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1980by The Journal of Boneand Joint Surgery, Incorporated

Complicationsof Colles’ Fractures*


From the Department of Orthopedics, Mayo Cl’inic and Foundation, Rochester

ABSTRACT: Patients with Colles’ fractures have se- cation whowas sent to us for treatment was also consid-
rious complications morefrequently than is generally ered to be a referral. The case histories, roentgenograms,
appreciated. A study of 565 fractures revealed 177 (31 and :follow-up data on all 565 patients were assessed with
per cent) with such complications as persistent respect to the mechanismof the injury and associated in-
_neuropathies of the median, ulnar, or radial nerves Juries.
(forty-five cases), radiocarpal or radio-ulnar arthrosis In evaluating and tabulating the results (Table I),
(thirty-seven cases), and malposition-malunion(thirty used the Frykmanclassification of the fracture. Type I was
cases). Other complications included tendon ruptures an extra-articular radial fracture; Type II, an extra-
(seven), unrecognized associated injuries (twelve), articular radial fracture plus an ulnar fracture; TypeIII, a
Volkmann’s ischemia (four cases), finger stiffness (nine fracture into the radiocarpal joint; and TypeIV, a fracture
cases), and shoulder, hand syndrome(twenty cases). into the radiocarpal joint plus an ulnar fracture. Type V
manypatients, incomplete restoration of radial length was a fracture into the radio-ulnar joint; TypeVI, a frac-
or secondary loss of the reduction position caused the ture into the radio-ulnar joint plus an ulnar fracture; Type
complications. VII, a fracture into both joints; and TypeVIII, a fracture
into both joints plus an ulnar fracture.
Current opinion seems to be that there are no impor- When there were complications, we especially
tant problems relating to the treatment of Colles’ frac- studied the methodof reduction, the anesthesia, the type of
tures z,lz,15,zl, despite admonitionsr,~.l~ that manypatients immobilization, and the post-fracture care, and we tried to
whohave had such a fracture are found to have permanent correlate each with the type of complication.
disability and poor function of the hand and wrist. In our Observations
hospitals, we have seen a steady flow of complications
which has significantly sharpened our awareness of the In the total of 565 cases, there were 177 serious
many difficulties associated with treatment. These complications in 128 patients, as categorized into these
difficulties are not commonlyappreciated. In the present eight major types: compression neuropathy (forty-five
study of patients referred to us for early and late manage- case:s), arthrosis after fracture (thirty-seven cases), malun-
menlO,we have accumulated sufficient material to report ion after loss of reduction (thirty cases), tendon rupture
figures on the incidence of complications from Colles’ (seven cases), unrecognized associated injuries (twelve
fracture. Treatment of these complications is a separate cases), complications of fixation (thirteen cases), Volk-
consideration that will not be discussed or analyzed, ex- ma~tn’sischemic contracture (four cases), arthrofibrosis
cep~ in delineating a general approachto a specific compli- the fingers (nine .cases), and shoulder-hand syndrome
cation. (upper-limb dystrophy) (twenty causes).
Somepatients had more than one complication. Pa-
Clinical Material tients with shoulder-hand syndromeoften had two or more
All patients treated for Colles’ fractures at the Mayo presenting complications that contributed to the dys-
Clinic from January 1968 through December 1975 were trophy. A tenth complication, early loss of reduction
.studied. There was a total of 565 patients. Of these, 356 (forty-one cases), was not included in the. analysis, except
(63 per cent) were seen primarily at our hospitals for to record its occurrence whenit produced a symptomatic
treatment of the Colles fracture, while the others were re- arthrosis or malunion.
ferred for evaluation and treatment because of complica- Minorcomplications were not recorded in this Study.
tions, either early (during the acute treatment of the frac- They included transitory radial and medianneuritis; flexor
ture) or .late (with specific complications). All patients and extensor tendinitis; cast-pressure sores; pin-site irrita-
whowere referred had had primary treatment of the frac- tion; and stiffness of the wrist, elbow;and shoulder joints.
ture elsewhere, and any patient with a recognized compli- Conservative treatment, applied early, relieved most of
these minor complications.
* Read at the Annual Meeting of The American Academy of Or- Complications were encountered whatever the form
thopaedic Surgeons, New Orleans, Louisiana, February 2, 1976. of fracture treatment used. Amongthe 356 patients who
? Department of Orthopedics, Mayo Clinic, Rochester, Minnesota
55901. Please address reprint requests to Dr. Cooney. were primarily treated at our institution, sixty-eight pa-



