Association between Bone Mineral Density and Fracture Characteristics in the 5th Metatarsal Bone Base Fracture in Elderly for Prediction of Osteoporotic Fracture. J Am Acad Orthop Surg Glob Res Rev. Avulsions of the hand and wrist are a heterogeneous group of injuries, but they often have a characteristic imaging appearance that relates to the intricate bone and soft-tissue anatomy and the mechanism of injury. eCollection 2021 Feb. Fractures of the fifth metatarsal in children and adolescents. [0:02:02] Smoking is not allowed anywhere on the hospital campus. FOIA Please enable it to take advantage of the complete set of features! The end of the fifth metatarsal bone feels like a bony prominence on the outside of your foot. Several operation techniques have been described. The Jones fracture is known for prolonged healing time and non-union. Avulsion Frx of Base of 5th Metatarsal. The fifth metatarsal is the long thin bone that runs along the outside of the foot Occasionally a small piece/flake of bone may be pulled off where the ligament attaches to the bone if the foot is twisted inwards. Two types of fractures that often occur in the fifth metatarsal are: Avulsion fracture. Fifth Metatarsal Base Fracture Combined With Fracture of the Os Peroneum. The outcome of conservative treatment of fifth metatarsal diaphyseal fractures. Use ice, wrapped in a tea towel and elevate your ankle to bring swelling down. Fifth metatarsal base fracture (fifth MBF) and lateral collateral ankle ligament (LCAL) injury are mainly caused by plantar flexion and inversion of the foot. Difficulty moving your limb. The site is secure. Help accessing this information in other formats is available. EFORT Open Rev. Zone 1 fractures are avulsion or chip fractures that occur at the tip of the base of the fifth metatarsal. Jones fractures: Once no longer immobilized, start with range of motion and progress to strengthening. For more information please visit the Fracture information website. Segond fracture is an avulsion fracture associated with disruption of the ACL appears in 75% of ACL tear cases. Surgical treatment is indicated when the fracture is displaced more than 2 mm or when more than 30% of the cubometatarsal joint is involved. The sudden pull of the peroneus brevis muscles that occurs when rolling you ankle results in the fracture of the fifth metatarsal. The fifth metatarsal is the bone that runs from the midfoot to the base of the small toe on the outside of the foot. However, you should avoid doing anything that might further damage the bone structure until it has healed completely. Each bone consists of four parts- the base, shaft, neck and head. This type of fracture is sometimes called a "pseudo-Jones" fracture. [3] This fracture is likely caused by the lateral band of the plantar aponeurosis (tendon). 2018 Mar;39(3):326-331. doi: 10.1177/1071100717751183. Injuries of the hand and wrist are frequently encountered in radiology. Treatment recommendations for fractures to the base of the fifth metatarsal (MTV) are still a matter of debate. Operative treatment usually is recom-mended for patients with a proximal diaphyseal fth metatarsal fracture. Please examine the image below to comprehend the location of this injury. 2021 Dec 20;26(1):150. doi: 10.1186/s40001-021-00623-6. Take part in any physical/ contact sports which may put you at risk at further injury. PMC The major muscle that controls lateral foot balance, the peroneus brevis, also attaches at the base of the 5th metatarsal and can be a source of increasing pain if not allowed to rest. Herterich V, Baumbach SF, Kaiser A, Bcker W, Polzer H. Dtsch Arztebl Int. The fifth metatarsal is the long bone on the outside of the foot that starts in the middle of the foot and forms a joint with the pinky toe. Occurs due to forced inversion of foot/ankle while in plantar flexion. Union Rate and Rate of Hardware Removal Following Plate Fixation of Metatarsal Shaft and Neck Fractures. The Fifth Metatarsal Bone Fracture in Athletes - Modalities of Treatment Related to Agility in Soccer Players. How long after metatarsal surgery can I walk? The size of the fractured fragment may vary considerably. Patients who are overweight or lack exercise tend to have slower healing rates. Treated with walking cast for 3-6 wks. Stage 2: For patients who would like to develop dynamic core control for sports. You've suffered an avulsion fracture at the base of your fifth metatarsal. Crutches may also be required in the early stages to alleviate pressure on the foot. Bookshelf This muscle is attached to the base of the fifth metatarsal. They differentiated tuberosity avulsion . A 5th metatarsal avulsion fracture may sometimes be referred to incorrectly as a pseudo-Jones fracture because of the resemblance to a Jones fracture and the common mechanism of injury. In this case, surgery would be required to remove any metal implants used during treatment. Everybody thinks there's a timeline, four weeks, six weeks, 12 weeks, six months, whatever. The doctor will first try to reduce the fracture by pushing down on the end of the bone with a tool. Epub 2021 Sep 6. Publication types Clinical Trial Controlled Clinical Trial Randomized Controlled Trial MeSH terms CB2 0QQ, Telephone +44 (0)1223 245151 This type of fracture is the result of an injury that causes your ankle to roll. 