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Background

Pelvic fracture is a disruption of the bony structures of the pelvis. In elderly persons, the most
common cause is a fall from a standing position. However, fractures associated with the greatest
morbidity and mortality involve significant forces such as from a motor vehicle crash or fall from a
height.
For related information, see Medscape's Fracture Resource Center.

Pathophysiology
The bony pelvis consists of the ilium (ie, iliac wings), ischium, and pubis, which form an anatomic
ring with the sacrum. Disruption of this ring requires significant energy. Because of the forces
involved, pelvic fractures frequently involve injury to organs contained within the bony pelvis. In
addition, trauma to extra-pelvic organs is common. Pelvic fractures are often associated with severe
hemorrhage due to the extensive blood supply to the region.
Pelvic fractures are most commonly described using one of two classification systems.
The Tile classification system is based on the integrity of the posterior sacroiliac complex.
In type A injuries, the sacroiliac complex is intact. The pelvic ring has a stable fracture that
can be managed nonoperatively.
Type B injuries are caused by either external or internal rotational forces resulting in partial
disruption of the posterior sacroiliac complex. These are often unstable.
Type C injuries are characterized by complete disruption of the posterior sacroiliac complex
and are both rotationally and vertically unstable. These injuries are the result of great force,
usually from a motor vehicle crash, fall from a height, or severe compression.
The Young classification system is based on mechanism of injury: lateral compression,
anteroposterior compression, vertical shear, or a combination of forces. Lateral compression (LC)
fractures involve transverse fractures of the pubic rami, either ipsilateral or contralateral to a
posterior injury.
Grade I - Associated sacral compression on side of impact
Grade II - Associated posterior iliac ("crescent") fracture on side of impact
Grade III - Associated contralateral sacroiliac joint injury
Anterior-posterior compression (APC) fractures, shown in the radiograph below, involve
symphyseal diastasis or longitudinal rami fractures.

Anterior-posterior (AP) compression pelvic fracture.


[ CLOSE WINDOW ]

Anterior-posterior (AP) compression pelvic fracture.


Grade I - Associated widening (slight) of pubic symphysis or of the anterior sacroiliac (SI)
joint, while sacrotuberous, sacrospinous, and posterior SI ligaments remain intact
Grade II - Associated widening of the anterior SI joint caused by disruption of the anterior
SI, sacrotuberous, and sacrospinous ligaments; posterior SI ligaments remain intact
Grade III (open book) - Complete SI joint disruption with lateral displacement and disrupted
anterior SI, sacrotuberous, sacrospinous, and posterior SI ligaments
Vertical shear (VS) involves symphyseal diastasis or vertical displacement anteriorly and
posteriorly, which is usually through the SI joint, though occasionally through the iliac wing or
sacrum. This is shown in the radiograph below.

Vertical shear (VS) fracture pattern.


[ CLOSE WINDOW ]

Vertical shear (VS) fracture pattern.


Combined mechanical (CM) fractures involve a combination of these injury patterns, with LC/VS
being the most common.
Recently reported intraobserver and interobserver variability among orthopedic surgeons asked to
use these systems to classify pelvic fractures may limit their utility.1
Acetabular fractures most commonly involve disruption of the acetabular socket when the hip is
driven backward in a motor vehicle accident. Occasionally, they occur in a pedestrian struck by a
vehicle moving at a significant rate of speed.
Falls in elderly persons may involve fractures (usually of the pubic rami) without disruption of the
ring.

Frequency
United States
Pelvic fractures represent 3% of all skeletal fractures and 1-2% of fractures seen by orthopedists
who care for children. Single pubic rami and avulsion fractures are most common.

Mortality/Morbidity
Over half of all pelvic fractures occur as a result of minimal-to-moderate trauma, such as a fall from
a standing position. Of these, 95% are minor. On the other hand, the more severe pelvic fractures
involve significant trauma. Most of this discussion relates to the severe pelvic fractures.

A recent analysis of a database of more than 63,000 trauma patients showed that pelvic
fracture was associated with higher mortality.2
Cited mortality rates for pelvic fractures range from 3-20%. One study of pelvic fractures in
children aged 16 years or younger cited a mortality rate of 5%, with death most commonly
due to hemorrhage or multiple injuries.3
Despite aggressive intervention, elderly patients with pelvic fractures have a worse outcome

than younger patients with similar injuries.4


Ultimately, the patient's Injury Severity Score, not the nature of the pelvic fracture, is the
best predictor of mortality. Hemorrhage, either pelvic or extrapelvic, or associated severe
head injury are the most common causes of early death, whereas multisystem organ failure
and sepsis resulting from soft tissue infection near the fracture site are the main causes of
delayed death.5
The complication rate associated with pelvic fractures is significant and is related to injury
of underlying organs and bleeding. Because of the tremendous force necessary to cause most
unstable pelvic fractures, concomitant severe injuries are common and are associated with
high morbidity and mortality.
Pelvic fractures also increase the incidence of pulmonary emboli.