Frykman No. of No. of Anesthesia Immobilization

Type Complications Patients Local Block/General Unknown Cast Pins Unknown
I 12 9 3 3 3 8 1 0
II 14 10 7 1 2 9 1 0
III 2 2 1 1 0 1 1 0
IV 16 12 6 6 0 9 2 1
V 19 12 8 4 0 11 1 0
VI 24 19 11 5 3 16 2 1
VII 27 18 10 6 2 14 3 1
VIII 42 32 20 12 0 26 6 0
Unknown 16 14 12 0 2 12 0 2

tients (19 per cent) had seventy-eight complications. patients). This complication was less frequent after bra-
Amongthe referred patients, sixty had ninety-nine com- chial block or general anesthesia (eleven patients). Radial
plications. Of the 128 patients with complications, seventy- neuropathy, attributable to improper immobilization (cast
eight had had local anesthesia and thirty-eight had had compressionat the spiral groove of the humerusor on the
block or general anesthesia; in twelve cases, the type of dorsumof the hand), was diagnosed in three patients. Irri-
anesthesia was not recorded. Eighty-six patients had tation from external pin fixation caused a severe radial
closed reduction and~ immobilization in a cast, seventeen neuropathy in two patients. Ulnar neuropathy occurred in
had primary external pin fixation, and twenty had failure six patients as a result of cast compression.All but five of
of cast immobilization with secondary pin fixation. For the early neuropathies required no treatment and resolved
five patients the types of reduction and immobilization after the offending compressing agent (cast or pin) was
were not specified. The comminuted displaced intra- removed. The five exceptions were patients who had a
articular fractures (the unstable ones, FrykmanTypes IV neuropathy as a result of initial injury. They had im-
through VIII) were associated with an increased numberof mediate carpal-tunnel release and no permanent sequelae.
complications, especially the more comminutedType-VII Late neuropathy of the median nerve occurred in
and VIII fractures (sixty-nine of the 177 complications). forty-one patients. All had persistent symptoms.In four
For sixteen fractures, the Frykmanclass could not be de- additional patients, the median neuropathy was combined
termined. The largest number of complications (74 per with ulnar neuropathy. There were no late radial
cent) was in patients who had had injection of a local neuropathies. Thirty-one of the forty-five patients required
anesthetic into the fracture site, although that methodof release of the carpal tunnel or Guyon’scanal, or both, and
anesthesia was used in only 56 per cent of the patijents who extensive exploration through an appropriate palmar or
had tr.eatment for Colles’ fracture. Complications after the forearm incision was essential for adequate decompres~s!on
reduction of displaced comminutedfractures were less (Fig. 1). In six patients, volar fracture fragments were
likely to occ.ur if either general anesthesia or an axillary found compressing both the ulnar and median nerves and
block was given, followed bYsustained traction (ten min- were removed. Excessive callus formation (seven pa-
utes) and gentle reduction. After primary external pin- tients), persistent hematoma(six patients), and localized
fixation techniques in seventy-five fractures there were swelling (twelve patients), usually the result of the forced
twenty-one complications, while after failed closed reduc- volar flexion-ulnar deviation position (Cotton-Loder),
tion and secondaryexternal pin fixation in forty fractures, were considered to be responsible for most of the other late
twenty-eight complications were encountered. There were neuropathies. Eleven of the twenty-four patients whowere
128 complications in patients whowere treated by closed referred to us and seven of the twenty-onetreated primar-
reduction and plaster-cast fixation, but that routine was ily had one additional complication associated with a com-
followed three times more frequently than the other pressive neuropathy, and one referral patient had three
methods of treatment combined. The age of the patient, associated complications.
sex, and mechanismof injury seemedto have no relation-
ship to the incidence of complications. Arthrosis after Fracture
Wheneither painful motion of the wrist or forearm
Compressive Neuropathy was evident or there was a mechanical obstruction to
This was the most frequent single complication (7.9 motion after fracture, we diagnosed the condition as ar-
per cent), occurring in twenty-onepatients treated locally throsi~. It was observedin thirty-seven patients and repre-
and in twenty-four whowere referred to us for treatment. sented. 20 per cent of the complications. Radio-ulnar ar-
It was observed both acutely and late after the injury had throsi.,; (twenty-seven patients) was more commonthan
occurred. Median neuropathy developed early in thirty- radiocarpal arthrosis (ten patients). FrykmanType-VI,
one patients, usually associated with reduction of the frac- VII, and VIII fractures most often elicited this complica-
ture in the emergencyroomunder local anesthesia (twenty tion. Whenexternal pin,fixation techniques that restored
the radial length were used to treat those fractures there community. Twowere lost to follow-up. In most of our
was a lower incidence of arthrosis (four patients), despite fourteen patients the corrective osteotomy was supplemen-
the fact that pin fixation was the preferred treatmentfor the ted by bone-grafting (Figs. 2-A through 2-D). Improve-