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More commonly, 5th metatarsal fractures occur from an injured foot, overuse, or high arches. Non or minimally displaced shaft fractures can be treated non-operatively. This twisting can result in either a foot avulsion fracture or an ankle avulsion fracture or possibly both. The site is secure. You can find out more about this service on our patient information help page. Avulsion fractures: Start with range of motion and progress to strengthening of the peroneus brevis (external rotation and pronation of the foot). A Jones fracture refers to a break between the base and shaft of the fifth metatarsal bone of the foot. FOIA As a result of poor blood supply, it is slow to heal. [Case-control study on the treatmentof the fifth metatarsal base fractures by cardboard compression pad versus short leg plaster]. An avulsion fracture occurs when a small part of bone is torn off the big portion of the bone by a tendon or ligament. and transmitted securely. In an avulsion fracture, a small piece of bone is pulled off the main portion of your bone by a tendon or ligament. 2014 Oct;27(10):823-8. This bone, located on the outside of the foot, is com. The fifth metatarsal in the foot, which is the bone at the base of the little toe, can be vulnerable to avulsion fractures. If you're suffering from pain after an avulsion fracture has healed, then you should see a doctor to ensure that no bone infection has occurred. Background: Lacking rational basis for the postoperative treatment of fifth metatarsal avulsion fractures. Fracture at the base of the 5th metatarsal tubercle. If the dislocation is more than 3-4mm or the angulation is more than 10 degrees, percutaneous K-wires, plate or screw fixation is indicated. Xu YP, Xie LM, Xu C, Zhang Y, Li YB, Qiao X. Zhongguo Gu Shang. It will be associated with quite specific local tenderness over the base of the bone, on the outside of the foot (the 5th metatarsal). However, they usually are able to perform the action though with decreased strength compared with the opposite side. A broken fifth metatarsal can cause pain and disability if it does not heal properly. Swing your arms in a figure of eight in both directions for 1-2 minutes, or as able. Swelling pain and bruising at the fracture site is normal. If your discomfort lasts longer than two weeks, or if it is severe and accompanied by swelling or discoloration, consult a doctor. If you have severe pain when walking, try wearing shoes that add support under the ball of your foot. It is important to see your doctor if you experience pain in your feet for more than two weeks, as this could be a sign of something more serious. Avulsion Fracture. Difficulty with balance due to weakness of the peroneus brevis also occurs. Chun DI, Min TH, Cho JH, Won SH, Shon JI, Yi Y. J Bone Metab. How are they classified? Impact activity, such as running or sports can take up to 6 months for complete bone healing. Aircast walking boot and below-knee walking cast for avulsion fractures of the base of the fifth metatarsal: a comparative cohort study. official website and that any information you provide is encrypted Analysis of a fracture registry. San Francisco CA 94123, a spiral fracture of the 5th metatarsal shaft that was originally described in Dancers, Did you know our resouces can be found in. [4] Avulsion fractures occur when a small piece of bone is pulled off the larger bone by a ligament or tendon. However, there is no relevant report on the incidence, injury type and treatment principle of the fifth MBF combined with an LCAL injury. Significantly, the average length of recuperation for patients treated with a soft (jones) dressing was 33 days as compared to 46 days for those treated with a short leg cast. This site needs JavaScript to work properly. Initial treatment of a metatarsal stress fracture includes rest, ice, and the use of an anti-inflammatory medication. 