Sex

In a 2007 study of a trauma registry in the United Kingdom, 58% of patients sustaining
a pelvic ring fracture were male.6 A trauma registry review that same year from New South
Wales, Australia, revealed that most patients sustaining high-energy pelvic ring fractures,
such as from an motor vehicle crash (MVC), were male, whereas females predominated in
low-energy injuries.7
Associated genitourinary (GU) injuries vary greatly between men and women and are
discussed in other articles. For many years, it was believed that women did not suffer
urethral injuries. It is now known that, while women suffer urethral injuries at a much lower
incidence than men, injuries do occur. Women suffer partial lacerations and partial
disruption. Complete urethral disruption is rare.

Age

Age distribution largely matches that of motor vehicle crashes, with car-car injuries more
prevalent in adults, especially younger adults, and car-pedestrian injuries more likely to
cause injury in children. The other group is the elderly, who tend to suffer pubic rami
fractures without internal injuries as a result of falls from a standing position.
In a 2007 study of a trauma registry in the United Kingdom, the median age of patients
sustaining a pelvic ring fracture was 39 years.6
In children, a recent study found that pelvic fractures were more likely when any of 4 factors
were present: Caucasian, aged 5-14 years, a pedestrian struck by a vehicle, or an occupant in
a motor vehicle crash.8

Clinical
History
Basic mechanism of significant blunt trauma should prompt consideration of a pelvic
fracture.

Physical

Tenderness, laxity, or instability on palpation of the bony pelvis suggests fracture. However,
while physical examination is specific for pelvic instability, it has a low sensitivity.9
Furthermore, in the later stages of pregnancy, the pelvic ligaments become stretched,

mimicking bony instability. Finally, extensive manipulation of a fractured pelvis can


increase the patient's discomfort and potentially increase bleeding.
Other signs that may suggest a pelvic fracture include hematuria; a hematoma over the
ipsilateral flank, inguinal ligament, proximal thigh, or in the perineum; neurovascular
deficits in the lower extremities; or rectal bleeding.
Vaginal bleeding or palpable fracture line on careful bimanual examination suggests pelvic
fracture in females.
Instability on hip adduction and pain on hip motion suggests an acetabular fracture, with or
without an associated hip fracture.
Urethral injuries vary widely by age with injuries to the prostatic urethra and bladder neck
limited to children. Direct lacerations to the urethra occur only in boys (small prostate) and
women. Signs of urethral injury in males include a high-riding or boggy prostate on rectal
examination, scrotal hematoma, or blood at the urethral meatus.
Note that digital rectal examination has a very low sensitivity for diagnosing pelvic
fractures. In fact, in a 2007 study assessing the utility of routine digital rectal examinations
to diagnose injury in 1401 trauma patients, the rectal examination missed 100% of the 67
pelvic fractures.10

Causes
Adults with significant pelvic fracture
Motor vehicle crash (50-60%)
Motorcycle crash (10-20%)
Pedestrian versus car (10-20%)
Falls (8-10%)
Crush (3-6%)
Children
Pedestrian versus car (60-80%)
Motor vehicle crash (20-30%)

Laboratory Studies
Serial hemoglobin and hematocrit measurements monitor ongoing blood loss.
Urinalysis may reveal gross or microscopic hematuria.
Pregnancy test is indicated in females of childbearing age to detect pregnancy as well as
potential bleeding sources (eg, miscarriage, abruptio placentae).

Imaging Studies
Radiography
Anteroposterior pelvic radiograph is the basic screening test and uncovers 90% of
pelvic injuries. However, as severely injured trauma patients often routinely undergo
CT scans of the abdomen and pelvis, plain pelvic radiographs in this patient
population are most appropriate for hemodynamically unstable patients to allow for
rapid diagnosis of pelvic fractures and early notification of interventional radiology.

Anteroposterior (AP) compression injury as seen on an AP radiograph of the


pelvis. Characteristic features of an AP compression injury include symphyseal
and sacroiliac joint diastasis. In this patient, the pubic symphysis and right
sacroiliac joint are widened.
[ CLOSE WINDOW ]

Anteroposterior (AP) compression injury as seen on an AP radiograph of the pelvis.


