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Scapular Fractures: What Radiologists Need To Know: Alan M. Ropp Derik L. Davis
Scapular Fractures: What Radiologists Need To Know: Alan M. Ropp Derik L. Davis
Musculoskeletal Imaging
Review
FOCUS ON:
S
capular fractures are uncommon, Normal Biomechanics
accounting for only 3–5% of Background
shoulder girdle fractures and few- The scapula functions at the shoulder girdle
er than 1% of all fractures [1]. as a base of motion and stability in association
High-energy trauma is the most common with the superior shoulder suspensory complex
cause, and scapular fractures are frequently as- and the scapulothoracic, glenohumeral, and ac-
sociated with other acute injuries, including rib romioclavicular joints. These articulations pro-
fracture (53%), lung injury (47%), head injury vide a functional link between the thorax and
(39%), spinal fracture (29%), and clavicle frac- the upper extremity [7]. The superior shoulder
ture (25%) [2]. The initial diagnosis of scapular suspensory complex comprises a bone and liga-
fracture is often delayed or ignored, because mentous ring formed by the scapula, distal clav-
clinical care in the acute setting is focused on icle, acromioclavicular joint, and coracoclavicu-
patient resuscitation after one or more life- lar ligament. Scapular contributions include the
threatening injuries [3–5]. glenoid, coracoid, and acromion process [8].
Imaging plays the key role in identifying The superior shoulder suspensory complex, in
and classifying scapular fractures and thus concert with the scapulothoracic muscles, acts
guides clinical decision making. This article to suspend the upper extremity from the thorax.
will review the use of diagnostic imaging for The scapula, through its relationship with the
Keywords: CT, fracture, radiography, scapula, shoulder,
evaluating traumatic scapular fracture and superior shoulder suspensory complex, is hung
trauma describe imaging findings associated with from the clavicle by the acromioclavicular joint
operative management indications. and coracoclavicular ligament [9].
DOI:10.2214/AJR.15.14446 Scapular motion and stability rely on the
Anatomy sensorimotor system to coordinate the static
Received January 18, 2015; accepted after revision
February 22, 2015. The scapula is a flat triangular bone with and dynamic stabilizers of the shoulder gir-
several distinct regions (Fig. 1). The glenoid dle [10]. Coordination of scapulothoracic and
1
Both authors: Department of Diagnostic Radiology and fossa forms the articular surface of the scap- scapulohumeral musculature contractions, in
Nuclear Medicine, University of Maryland School of ula and connects to the scapular body via the concert with biofeedback from the glenohu-
Medicine, 22 S Greene St, Baltimore, MD 21201. Address
correspondence to D. L. Davis (ddavis7@umm.edu).
neck of the scapula. The scapula serves as an meral-capsuloligamentous complex, allows
attachment site for 17 muscles, which facil- normal motion and functional stability [10].
This article is available for credit. itate movement and form a functional soft-
tissue envelope for the shoulder girdle [6]. Scapulothoracic Joint
AJR 2015; 205:491–501
These muscles are subdivided into scapulo- The scapulothoracic joint provides dy-
0361–803X/15/2053–491 thoracic and scapulohumeral groups (Appen- namic stability at the shoulder girdle through
dix 1). The rotator cuff muscles are a sub- biomechanical support of the scapula and ro-
© American Roentgen Ray Society component of the scapulohumeral group. tator cuff musculature [11]. The scapulotho-
racic joint is fairly incongruent, with no di- TABLE 1: Ideberg Classification of Intraarticular Glenoid Fractures [33]
rect bony connection between the scapula
Type Description
and thorax [12]. The serratus anterior, trape-
zius, rhomboid major and minor, and levator 1 Anterior glenoid rim fracture
scapulae muscles are the main muscular sta- 2 Inferior glenoid fracture involving the inferior neck
bilizers. The serratus anterior is most impor- 3 Superior glenoid fracture involving the base of coracoid process
tant for maintaining normal medial scapular
4 Horizontal fracture through the neck and body, inferior to the spine
angle and chest wall alignment, and the tra-
pezius is most helpful for facilitating scapu- 5 Combination of types 2 and 4
lar motion in concert with the glenohumer-
al joint [6, 12]. The coordinated summation depth of the glenoid fossa and labrum is 5 clavicle fractures, as well as acromioclavicular
of scapulothoracic muscular forces acting on mm, compared with 9 mm for the superoin- and glenohumeral joint injuries. Grashey and
the scapula ultimately results in a movement ferior depth [19]. A decrease in glenoid bone axillary views are particularly useful for detec-
of protraction or retraction from the normal stock has a negative effect on glenohumer- tion of intraarticular scapular fractures by pro-
resting orientation of the scapula [6, 13] (Fig. al stability [6]. A loss of glenoid bone stock viding direct visualization of the glenoid fossa
2A). Protraction is the movement of the scap- of more than 21% in superoinferior depth or and glenohumeral joint space. Acquisition of
ula toward the anterior thorax, whereas re- more than 25% of the anterior glenoid places additional axillary views increases diagnostic
traction is the movement of the scapula to- stability at risk [20–22]. Additionally, the sensitivity for difficult to see acromion and cor-
ward the vertebral column [12]. glenoid fossa is retroverted by 7° relative acoid process fractures.