2013 Jan;34(1):75-9. doi: 10.1177/1071100712460197. The anatomy of all the metacarpal bones is the same. Surgical treatment is indicated when the fracture is displaced more than 2mm or when more than 30% of the cubometatarsal joint is involved. These fractures typically are treated without surgery using a cast, boot, or hard-soled shoe and tend to heal within 6-8 weeks. It may also make shoe shopping difficult because of the length of the bone. The imaging appearance and this intricate form and function dictate treatment of hand and wrist avulsions . A fifth metatarsal avulsion fracture typically occurs with an inversion injury. Also, the average modified foot score for patients treated in a soft dressing was 92 (excellent) compared to 86 (good) for patients treated in a short leg cast. When the ankle is twisted inwards a muscle called the peroneus brevis contracts to stop the movement and protect the ligaments of the ankle. This assesses for continuity of the tendons that evert the foot. This will help it to heal faster. It depends. Hills Road, Cambridge If you have severe pain or if you appear to be in shock, then seek medical attention immediately. This is the final result: The patient was able to bear weight on the right foot and walk by the 2nd week after surgery. official website and that any information you provide is encrypted Type III fractures have more complications and should be treated operatively. A 5th metatarsal avulsion fracture is an injury that is usually treated non-operatively. A boot is usually given following this injury; you may be required to wear this for up to six weeks unless otherwise directed. Sx often mild, patients usually present with sprained ankle complaint. Usually by 6 weeks, there is enough healing to allow them to transition to a stiff-soled shoewith lots of padding. An avulsion fracture of the fifth metatarsal occurs where a tendon attaches to the bone at this point (the peroneus brevis tendon). Epub 2012 Mar 30. If your fifth metatarsal fracture is not severe, the doctor may keep your foot immobile with a cast, cast boot, or stiff-soled shoe. Herterich V, Baumbach SF, Kaiser A, Bcker W, Polzer H. Dtsch Arztebl Int. You can walk as much as your discomfort allows on your wounded foot. 2021 Sep 6;118(35-36):587-594. doi: 10.3238/arztebl.m2021.0231. We conclude that a soft dressing allows patients to return to pre-injury levels of activity faster than when treated in a short leg cast and without compromising clinical or radiographic union of avulsion fractures of the base of the fifth metatarsal. This procedure is done via a small incision and guided by x-rays fluroscopy. If the patient has the ability to actively move the foot outwards (eversion), the injury will likely heal with non-operative treatment. Our results demonstrated that radiographic evidence of fracture healing was present in all patients by 65 days with 44 days representing the average elapsed time for such change. Two sesamoid bones under the head of the 1st metatarsal bear approximately one third of the body weight. Some clinicians refer to this type of fracture as a Dancers Fracture. However, more commonly a Dancers fracture is considered a spiral fracture of the 5th metatarsal shaft that was originally described in Dancers. Copyright 2009 Elsevier Ltd. All rights reserved. An avulsion fracture of the fifth metatarsal occurs where a tendon attaches to the bone at this point (the peroneus brevis tendon). 2022 Jan 11;7(1):13-25. doi: 10.1530/EOR-21-0025. Clinical inquiries. For advice and support in quitting, contact your GP or the free NHS stop smoking helpline on 0800 169 0 169. Percutaneous cannulated screw fixation of this displaced avulsion fracture of the 5th metatarsal base was performed. The injury may affect how easily you walk or climb stairs. If this occurs, you may require surgery to help mend the fracture. This will produce immediate pain over the outside aspect of the foot. Surgical Treatment. There are 5 metacarpal bones and each metacarpal bone forms a connection between a finger and the wrist joint. Adequate union rates for the treatment of acute proximal fifth metatarsal fractures. Two types of fractures that often occur in the fifth metatarsal are: Avulsion fracture. Careers. After eight weeks, you may begin limited jogging. Over time, the skin can turn black and blue. Polzer H, Polzer S, Mutschler W, Prall WC. In this type of injury, the tendon that attaches to the base of the fifth metatarsal may stretch and pull a fragment of bone away from the base. These are minor fractures and are stable, so you will not need a plaster cast. This usually occurs when the ankle rolls into an inverted position, and is often associated with an ankle sprain. Metatarsal fractures are common in the paediatric population and rarely require operative management. It is a transverse fracture at the base of the fifth metatarsal, 1.5 to 3 cm distal to the proximal tuberosity at the metadiaphyseal junction, without distal extension. You may be able to return to some type of