more comrninuted fractures. ment in grip strength and motion was achieved in all but
Of the ten patients with radiocarpal arthrosis, nine one of these fourteen patients, and that patient required ar-
were treated surgically: three by dorsal ostectomy, two by throdesis.
proximal row carpectomy, two by arthrodesis, and two by Nine of the referral patients in this group had an
total prosthetic arthroplasty of the wrist. Of the twenty- additional complication, as did one of the twelve primary
seven patients with radio-ulnar arthrosis, nineteen had a patients. Tworeferral patients had two additional compli-
painful radio-ulnar joint that required a Darrachresection cations.
of the distal end of the ulna (fourteen patients), a Milch
procedure (one patient), or a Silastic replacement arthro- Tendon Rupture
plasty (four patients). Six other patients had symptomatic Rupture of the extensor pollicis longus was noted in
radio-ulnar subluxation with a mechanical obstruction to five patients, and rupture of the index flexor digitorumpro-
motion and required Darrach excision of the distal end of fundus or flexor pollicis longus was noted in one patient
the ulna. All twenty of the patients whohad the Darrach each. The: rupture was primarily related to bone fragments
procedure had improvementin motion of the wrist and, in from displaced fractures that abraded the tendon during the
particular, in pronation and supination of the forearm. weeksafter healing of the fracture. All five patients with
Ten of the twenty-one referral patients and seven of loss of the extensor pollicis longus tendon had rupture
the sixteen primary patients had an additional complica- within two monthsfrom the initial injury (two, two, three,
tion. four, and eight weeks), while in the two patients with
flexor tendon rupture the rupture occurred after three
Malposition- Malunion 1 months. All patients had either a tendon transfer or a ten-
Thirty patients had this complication, the majority don graft.. Direct tendon repair was not possible because
having been referred for treatment. Five patients had frac- several centimeters of tendon substance had been lost.
tures that were not yet fully united whenthey were seen for
treatment. They required early open reduction. The other Associated Injuries Unrecognized Primarily
twenty-five patients required osteotomy. Malunion was These included scaphoid fractures (four patients),
most commonlyrelated to loss of the reduction position, radial head fractures (two patients), Bennett’s fracture
which commonlyoccurs when the fracture is unstable and (one patient), and intercarpal ligament injuries (five
comminuted.This loss of reduction early in the treatment tients), which were recognized between two days and one
¯ period wasa frequent problem.In this series, treatment for monthfrom the time of the original injury. These injuries
loss of reduction was required in 27 per cent of the 565 usually were caused by the same mechanism that caused
patients. A corrective reduction was usually performed by the Colles fracture. In our series, ligament instability of
distraction and gentle manipulation, the patient having had the wrist required operative reconstruction of the
brachial b!ock or general anesthesia. It was successful in scapholunate ligament in four patients. Scaphoid fractures
most patients (more than 92 per cent) when accomplished required open reduction in two patients, and radial head-
within two week.s of the fracture and when the reduction fractures required excision of the radial head in two pa-
was maintained with some form of external pin fixation. tients.
Our preference was to insert in the base of the second and
third metacarpals two 2.0-millimeter (5/64-inch) Stein- Complications of Fixation
mannpins oriented at 60 to 90 degrees to each other. Two Three patients with pin fixation had pin breakage that
slightly larger pins(2.3 millimeters, 3/32 inch) were required operative removalof the pins. Pin loosening with
placed in the middle third of the radius. A Roger Anderson purulent drainage occurred in eight patients, and an ulcer-
external-fixation apparatus attached to these pins main- ation of the area arounda pin occurred in one patient. One
tained the reduction and provided stabilization. Additional patient sustained a fracture throughthe pin site in the distal
pins or Kirschner wires were. used, as required, to secure end of the radius. Twopatients had nerve irritation caused
loose fragments. Whenthe pins applied above and below by the casL which led to sympathetic dystrophy (as will be
were inadequate to maintain ~eduction open reduction was discussed). Casts caused other complications, as described
done (five patients), with sa.tisfactory results. in the paragraphs on compressive neuropathies, Voik-
After inadequate treatment of the fresh fracture was mann’s ischemia, and shoulder-hand syndrome.
followed by malunion, the complaints of significant pain,
deformity, and limitation of motion present in twenty-five Volkmann’s Ischemic Contracture
patients led to recommendationsfor corrective osteotomy. This was seen in four referral patients, three of whom
Fourteen patients had that operation at our institution. had had a constricting cast that was retained despite the
Three patients accepted the deformity or preferred not to patient’s complaints of persisting pain. Continued use of
have surgery, and six had the operation in their home analgesics in two patients further maskedthe symptoms.