Three distinct individual variables of to the scapular body in healthy individuals
scapulothoracic motion are internal-exter- [23]. Excessive retroversion or anteversion of CT
the glenoid is also associated with glenohu- Conventional 2D and 3D CT examinations
American Journal of Roentgenology 2015.205:491-501.
[32, 36–38] (Fig. 4). Falling from a height or living despite scapular posttraumatic deformi- vehicle accidents are the most common cause
a pedestrian’s being struck by a moving vehi- ty [1]. Certain extraarticular fractures, wheth- [37]. In addition to direct blunt trauma, other
cle are other common mechanisms [36, 38]. In- er occurring alone or in combination with oth- mechanisms of acromion process fracture in-
traarticular fractures of the glenoid account for er injuries, have more recently challenged this clude indirect trauma after shoulder dislocation
the vast majority of open reduction and inter- dogma (Appendix 2). ORIF of displaced frac- and avulsion by the deltoid muscle [37, 46].
nal fixation (ORIF) procedures performed for tures has been touted as an avenue to decrease Fractures of the acromion process have been
management of scapular fracture [39]. long-term pain, weakness, and functional dis- classified according to anatomic location rela-
Anterior shoulder dislocation is an addi- ability [4, 8, 9, 41–43]; nevertheless, relative in- tive to the acromioclavicular joint, acromial
tional mechanism associated with intraartic- dications for extraarticular scapular fractures angle, or scapular spine [59]. Kuhn et al. [60],
ular fracture of the anterior glenoid [40] (Fig. remain controversial [1]. however, described an alternative functional
5). These Ideberg type 1 fractures of the gle- method based on the presence or absence of
noid are the most typical scapular fracture Coracoid Process subacromial impingement: Kuhn type I frac-
pattern encountered after shoulder disloca- Coracoid process fractures represent 2–13% tures are minimally displaced, type II fractures
tion, with shoulder dislocations accounting of scapular fractures [37, 42, 44]. These frac- are significantly displaced without subacromi-
for two thirds of type 1 fractures [33]. tures most often occur at the base with mini- al space narrowing, and type III fractures are
Most nondisplaced intraarticular glenoid mal displacement [37, 45, 46]. Several mech- significantly displaced with subacromial space
fractures are managed nonoperatively. How- anisms account for coracoid process fractures narrowing. Patients with Kuhn type III acro-
ever, displaced fractures demand consideration including direct blunt trauma or indirect trau- mion fractures are prone to develop decreased
for operative fixation, because the various myo- ma from a shoulder dislocation [47–49] (Fig. range of motion and rotator cuff injury [60].
tendinous units attaching to the scapula pull in 6). An isolated fracture of the coracoid process Nondisplaced acromion process fractures
different directions and contribute to distrac- in association with an anterior dislocation is of- are most commonly treated with conservative
ten overlooked on radiographs [48]. Additional management with good outcomes [58]. How-
American Journal of Roentgenology 2015.205:491-501.
favorable long-term outcomes with non- ment cortex. Translation is defined by the dis- disruptions of the superior shoulder suspensory
operative management [5, 8]. tance of anteroposterior displacement between complex [57, 62, 70].