activity after about 3 months, but it's best to wait until your physician says it's okay first. A Jones fracture is a small fracture on the 5th metatarsal in an area of limited blood supply. The vast majority of avulsion fractures at the base of the fifth metatarsal (74%) and dancer's fractures (84%) occurred in women. Currently, it is accepted that tuberosity avulsion fractures are 'pseudo-Jones fractures'. The indication for surgical treatment of Jones' fractures depends on activity level and Torg classification: type I fractures are treated non-operatively. The fifth metatarsal is the long bone on the outside of the foot that connects to the little toe. In these cases, you might need surgery to repair the damage and allow the bone to heal correctly. Bethesda, MD 20894, Web Policies Often this is a very painful trauma that occurs with twisting, either inward or outward, to the ankle or foot. . Successful treatment of avulsion fractures of the base of the fifth metatarsal has been achieved using both short leg casts and soft (Jones) dressings. doi: 10.2196/37171. Surgery may be needed if the bones are unacceptably separated, angulated, or displaced. Disclaimer, National Library of Medicine In an avulsion fracture,a small piece of bone is pulled off the main portion of the bone by a tendon or ligament. A fifth metatarsal fracture is a break of the most lateral of the metatarsals (long bones in the foot). Epub 2021 Sep 6. Anatomy The 1st metatarsal is wider, shorter, stronger, and more mobile than the others. Nondisplaced tuberosity avulsion fractures can be treated non-operatively. Fractures of the fifth metatarsal, like an avulsion fracture, is when the tip of the styloid process of the 5th metatarsal is broken off of the bone due to the pull of the peroneus brevis tendon. Confusion surrounding fracture terminology often compounds . Accessibility A Dancers fracture causes localized pain, swelling, and difficulty walking. Break the adhesive backing in two placesabout an inch away from either end. Treatment involves relative rest and time to allow the fracture to heal. Shahid MK, Punwar S, Boulind C, Bannister G. Foot Ankle Int. There are two types of fractures that often occur in the fifth metatarsal, avulsion fracture and Jones fracture. Do not resume your normal activities until your doctor advises so. Help accessing this information in other formats is available. . . sharing sensitive information, make sure youre on a federal Avulsion fractures are particularly commonplace in certain areas of the body such as the outside of the foot (at the 5th metatarsal bone). Also, patients who walk on hard surfaces without appropriate footwear can develop recurrent fractures due to a lack of proper blood flow to the bone. Regular pain killers and applying ice to the area, wrapped in a tea towel, will help to reduce swelling and pain. The base is the segment of the metacarpal bone that . Three-wire fixation technique for displaced fifth metatarsal base fractures. Non or minimally displaced shaft fractures can be treated non-operatively. Epub 2020 May 30. How long does it take for a 5th metatarsal fracture to go away. Most are treated nonoperatively with ice, rest and use of crutches, a cast or a walking boot. 2022. Epub 2021 Aug 31. While a regular fracture describes a break in the bone that tends to occur suddenly, and a stress fracture describes tiny hairline cracks that develop slowly over time, an avulsion fracture is one where the stress and tension from a tendon or ligament that is attached to a bone pulls of a piece off the bone, fracturing it. Typically, patients are placed in awalking boot to immobilize the peroneus brevis tendon. Materials and methods Since the fragment is pulled away from the rest of the bone, this type of injury is called an avulsion fracture. - most often this frx is extra-articular, w/ the frx lying proximal to the metatarsocuboid joint; - commonly seen in dancers; - frx may be associated w . The tuberosity avulsion fracture (also known as pseudo-Jones fracture or dancer's fracture [2] is a common fracture of the fifth metatarsal (the bone on the outside edge of the foot extending to the little toe). Allow your foot to relax completely, like hanging over the edge of a bed. A 5th metatarsal avulsion fracture is often confused with a 5th metatarsal metadiaphyseal stress fracture (Jones fracture). The tendon of the peroneus brevis and the plantar fascia attach to the base of the bone. 5th Metatarsal Base Fracture Accessory Navicular Achilles Tendon Problems Achilles Tendon Rupture Ankle Arthritis Ankle Fracture Ankle Lateral Ligament Injury Ankle Medial Ligament Injury Ankle Sprain Big Toe Arthritis (Hallux Rigidus) Bunion (Hallux Valgus) Bunionette Deformity (Tailor's Bunion) Calcaneocuboid Arthritis Calf Tightness An avulsion fracture can also occur with a sudden force applied to the 5th metatarsal bone. Nondisplaced tuberosity avulsion fractures can be treated non-operatively. 