VOL. 62-A, NO. 4, JUNE 1980


Shoulder-Hand Syndrome
This is more appropriately called upper-limb dys-
trophy or pain-dysfunction, and was a significant problem
in twenty patients, sixteen of whomhad been referred.
Four patients had acute symptomswith predominant sym-
pathetic componentsof change in skin temperature, color,
and texture; pain and loss of motion in the shoulder; and
stiffness of the hand or specific local trigger areas of ex-
quisite pain and tenderness (or both). In one patient it was
the result of radial-nerve irritation from pin fixation; in
two patients, from excessive wrist flexion which produced
Fro. 1 acute median neuropathy; and in one, from an unreduced,
Median neuropathy associated with Colles’ fracture may involve a
prominent volar callus, which in this patient compressed the median severely displaced fracture with associated disuse of the
nerve proximal to the. carpal tunnel. Surgical release was extended into limb. Twoof the four patients had one other complication
the distal end of the forearm tO ensure adequate decompression.
and two had two additional complications.
The sixteen referral patients had late upper-limb dys-
Oneof the three patients had had an undisplaced fracture. trophy. They had fewer sympathetic components than did
Our treatment of these patients was difficult and pro- the patients with the acute condition, but had long-
longed. Wevariably used nerve and muscle decompres- established clinical complaints of stiffness and disuse of
sion, lysis of tendons and nerves, release or lengthening of the shoulder, stiffness of the hand, painful motion, carpal

Figs. 2-A throi~gti 2-D: Maluni0nof the distal end of the radius developedin the wrist of a forty-five-year-old farmer whohad been gored by a bull.
During life-saving measures the fracture was overlooked.
Figs. 2-A and 2-B: Whentreatment of the malunion was begun at six months, there was marked shortening and radial angulation, median
neuropathy, and weakgrip. An open-wedgeosteotomy, a bone graft from the distal end of the ulna, and a small plate were employedto regain length
and restore alignment of the forearm. The carpal tunnel ~,as released.