Even though conservative management is the superior and inferior scapular neck fracture The criteria for superior shoulder suspen-
also the mainstay of treatment of most dis- fragments. Translation is measured as the dis- sory complex double disruption ORIF re-
placed scapular neck and spine fractures, sur- tance between the anterior cortex of the supe- main controversial because no uniform stan-
geons may choose to perform ORIF in certain rior fragment and the anterior cortex of the in- dards exist, and nonoperative management
instances. The displaced scapular neck fracture ferior fragment. Translation of at least 1 cm is a of extraarticular scapular fractures has been
has received the most attention, because mal- relative indication for surgery [9]. the traditional norm. The minimum amount
union has been implicated for the loss of nor- of displacement to indicate surgical manage-
mal biomechanics at the shoulder, stemming Floating Shoulder Injuries ment is still debated [9, 71]. The decision to
from rotator cuff dysfunction, scapulothoracic The original description of a “floating perform ORIF in these circumstances is de-
muscular injury, muscular fibrosis, and altered shoulder” injury comprised simultaneous pendent on the surgeon’s preference and pa-
muscular efficiency [1, 5, 43]. Biomechani- scapular neck and ipsilateral clavicle fractures tient comorbidity, age, hand dominance, over-
cal studies also have suggested that displaced [8] (Fig. 9); however, the meaning of this term all health, activities of daily living, and level
scapular neck fractures negatively affect the has more recently been expanded to include of physical activity [1]. The goal of surgical
stability of the glenohumeral joint by altering two or more disruptions of the superior shoul- intervention for floating shoulder injuries is to
the length of rotator cuff muscles during cer- der suspensory complex [9]. Floating shoulder reduce unstable fracture patterns, support an
tain phases of movement [43]. Pain and weak- injuries are rare and represent less than 0.2% early program of physical rehabilitation, and
ness also have been reported in patients with of shoulder girdle fracture patterns [64]. An prevent long-term functional deficits [58, 69].
significant displacement and malalignment of unstable shoulder girdle occurs with two or
scapular neck fractures [5, 41, 42]. more displaced fractures involving the scap- Conclusion
ular neck and clavicle, acromion process, or
American Journal of Roentgenology 2015.205:491-501.
cepts: the stabilizing structures of the glenohu- Clin Orthop Relat Res 2011; 469:3371–3378 erature. J Bone Joint Surg Am 1977; 59:358–362
meral joint. J Orthop Sports Phys Ther 1997; 29. Bartoníček J, Frič V. Scapular body fractures: re- 45. Eyres KS, Brooks A, Stanley D. Fractures of the
25:364–379 sults of operative treatment. Int Orthop 2011; coracoid process. J Bone Joint Surg Br 1995;
12. Paine R, Voight ML. The role of the scapula. Int J 35:747–753 77:425–428
Sports Phys Ther 2013; 8:617–629 30. Armitage BM, Wijdicks CA, Tarkin IS, et al. 46. Goss TP. The scapula: coracoid, acromial, and
13. Halder AM, Itoi E, An KN. Anatomy and biome- Mapping of scapular fractures with three-dimen- avulsion fractures. Am J Orthop 1996; 25:106–115
chanics of the shoulder. Orthop Clin North Am sional computed tomography. J Bone Joint Surg 47. Froimson AI. Fracture of the coracoid process of the
2000; 31:159–176 Am 2009; 91:2222–2228 scapula. J Bone Joint Surg Am 1978; 60:710–711
14. Ludewig PM, Phadke V, Braman JP, Hassett DR, 31. Tadros AM, Lunsjo K, Czechowski J, Corr P, 48. Benchetrit E, Friedman B. Fracture of the cora-
Cieminski CJ, LaPrade RF. Motion of the shoul- Abu-Zidan FM. Usefulness of different imaging coid process associated with subglenoid disloca-
der complex during multiplanar humeral eleva- modalities in the assessment of scapular fractures tion of the shoulder: a case report. J Bone Joint
tion. J Bone Joint Surg Am 2009; 91:378–389 caused by blunt trauma. Acta Radiol 2007; 48:71–75 Surg Am 1979; 61:295–296