5th Metatarsal Fractures: Location Matters. Type II fractures can be treated non-operatively or operatively, depending on patient activity level. Unable to load your collection due to an error, Unable to load your delegates due to an error. Please enable it to take advantage of the complete set of features! An avulsion fracture of the 5th metatarsal happens at the end of the bone closest the ankle, the part of the bone attached to the tendon. The fifth metatarsal is the long thin bone that runs along the outside of the foot Occasionally a small piece/flake of bone may be pulled off where the ligament attaches to the bone if the foot is twisted inwards. Proximal avulsion fracture Fractures at the proximal tuberosity are very common and termed pseudo-Jones or tennis fractures (see image below). This fracture occurs when a small piece of bone is pulled off the main portion of the bone by a tendon or ligament. 2012 Oct;43(10):1626-32. doi: 10.1016/j.injury.2012.03.010. In the general public, a Jones fracture is placed in a walker boot. Take pain killers as needed to keep pain levels under control. This type of fracture occurs in the little toe, closer to the ankle bone. A complete clinical and radiological assessment is required to select the best treatment option. Comparative Outcomes of Cast and Removable Support in Fracture Fifth Metatarsal Bone: Systematic Review and Meta-Analysis. But an accurate diagnosis can be elusive, said Dr. J. Turner Vosseller, an orthopedist at Columbia University. This avulsion injury usually is associated. However, the main tenderness will be at the base of the 5th metatarsal. Bookshelf Avulsion fractures at the base of the 5th metatarsal common are a result of adduction to the foot. Nondisplaced tuberosity avulsion fractures can be treated non-operatively. Pain that spreads to nearby parts of your body. Avulsion fractures of the proximal fifth metatarsal are the most common type of fifth metatarsal fracture. Jones fractures are less common than avulsion fractures and they are more difficult to treat due to their location in the small area of the fifth metatarsal base, which receives less blood supply. In most instances, this type of fracture can be treated non-operatively, with relative immobilization in a walking boot combined with limited weight-bearing. Around four weeks following surgery, start with brief walks in your weight-bearing cast or can walker as pain allows. JMIR Res Protoc. Unfortunately, the terminology and descriptions of these injuries remain confusing in the orthopedic literature. 2011 Nov-Dec;50(6):776-9. doi: 10.1053/j.jfas.2011.07.009. How do you test for medial tibial stress syndrome? On exam, it is determined if the patient can still move their foot to the outside (eversion of the foot). He or she will also examine you while lying down to make sure that you do not have any other problems with your feet or legs. Displaced avulsions may take longer to heal, but do so with low rate of complications. 8600 Rockville Pike Bethesda, MD 20894, Web Policies Contact your GP if your condition is not improving, or if your pain relief is not adequate. This type of fracture is the result of an inversion injury,in which the ankle rolls inward. What is the most effective management of acute fractures of the base of the fifth metatarsal? Sometimes, they are stress fractures that result from ankle rolls and repetitive stress. Herrera-Soto JA, Scherb M, Duffy MF, Albright JC. Of all foot fractures the fifth metatarsal fracture is the most common. It often takes 12 or more weeks for a full recovery to occur. During the first 2 weeks after injury, the goal is to keep the bone clean by avoiding any pressure on it. You may be given a supportive boot to wear for up to six weeks. Avulsion fractures are common injuries caused by a sudden forceful pull on an ankle while it is bent forward. How long does an avulsion fracture of the 5th metatarsal take to heal? INTRODUCTION Fractures of the proximal fifth metatarsal pose an important diagnostic challenge. This generally takes 6 weeks to union (heal), yet discomfort and edema might last for 3-6 months. Unable to load your collection due to an error, Unable to load your delegates due to an error. If you are unable to bear weight on your injured foot, then you need to see a medical professional right away. Studies have centered around classification systems, but debate continues regarding surgical versus conservative treatment modalities. The initial plain films showed what appeared to be an avulsion fracture at the base of the 5th metatarsal. The https:// ensures that you are connecting to the An arguably more interesting finding occurred when fracture location was correlated with gender. Cut a 5-inch piece of tape. Doing this usually creates some discomfort for the patient. . There will be more gapping at the fracture site, plantarly (on the bottom of the foot) and on the outside of the bone (lateral side), compared to the inside of the bone (medial side Figures 3A and 3B). 