cartilage, and type IVD fractures have multiple metaphyseal-physeal-epiphyseal fragments, usually from severe trauma.
Salter V (Ogden V) — This fracture is thought to be caused by a force transmitted through the epiphysis and physis. The resultant disruption of the germinal matrix, hypertrophic regions, and vascular supply causes a severe injury with growth arrest and poor prognosis (figure 9). Type V injuries usually occur in joints that only move in one plane, such as the knee or ankle. Causes of type V injuries include electric shock, frostbite, and irradiation . The mechanism for this growth arrest is unknown but most theorize that compression, vascular insult, or an otherwise unrecognized direct injury are the most likely mechanisms . Because displacement of the epiphysis can be minimal, this fracture pattern may go unrecognized on initial radiographs although physeal injury can be demonstrated on magnetic resonance imaging (MRI).
Ogden Type VII — The fracture line is completely intraepiphyseal, from the epiphyseal cartilage into the secondary ossification center. These fractures classically occur as avulsions of fibrocartilaginous complexes at ossification centers, such as the tibial tuberosity (figure 9).
Peterson fractures — The Peterson classification system was developed based upon the epidemiologic results of 951 physeal fractures [24,43]. It describes two unique patterns not reflected in the Salter-Harris and Ogden systems; Peterson type I and VI fractures:
●Peterson type I – A Peterson type I fracture is a complete transverse metaphyseal disruption with an additional extension that extends longitudinally to the physis. This injury typically does not cause significant growth disturbance.
●Peterson type VI – A Peterson type VI fracture is a partial physeal loss usually including the epiphysis. This injury occurs largely from lawn mower trauma which is frequently associated with neurovascular injury and soft tissue damage.
AO pediatric classification — The Arbeitsgemeinschaft fur Osteosynthesefragen or AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF) is an adaptation of a similar system used in adult orthopedic trauma . This elaborate tool uses body location (bone, segment) and morphology (severity, displacement) to more distinctly identify the breadth of physeal and non-physeal pediatric long-bone fractures. Because there are more than 200 different categorizations according to the AO framework, this classification system may be better used for research purposes rather than routine clinical documentation.
ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General management of pediatric fractures" and "Society guideline links: Upper extremity, thoracic, and facial fractures in children" and "Society guideline links: Lower extremity fractures in children" and "Society guideline links: Acute pain management".)
●Fracture description – Describing a fracture entails a thorough explanation of both the clinical scenario and the radiographic findings (table 1). (See 'Fracture description in children' above and "General principles of fracture management: Bone healing and fracture description", section on 'Fracture description'.)
●Radiographic views – An accurate radiologic evaluation begins with obtaining the appropriate imaging study. Plain radiographs are usually the first study in children with suspected fractures. Standard radiographic series in fracture evaluations are often two or three views and vary by the anatomic region of interest (table 2). (See 'Plain radiograph views' above.)
●Pediatric fracture patterns – Children exhibit unique fracture patterns because of the relative compressibility of their bone, the increased fibrous strength of the periosteum, and the presence of the physis (growth plate). Examples of these fractures include buckle (image 1), greenstick (image 6), and plastic deformation (or bowing) (image 4). (See 'Fracture patterns' above.)
Clinicians should be cognizant of certain fracture patterns that are associated with child abuse, especially when other red flags for child abuse are present on history (table 4) or physical examination (table 5). (See 'Child abuse' above and "Orthopedic aspects of child abuse", section on 'Fracture patterns'.)
●Physeal fractures – The physis is susceptible to fracture and therefore similar forces that cause ligamentous injuries in adults may lead to physeal bone fractures in children. The Salter-Harris classification system has become the most widely accepted method for describing physeal fractures. Physeal fractures are graded as types I through V (figure 8). Special attention is needed for physeal injuries because growth arrest can occur. (See 'Physeal fracture description' above.)
Once the physis closes, then adult patterns of fracture are seen. The timing of physeal closure in the extremities varies in individual patients and by bone and patient sex (figure 5). (See 'Physeal (growth plate)' above.)
●Occult fractures – Some pediatric fractures may not be evident on initial plain radiographs and often require diagnosis based upon physical findings and follow-up imaging. Common examples include toddler's fractures (nondisplaced spiral fracture of the tibia) (image 11), Salter-Harris I fractures, Gartland type I supracondylar fractures of the elbow (figure 6 and image 12), and stress fractures (table 3). (See 'Potentially occult fractures' above.)
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