15. McClure PW, Michener LA, Karduna AR. Shoul- 32. Herrera DA, Anavian J, Tarkin IS, Armitage BA, 49. Wong-Chung J, Quinlan W. Fractured coracoid
der function and 3-dimensional scapular kinemat- Schroder LK, Cole PA. Delayed operative man- process preventing closed reduction of anterior dis-
ics in people with and without shoulder impinge- agement of fractures of the scapula. J Bone Joint location of the shoulder. Injury 1989; 20:296–297
ment syndrome. Phys Ther 2006; 86:1075–1090 Surg Br 2009; 91:619–626 5 0. Martín-Herrero T, Rodríguez-Merchán C,
16. Terry GC, Chopp TM. Functional anatomy of the 33. Ideberg R, Grevsten S, Larsson S. Epidemiology of Munuera-Martínez L. Fractures of the coracoid
shoulder. J Athl Train 2000; 35:248–255 scapular fractures: incidence and classification of 338 process: presentation of seven cases and review of
17. Bahk M, Keyurapan E, Tasaki A, Sauers EL, fractures. Acta Orthop Scand 1995; 66:395–397 the literature. J Trauma 1990; 30:1597–1599
McFarland EG. Laxity testing of the shoulder: a 34. McGinnis M, Denton JR. Fractures of the scapu- 51. Baccarani G, Porcellini G, Brunetti E. Fracture of
review. Am J Sports Med 2007; 35:131–144 la: a retrospective study of 40 fractured scapulae. the coracoid process associated with fracture of
American Journal of Roentgenology 2015.205:491-501.
18. Pagnani MJ, Warren RF. Stabilizers of the glenohu- J Trauma 1989; 29:1488–1493 the clavicle: description of a rare case. Chir Or-
meral joint. J Shoulder Elbow Surg 1994; 3:173–190 35. Nork SE, Barei DP, Gardner MJ, Schildhauer TA, gani Mov 1993; 78:49–51
19. Howell SM, Galinat BJ. The glenoid-labral sock- Mayo KA, Benirschke SK. Surgical exposure and 52. Montgomery SP, Loyd RD. Avulsion fracture of
et: a constrained articular surface. Clin Orthop fixation of displaced type IV, V, and VI glenoid the coracoid epiphysis with acromioclavicular
Relat Res 1989; 122–125 fractures. J Orthop Trauma 2008; 22:487–493 separation: report of two cases in adolescents and
20. De Wilde LF, Berghs BM, Audenaert E, Sys G, 36. Schandelmaier P, Blauth M, Schneider C, Krettek review of the literature. J Bone Joint Surg Am
Van Maele GO, Barbaix E. About the variability C. Fractures of the glenoid treated by operation: a 1977; 59:963–965
of the shape of the glenoid cavity. Surg Radiol 5- to 23-year follow-up of 22 cases. J Bone Joint 53. Ishizuki M, Yamaura I, Isobe Y, Furuya K, Tanabe
Anat 2004; 26:54–59 Surg Br 2002; 84:173–177 K, Nagatsuka Y. Avulsion fracture of the superior
21. Burkhart SS, Debeer JF, Tehrany AM, Parten 37. Anavian J, Wijdicks CA, Schroder LK, Vang S, border of the scapula: report of five cases. J Bone
PM. Quantifying glenoid bone loss arthroscopi- Cole PA. Surgery for scapula process fractures: Joint Surg Am 1981; 63:820–822
cally in shoulder instability. Arthroscopy 2002; good outcome in 26 patients. Acta Orthop 2009; 54. Benton J, Nelson C. Avulsion of the coracoid
18:488–491 80:344–350 process in an athlete: report of a case. J Bone Joint
22. Itoi E, Lee SB, Berglund LJ, Berge LL, An KN. 38. Cole PA, Gauger EM, Herrera DA, Anavian J, Surg Am 1971; 53:356–358
The effect of a glenoid defect on anteroinferior Tarkin IS. Radiographic follow-up of 84 opera- 55. Ogawa K, Matsumura N, Ikegami H. Coracoid frac-
stability of the shoulder after Bankart repair: a tively treated scapula neck and body fractures. tures: therapeutic strategy and surgical outcomes. J
cadaveric study. J Bone Joint Surg Am 2000; Injury 2012; 43:327–333 Trauma Acute Care Surg 2012; 72:E20–E26
82:35–46 39. Zlowodzki M, Bhandari M, Zelle BA, Kregor PJ, 56. Ogawa K, Yoshida A, Takahashi M, Ui M. Frac-
23. Saha AK. Dynamic stability of the glenohumeral Cole PA. Treatment of scapula fractures: system- tures of the coracoid process. J Bone Joint Surg
joint. Acta Orthop Scand 1971; 42:491–505 atic review of 520 fractures in 22 case series. J Br 1997; 79:17–19
24. Brewer BJ, Wubben RC, Carrera GF. Excessive Orthop Trauma 2006; 20:230–233 57. Kim SH, Chung SW, Kim SH, Shin SH, Lee YH.