muscle-tendonunits, and tendon transfers whenindicated, tunnel symptoms,and radiocarpal arthrosis. Ten of the six-
and the long-term results in three patients were only fair. teen patients had fracture malunion. Fourteen of them
The fourth patient had persistent pain and finally had to were referred with long-established complaints, but im-
have a below-the-elbow amputation. proved on conservative treatment extending for from six
weeks to four months. Six of the sixteen had one other
reduction (seven patients), improper immobilization in the
complication and four, two or more complications. cast (four patients), poor mobilization of the joint (eight
Stiff Hands patiients), and inadequateefforts at rehabilitation.
Stiff hands from arthrofibrosis of the fingers were a Discussion
severe complication in nine patients. It was manifested by
Severe complications from Colles’ fracture continue
pain and swelling limited to the hand, with a loss of finger to occur frequently. Wefound that there were more pa-
motion and occasionally a loss of motion of the wrist.
tients than we anticipated whose complications required
Swelling and pain, particularly in the structures lined with exte.nsive treatment. Possibly the percentage of complica-
synovial tissue, were the most characteristic findings in
tions in this report is higher than in other reports because
seven patients. Swelling of the proximal interphalangeal
more than 46 per cent of the patients (sixty of 128):with
joint was the major source of pain and resulted in a severe
complications were referred for treatment. Wehave di-
loss of motion. The factor most commonlyassociated with
vide, d the complications into nine groups, of which the
the clinical symptomsand signs was improper application
largest was the neuropathies.
of a cast. Stiff hands occurred most often after improper
Compression neuropathies occurred both early
cast application (seven of nine patients in this category).
(within the first two weeks) and later during the period
lack of early motion of the hand was evident in five of the
treatment. Whenthe median nerve was involved, early
nine patients, and pre-existing degenerative arthritis was recognition was common. However, in some "patients,
present in three patients. Three patients had a mild
whenthe radial or ulnar nerve was compressed, the diag-
Dupuytren’s contraeture in the affected hand. Six of the
nosis was delayed because the physicians failed to ap-
nine patients had full recovery, and the other three had
preciate or suspect that the nerve was compressed,
improvedfunction after conservative treatment.
stretched, or irritated. This failure was especially evident
Multiple Complications whenfixation pins were utilized. Delay in diagnosis usu-
ally lied to complicationssuch as a stiff handor carpal tun-
A study of the patients whohad multiple complica-
nel syndrome.
tions that usually included the shoulder-hand syndromere-
Medianneuropathy was identified more often in this
vealed that the underlying cause of the dystrophy appeared ’~,
series of patients than in previously reported series1,6,
to be a combinationof predisposing factors in conjunction
probably because there is increased recognition of this
with difficulties in treatment, such as repeated attempts at
condition and because more patients are referred for surgi-