Characteristic features of an AP compression injury include symphyseal and
sacroiliac joint diastasis. In this patient, the pubic symphysis and right sacroiliac joint
are widened.
Plain radiographs may also be used in patients who otherwise would not have a CT
scan of the abdomen and pelvis performed.
Computed tomography
CT scan is the best imaging study for evaluation of pelvic anatomy and degree of
pelvic, retroperitoneal, and intraperitoneal bleeding. CT scan also confirms hip

dislocation associated with an acetabular fracture.


CT scanning has largely replaced plain radiographs except for screening, and it has
virtually eliminated the use of auxiliary views.

Windswept pelvis (lateral compression injury) as seen on a pelvic CT scan. The


patient sustained a left lateral compression injury with internal rotation of the left
hemipelvis and a characteristic sacral buckle fracture. Note the concomitant left
sacroiliac joint diastasis. The lateral force vector continued across the pelvis to
produce external rotation of the right hemipelvis and diastasis of the right
sacroiliac joint. The combination of injuries resulted in a windswept pelvis.
[ CLOSE WINDOW ]

Windswept pelvis (lateral compression injury) as seen on a pelvic CT scan. The patient
sustained a left lateral compression injury with internal rotation of the left hemipelvis
and a characteristic sacral buckle fracture. Note the concomitant left sacroiliac joint
diastasis. The lateral force vector continued across the pelvis to produce external
rotation of the right hemipelvis and diastasis of the right sacroiliac joint. The
combination of injuries resulted in a windswept pelvis.

MRI may provide more definitive identification of pelvic fractures when compared to plain
radiographs, thereby prompting patients to more timely and appropriate therapy. In one
retrospective study, a large number of false positives and false negatives were noted when

comparing plain films to MRI.11


Ultrasonography
As part of the Focused Assessment with Sonography for Trauma (FAST)
examination, the pelvis should be visualized for intrapelvic bleeding/fluid.
In addition, the FAST examination may identify intraperitoneal bleeding to explain
shock. However, recent studies suggest that ultrasonography has a lower sensitivity
for identifying hemoperitoneum in patients with pelvic fractures than previously
reported.12 Therefore, keep in mind that, although the positive predictive value of
noting hemoperitoneum as part of a FAST examination is good, therapeutic decisions
using FAST as a screening examination may be limited.
Urethrography
Retrograde urethrography is necessary for males with a displaced or boggy prostate
or blood at the urethral meatus and for females in whom a Foley catheter cannot
easily pass on gentle attempts.
This study should also be used in females with a vaginal tear or palpable fracture
fragments adjacent to the urethra.
Arteriography
Consider this study in hemodynamically unstable patients when CT scanning or other
appropriate diagnostic studies exclude significant intraperitoneal bleeding and after
the external pelvis is stabilized.
Arteriography allows for determination of the bleeding site. In addition, embolization
may be very effective for hemorrhage control.
Cystography: Consider this study in any patient with hematuria and an intact urethra.

Procedures
Use a suprapubic catheter for patients in whom urethral injuries are suspected but a
urethrogram cannot be obtained.
Early application of an external pelvic fixator may be necessary to control hemorrhage.

Treatment
Prehospital Care

Address acute life-threatening conditions. Be very aware that the amount of force necessary
to cause a significant pelvic fracture is likely to have caused other significant injuries.
Application of an external compression device to a grossly unstable pelvis will provide
mechanical stabilization while controlling hemorrhage from the fracture site. A sheet or one
of a variety of inexpensive, commercial products may be used.13
Avoid excessive movement of the pelvis.
Obtain large-bore intravenous (IV) access, and administer analgesia and fluids in accordance
with local protocols.
Closely monitor vital signs.

Emergency Department Care

Treatment involves an algorithmic, multidisciplinary approach.


Investigate associated intra-abdominal and intrapelvic injuries. A FAST examination should

be performed as soon as possible, as well as a chest radiograph to look for other injuries or
bleeding sources, especially in the unstable patient.
Avoid excessive movement of the pelvis.
If not done by prehospital providers, the pelvis should be rapidly stabilized with a sheet or
commercial pelvic external stabilizer.
This is very important prior to neuromuscular blockade because the muscles may be
the only thing maintaining pelvic stability.
In some patients, such as those with truncal obesity, internal rotation of the lower extremities
and taping together the knees may be more effective than a compression binder.14
In the case of unstable pelvic fractures, early application of an external fixation device by
the appropriate surgical consultant should be considered.
Administer fluid replacement and analgesics as needed.
Do not place a urinary catheter until urethral injury has been ruled out or determined to be
unlikely by physical examination or retrograde urethrography.