retroversion of the glenoid cavity: a cause of non- 40. Aston JW Jr, Gregory CF. Dislocation of the Triple disruption of the superior shoulder suspen-
traumatic posterior instability of the shoulder. J shoulder with significant fracture of the glenoid. J sory complex. Int J Shoulder Surg 2012; 6:67–70
Bone Joint Surg Am 1986; 68:724–731 Bone Joint Surg Am 1973; 55:1531–1533 58. Hill BW, Anavian J, Jacobson AR, Cole PA. Sur-
25. Abboud JA, Soslowsky LJ. Interplay of the static 41. Bozkurt M, Can F, Kirdemir V, Erden Z, gical management of isolated acromion fractures:
and dynamic restraints in glenohumeral instabili- Demirkale I, Basbozkurt M. Conservative treat- technical tricks and clinical experience. J Orthop
ty. Clin Orthop Relat Res 2002; 48–57 ment of scapular neck fracture: the effect of sta- Trauma 2014; 28:e107–e113
26. Ha AS, Petscavage-Thomas JM, Tagoylo GH. Ac- bility and glenopolar angle on clinical outcome. 59. Ogawa K, Naniwa T. Fractures of the acromion
romioclavicular joint: the other joint in the shoul- Injury 2005; 36:1176–1181 and the lateral scapular spine. J Shoulder Elbow
der. AJR 2014; 202:375–385 42. Ada JR, Miller ME. Scapular fractures: analysis Surg 1997; 6:544–548
27. McAdams TR, Blevins FT, Martin TP, DeCoster of 113 cases. Clin Orthop Relat Res 1991; 174–180 60. Kuhn JE, Blasier RB, Carpenter JE. Fractures of
TA. The role of plain films and computed tomog- 43. Chadwick EK, van Noort A, van der Helm FC. the acromion process: a proposed classification
raphy in the evaluation of scapular neck fractures. Biomechanical analysis of scapular neck mal- system. J Orthop Trauma 1994; 8:6–13
J Orthop Trauma 2002; 16:7–11 union: a simulation study. Clin Biomech (Bristol, 61. Gorczyca JT, Davis RT, Hartford JM, Brindle TJ.
28. Anavian J, Conflitti JM, Khanna G, Guthrie ST, Avon) 2004; 19:906–912 Open reduction internal fixation after displacement
Cole PA. A reliable radiographic measurement 44. Wilber MC, Evans EB. Fractures of the scapula: of a previously nondisplaced acromial fracture in a
technique for extra-articular scapular fractures. an analysis of forty cases and a review of the lit- multiply injured patient: case report and review of
literature. J Orthop Trauma 2001; 15:369–373 coid process of the scapula with acromioclavicu- servative treatment of ipsilateral fractures of the
62. Hardegger FH, Simpson LA, Weber BG. The op- lar separation: case report and review of the litera- scapula and clavicle. J Trauma 1997; 42:239–242
erative treatment of scapular fractures. J Bone ture. Acta Orthop Belg 1989; 55:499–503 69. Oh W, Jeon IH, Kyung S, Park C, Kim T, Ihn C.