FIG. 2-C F~G. 2-D


cal decompression. Weagree with previous authors produce a proximal carpal thrust that results in a dorsal
that a significant contributor to the neuropathyis the force compressive force leading to collapse and displacement.
of fracture reduction and the position of immobilization; Present methodsof fracture reduction and cast sup-
the higher frequencyof this complicationafter local block, port do not always prevent these potentially deforming
with or without systemically administered analgesics, forces, particularly in comminutedfractures. In unstable
tends to support this belief. fractures, weprefer to use external pin fixation in order to
Post-fracture arthrosis was the second most common maintain a distracting force, prevent collapse, and allow
complication in our patients, yet often it went unrecog- the volar fragmentsof the cortex to unite in goodposition.
nized for sometime. Subtle forms of this arthrosis are re- Wehave used this methodfor patients in whomreduction
sponsible for a large portion of the weaknessof grip and of the fracture was lost after cast immobilizationand also
limited motion that are commonlyseen after this fracture. for potentially unstable intra-articular fractures (Frykman
Whenthe condition is recognized, the patient often can be Types V through VIII), and have achieved satisfactory re-
improvedby conservative measures, such as splinting, the sults 3. ~
local injection of steroids, and the use of salicylates. Open reduction of Coltes’ fracture is rarely advo-
Operative treatment for radiocarpal arthrosis Wasneces- cated, despite the need for accurate reduction of the frac-
sary in only nine patients in our series. The radio-ulnar ar- ture s. Becausethe functional results so closely parallel the
throsis that was seen in twenty-seven patients mostly anatomical results, it is our practice that whenclosed re-
stemmedfrom the inability to obtain an adequate anatomi- duction, including the use of external pin fixation, is not
cal reduction, manifested in two ways. One was successful, open reduction is indicated. Definite criteria
malalignmentof the sigmoid notch of the distal end of the for open reduction of Colles’ fractures have not been
radius with the ulnar head, owing to radial deviation and completely formulated, but for the present the technique
dorsiflexion of the distal radial component.The other was should be more strongly considered for use in youngadults
inadequate restoration of length to maintain the normal re- in whomcomminuted, unstable intra-articular fractures
lationship of the radio-ulnar joint. This problemwas sig- have been treated unsuccessfully by closed reduction
nificant enoughto require surgical treatment in nineteen of techniques.
the twenty-seven patients. Webelieve that the common The incidence of complications from Colles’ fractures
technique of reduction and immobilization in full prona- reported here does not differ significantly from the types
tion with ulnar deviation so that the distal end of the ulna and frequency of problems reported by others. Frykman
provides stability is mechanicallyunsound, particularly in noted the significant sequelae of radio-ulnar arthrosis
displaced, highly Comminuted fractures. The distal (18.6 per cent), shoulder-hand syndrome(2 per cent),
radio-ulnar joint often is unstable, and any radio-ulnar sub- peripheral neuropathy (315 per cent) in his series of 430
luxation or dislocation that exists is only increased by im- "’cases. He found that symptomsat the distal radio-ulnar
mobilizing the hand in full pronation. The end result may joint weremost frequently related to fractures into the joint
be that rotation of the forearm, especially supination, be- (41 per cent) combinedwith dorsal angulation and shorten-
/comes severely limited. ing of the distal end of the radius. Lippmanand. Lidstr6m
Weagree with Sarmiento et al., and others ~,6, that had similar findings (10 per cent and 15 per cent inci-
the best position for maintaining normal alignment and dences of radio-ulnar arthrosis, respectively) and stressed
minimizing deforming forces is supination. Whenthe that radio-ulnar instability was the most commoncause of
proper length of the distal end of the radius is difficult to a poor result. Gartland and Werley reported an incidence
maintain, strong, protracted traction and external pin fixa- of arthrosis of 22 per cent. In combiningboth radiocarp~l
tion maybe the best form of treatment. and radio-ulnar arthroses, we found symptomsthat were
Early loss of reduction and late collapse after Colles’ significant enoughto require surgical treatment in thirty-
fracture probably are two commoncomplications that are seven (6.5 per cent) of 526 patients.
too readily accepted by treating physicians. To us, each of Shoulder-hand syndrome was present in 1.4 per cent
these conditions signifies that the fracture being treated is of patients reviewed by Bacorn and Kurizke, in 3.4 per
unstable. It usually has one or more of the following cent in Rosen’sseries, and in 10 per cent in Lidstr6m’sse-
¯ characteristics: extensive comminution,markeddisplace- ries of 515 patients. The latter included finger-joint stiff-
ment of fragments, or interposition of soft tissue -- and hess and Siideck’s atrophy. Unsatisfactory results were re-
any one of them can lead to an incomplete reduction. ported in 67 per cent. The incidence in our series was four.
Webelieve that whenever a fracture is unstable, no (1.1 per cent) of 356 local patients. Whileaffected patients
amountof residual dorsal angulation after reduction is are fewer in number,this complicationis the most difficult
permissible. Adequatereduction requires that the full dor- to treat, and prevention by the techniques described by
sal length of the radius be restored and maintained. This Mobergshould be studied.
requires a stable volar buttress plus dorsal tension by tissue Peripheral neuropathy as a serious complication was
or an apparatus that prevents dorsal collapse. Otherwise not noted by others to be as frequent as we have reported it
the force of active finger flexor and extensor tendons, to be (forty-five patients over-all and twenty-one[3.7 per
combinedwith dorsal translation of the lunate, tends to cent] of patients who were primarily under our care).
Lidstr6mbelieved that nerve injuries are rare after frac- commonwheneverthree complications -- neuropathy, ar-
tures of the distal end of the radius (slightly morethan throsis, and shoulder-hand syndrome-- were present.
per cent). Bacornand Kurtzkereported an incident of 0.2 Frykman foundthat of eighty patients with radio-ulnar ar-
per cent and Schlesinger and Liss noted only one case per throsis, five (6.3 per cent) had medianneuropathyandfive
1,000 fractures. Webelieve that these negative reports had shoulder-handsyndrome.Of our twenty patients with
weredue in part to a lack of recognition andpossibly more shoulder-hand syndrome, sixteen had one or more as-
concernwith treatmentof the fracture than with potential sociated complications(arthrosis in ten patients, median
sequelae. Lynch and Lipscomb, Frykman, Robbins, and neuropathyin nine patients, malunionin ten patients, and
others5 have placed proper emphasison the causes of me- sympatheticdystrophyin five patients). Evidently, these
dian neuropathyand the need for aggressive treatment in complicationsandothers contributedirectly to the 24 to 27
certain acute as well as late cases. per cent incidenceof poorfunctional results that has been
Complicationsrelated to morethan one factor were reported3"6"~fromthe treatmentof Colles’ fractures.

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