Consultations

Consult an orthopedic surgeon when a pelvic fracture is diagnosed. Hemodynamically


unstable patients with unstable pelvic fractures require emergent orthopedic consultation for
possible external fixation. Pelvic or retroperitoneal packing may be required for hemorrhage
control.15 Intra-aortic balloon occlusion may also have a role to control massive bleeding.16
Consult an interventional radiologist for embolization in the unstable patient.
Consult a urologist for any suspected urethral injury.

Medication
Primary treatment of pelvic fracture is for pain with narcotic analgesics. Administer antibiotics
whenever disruption of bowel, vagina, or urinary tract is suspected. Since bleeding is the major lifethreatening complication of pelvic fractures, avoid nonsteroidal anti-inflammatory drugs in initial
treatment. They may be considered later if inflammation is a concern.

Analgesics
Narcotic analgesics are the treatment of choice in the acute setting. Pain control is essential to
quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy
regimens. Many analgesics have sedating properties that benefit patients who have sustained
fractures. Adequate pain control helps keep the patient quiet and avoids movement of the pelvis.

Morphine sulfate (Duramorph, Astramorph, MS Contin)


DOC for narcotic analgesia because of its reliable and predictable effects, safety, and ease of
reversibility with naloxone. Administered IV, may be dosed in a number of ways and commonly is
titrated until desired effect obtained. Titrated doses especially useful in trauma patients to avoid
oversedation or hypotension. Caution in hypotensive patients as may worsen hypotension because
of histamine release. Consider fentanyl in this setting.
Dosing
Interactions
Contraindications

Precautions
Adult

Starting dose: 0.1 mg/kg IV


Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV and reassess hemodynamic effects of dose
Pediatric

Neonates: 0.05-0.2 mg/kg IV/IM/SC q2-4h prn


Children: 0.1-0.2 mg/kg IV/IM/SC q2-4h prn

Dosing
Interactions
Contraindications
Precautions

Phenothiazines may antagonize analgesic effects; tricyclic antidepressants, MAOIs, and other CNS
depressants may potentiate adverse effects

Dosing
Interactions
Contraindications
Precautions

Documented hypersensitivity; hypotension; potentially compromised airway in which establishing


rapid airway control would be difficult

Dosing
Interactions
Contraindications
Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions

Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention;
caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may
increase ventricular response rate

Fentanyl (Sublimaze, Duragesic)


Excellent drug for analgesia in patients with hypotension or whose cardiovascular condition is
unstable. Does not release histamine. Short-acting acutely, duration becomes longer with repetitive
dosing.
Dosing
Interactions
Contraindications

Precautions
Adult

1-2 mcg/kg IV then titrate to pain relief


Pediatric

1-3 mcg/kg IV then titrate to pain relief

Dosing
Interactions
Contraindications
Precautions

Phenothiazines may antagonize analgesic effects; tricyclic antidepressants may potentiate adverse
effects

Dosing
Interactions
Contraindications
Precautions

Documented hypersensitivity; hypotension; potentially compromised airway in which establishing


rapid airway control would be difficult

Dosing
Interactions
Contraindications
Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions

Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention;
idiosyncratic reaction, known as chest wall rigidity syndrome (never reported in analgesic dosages,
<200-mcg bolus), may require neuromuscular blockade to increase ventilation

Acetaminophen (Tylenol, Panadol, aspirin-free Anacin)


DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs or
those at high risk of bleeding, with upper GI disease, or taking oral anticoagulants. DOC for pain
relief in noninflammatory conditions.

Dosing
Interactions
Contraindications
Precautions

Adult

325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d


Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d

Dosing
Interactions
Contraindications
Precautions

Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, and isoniazid may
increase hepatotoxicity

Dosing
Interactions
Contraindications
Precautions

Documented hypersensitivity; known G-6-P deficiency

Dosing
Interactions
Contraindications
Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions

Severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is
contained in many OTC products and combined use with these products may result in cumulative
acetaminophen doses exceeding recommended maximum dose

Hydrocodone bitartrate and acetaminophen (Vicodin ES)


Drug combination indicated for relief of moderately severe to severe pain.

Dosing
Interactions
Contraindications
Precautions

Adult

1-2 tab/cap PO q4-6h prn based on hydrocodone content 5-10 mg dosage


Pediatric

<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen

>12 years: 750 mg acetaminophen PO q4h; single dose not to exceed 10 mg of hydrocodone
bitartrate; not to exceed 5 doses/d

Dosing
Interactions
Contraindications
Precautions

Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants


increase toxicity

Dosing
Interactions
Contraindications
Precautions

Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure

Dosing
Interactions
Contraindications
Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions

Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on
opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe
renal or hepatic dysfunction; be careful when adding to other drugs that contain acetaminophen

Oxycodone and acetaminophen (Percocet, Tylox, Roxicet, Roxilox)


Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirinhypersensitive patients.