Joint Surg Br 1984; 66:725–731 66. Kibler WB, Ludewig PM, McClure PW, Michener The treatment of double disruption of the superior
63. Dounchis JS, Pedowitz RA, Garfin SR. Symptom- LA, Bak K, Sciascia AD. Clinical implications of shoulder suspensory complex. Int Orthop 2002;
atic pseudarthrosis of the acromion: report of a scapular dyskinesis in shoulder injury: the 2013 26:145–149
case and review of the literature. J Orthop Trau- consensus statement from the ‘Scapular Summit.’ 70. Lecoq C, Marck G, Curvale G, Groulier P. Triple
ma 1999; 13:63–66 Br J Sports Med 2013; 47:877–885 fracture of the superior shoulder suspensory com-
64. Herscovici D Jr, Fiennes AG, Allgower M, Ruedi 67. Edwards SG, Whittle AP, Wood GW II. Non- plex [in French]. Acta Orthop Belg 2001; 67:68–72
TP. The floating shoulder: ipsilateral clavicle and operative treatment of ipsilateral fractures of the 71. Williams GR Jr, Naranja J, Klimkiewicz J, Karduna
scapular neck fractures. J Bone Joint Surg Br scapula and clavicle. J Bone Joint Surg Am 2000; A, Iannotti JP, Ramsey M. The floating shoulder: a
1992; 74:362–364 82:774–780 biomechanical basis for classification and manage-
65. Barentsz JH, Driessen AP. Fracture of the cora- 68. Ramos L, Mencia R, Alonso A, Ferrandez L. Con- ment. J Bone Joint Surg Am 2001; 83:1182–1187
APPENDIX 1: Muscles With Scapular Attachments APPENDIX 2: Relative Indications for Operative Management
Scapulothoracic group of Scapular Fractures
Serratus anterior Intraarticular fractures: glenoid fossa
Trapezius Displacement of at least 4 mm
Pectoralis minor Articular surface fracture involving at least 20%
American Journal of Roentgenology 2015.205:491-501.
Rhomboid major Anterior rim fracture involving at least 25% of articular surface
Rhomboid minor Posterior rim fracture involving at least 33% of articular surface
Levator scapulae Extension to medial scapular border
Latissimus dorsi Extraarticular fractures
Scapulohumeral group Coracoid process (isolated)
Rotator cuff Displacement of at least 10 mm
Supraspinatus Intraarticular extension
Infraspinatus Significant future biomechanical demands
Subscapularis Acromion process (isolated)
Teres minor Displacement of at least 10 mm
Deltoid Painful nonunion
Long head of the biceps brachii Associated subacromial impingement
Short head of the biceps brachii Scapular neck
Coracobrachialis Glenopolar angle up to 22°
Teres major Lateral border offset of at least 10 mm
Triceps brachii Angulation of at least 40°
Translation of at least 10 mm
Superior shoulder suspensory complex
At least two disruptions with displacement of at least 10 mm
A B
A B C
Fig. 3—Example measurements for scapular neck fracture.
A, Coronal volume-rendered 3D CT image corresponding to anteroposterior radiograph shows measurement of
glenopolar angle by tracing confluence of lines between superior-inferior glenoid pole axis and superior glenoid
pole-inferior scapular angle axis. (Acromion is not shown.)
B, Coronal volume-rendered 3D CT image corresponding to anteroposterior radiograph shows measurement of
lateral border offset by tracing distance between lateral margins of superior and inferior scapular neck fracture
American Journal of Roentgenology 2015.205:491-501.
fragments.
C, Sagittal volume-rendered 3D CT image corresponding to scapular Y radiograph shows measurement of
angulation for scapular neck fracture by tracing confluence of lines parallel to superior and inferior neck
fragment cortexes.
D, Sagittal volume-rendered 3D CT image corresponding to scapular Y radiograph shows measurement of
translation for scapular neck fracture by tracing distance between superior and inferior fragment anterior
cortexes.
A B C
Fig. 5—69-year-old man after fall from height.
A, Anteroposterior radiograph shows acute anterior shoulder dislocation.
B, Sagittal volume-rendered 3D CT image shows acute fracture and anterior displacement of large fracture fragment (arrow) from anterior glenoid rim (Ideberg type 1).
C, Axial T2-weighted fat-saturated image shows acute displaced bony Bankart fracture at anterior inferior glenoid rim (long arrow) with associated bone marrow edema
at posterolateral head (short arrow).
A B
A B
A B
Fig. 11—42-year-old man after fall from ladder.
A, Oblique coronal volume-rendered 3D CT image shows acute displaced acromion and coracoid process
American Journal of Roentgenology 2015.205:491-501.
fractures. Nondisplaced acute fractures are also present at base of coracoid process and scapular body.
B, Sagittal volume-rendered 3D CT image shows associated intraarticular comminuted glenoid fracture with
significant displacement.
F O R YO U R I N F O R M AT I O N
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