Dosing
Interactions
Contraindications
Precautions

Adult

1-2 tab/cap PO q4-6h prn


Pediatric

0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone


Dosing
Interactions

Contraindications
Precautions
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants
increase toxicity

Dosing
Interactions
Contraindications
Precautions

Documented hypersensitivity

Dosing
Interactions
Contraindications
Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus
Precautions

Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen
patient is receiving; do not exceed 4000 mg/24 h of acetaminophen; higher doses may cause liver
toxicity

Oxycodone and aspirin (Percodan, Roxiprin)


Drug combination indicated for relief of moderately severe to severe pain. Avoid in early treatment
because of platelet inhibition from aspirin and increased risk of bleeding. See discussion under
NSAIDs above.

Dosing
Interactions
Contraindications
Precautions

Adult

1-2 tabs/caps PO q4-6h prn


Pediatric

0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone

Further Inpatient Care


Monitor patients with pelvic fracture for signs of ongoing blood loss and signs of infection.
In addition, patients should be closely observed for development of neurovascular problems
in the lower extremities. For example, injury to the sacral nerves, lower lumbar nerves, and
sympathetic chain may occur.

Consider deep venous thrombosis (DVT) prophylaxis in all patients. Pelvic fractures give an
odds ratio for venous thromboembolic events (VTE) of 2.93.
Pain management is very important to facilitate early mobilization, thereby reducing the risk
of thromboembolic disease.
Management of urethral injuries should be directed by a urologic consultation. If a urinary
catheter is required prior to the urologist's arrival, a suprapubic catheter should be placed.

Further Outpatient Care


Elderly patients with isolated pubic rami fractures can be safely discharged if they can be
cared for at home or in another facility. They will require sufficient pain management to
allow them to ambulate, or they should have sufficient help. If they are nonambulatory, DVT
prophylaxis should be considered.

Inpatient & Outpatient Medications


Inpatient medications should be determined by the orthopedic specialist or trauma surgeon
depending on associated injuries. Pain medications as outlined above will be required (see
Medication); other medications depend on associated injuries.

Transfer
If possible, hemorrhage should be controlled and the pelvis stabilized prior to transfer.
Transfer all patients except those with minor pelvic fractures to a trauma center.
Complex acetabular fractures may require transfer to a specialist in acetabular fractures.

Deterrence/Prevention
Encourage use of seat belts, airbags, and other protective gear.
Promote antidrunk driving programs and laws.

Complications
Complications of pelvic fracture include the following:
The incidence of deep venous thrombosis is increased.
Continued bleeding from fracture or injury to pelvic vasculature may occur.
GU problems from bladder, urethral, prostate, or vaginal injuries: The incidence of urethral
injuries varies by the type of pelvic fracture. Straddle fractures associated with sacroiliac
diastasis have the highest incidence (odds ratio of 24). Without diastasis, the odds ratio
dropped to 3.85. Urethral injuries are uncommon in patients with fractures not involving the
ischiopubic rami.
Sexual dysfunction may develop.
Infections from disruption of bowel or urinary system may develop.
Chronic pelvic pain, more so if the sacroiliac joints are involved, may occur.17

Prognosis

Lower long-term quality of life based on validated questionnaires has been reported in
patients with pelvic fractures following high-energy trauma.18

Patient Education
For excellent patient education resources, visit eMedicine's Breaks, Fractures, and
Dislocations Center. Also, see eMedicine's patient education article, Total Hip Replacement.

Miscellaneous
Medicolegal Pitfalls
Failure to diagnose concomitant genitourinary, intra-abdominal, or retroperitoneal injuries
Failure to consider a urethral injury in a female
Failure to clinically (or radiographically) exclude urethral injury prior to attempting to insert
a urinary catheter or to cease attempts at Foley catheterization after encountering resistance
Failure to obtain urethroscopy in women with suspected urethral injuries
Failure to assess for vaginal bleeding in a female with a pelvic fracture
Failure to diagnose a hip dislocation associated with an acetabular fracture
Failure to appreciate ongoing blood loss
Failure to obtain prompt orthopedic consultation for an unstable pelvic fracture
Failure to promptly apply external stabilization to an unstable pelvic fracture

Special Concerns
Pregnant patients
While the welfare of the fetus is most dependent on the clinical outcome of the
mother, diagnostic imaging and therapeutic options may need to be modified in the
pregnant patient.
Patients in later stages of pregnancy are at increased risk for complications.
Placental abruption and uterine rupture are a concern.

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