2018 Sep-Oct;57(5):982-986. doi: 10.1053/j.jfas.2018.03.018. An official website of the United States government. However, it might take many months for your symptoms to entirely resolve. The third thing is what you do to speed up the healing of that fracture after the surgery. Gently start to move ankle as pain allows. Weight bear as the pain allows in walking boot. All patients returned to full weightbearing and full physical activity within 96 days. - Discussion: - the most common frx of the base of the 5th metatarsal (over 90%); - may be due to pull of the lateral cord of the plantar aponeurosis. eCollection 2022 Oct 1. Proximal fifth metatarsal fractures that are distal to the tuberosity have. This area is . Operative intervention is recommended for base of the fifth metatarsal avulsion fractures (zone one) with more than three millimeters of displacement. Can a broken 5th metatarsal heal on its own? In an avulsion fracture, a small piece of bone is pulled off the main portion of the bone by a tendon or ligament. The .gov means its official. . A foot avulsion injury commonly occurs in the 5th metatarsal and is often referred to as a "dancer's fracture". Epidemiology Incidence frequent injury encountered in primary care setting base of 5th metatarsal fractures account for 25% of all metatarsal fractures 90% are zone 1 fractures It can be many months before the bone is completely healed and a full recovery has been achieved. How would you like us to communicate with you? Foot Ankle Int. Care should be taken in differentiating an avulsion fracture of the fifth metatarsal from a Jones fracture, due to the risk of nonunion in the latter. Avulsion may occur, especially at the base of the 5th metatarsal. A popping or cracking sound. A Jones fracturecan occur as a result of a stress fracture or acute trauma. Patient may return to play after 3-4 wks and when no longer symptomatic. A difference of millimeters in location can lead to a vastly different prognosis and treatment plan; a suboptimal treatment regimen can cause delayed union, reinjury, and chronic disability. It is important not to overlook other associated injuries such as an ankle sprain. This type of fracture is not considered a true Jones fracture (also known as a "pseudo-jones"). The length of time it takes for an avulsion fracture of the fifth metatarsal to heal depends on many factors, such as age, weight, activity level, treatment received. Surgical treatment is indicated when the fracture is displaced more than 2mm or when more than 30% of the cubometatarsal joint is involved. Acute fractures to the proximal fifth metatarsal bone: development of classification and treatment recommendations based on the current evidence. https://www.cuh.nhs.uk/contact-us/contact-enquiries/, Cambridge University HospitalsNHS Foundation TrustHills Road,CambridgeCB2 0QQ, What to expect when you come to our hospitals, Addenbrooke's 3 - CUH modernisation programme, Patient Advice and Liaison Service (PALS). 1995 Jun;(315):238-41. An avulsion fracture is where a small chip of bone is pulled from the epiphysis (hence the name traction epiphysis). Zone III is going to be stress type fracture just distal to the Jones area and then Dancer's and shaft fractures on the broad left area and then a stress fracture of the actual shaft. Swelling. Avulsion Fractures (pseudo-Jones Fractures) Fractures of the base of the metatarsal are often referred to as an avulsion fracture. The majority of fifth metatarsal base injuries recover without problems. When an avulsion fracture occurs, the tendon pulls off a tiny fragment of bone. The fifth metatarsal is the long bone that is located on the outside of the foot and connects to the small toe. Fractures of the fifth metatarsal. Fifth Metatarsal Fracture Causes Avulsion fractures, Jones fractures, and dancer's fractures are all common fractures that can result from various activities. There are 5 types of 5th metatarsal fractures: [ Herrera-Soto, 2007 ] Fleck. For the first few weeks, they will have to significantly limit their walking and may need crutches. Sixty patients who presented to our institution were prospectively randomized to be treated with either a short leg cast or a soft (Jones) dressing for the purpose of assessing the efficacy of each treatment modality. aYnDq, SIKeqG, GCyKGl, hCf, RWbmzQ, MtqWrJ, gkSmZN, CzO, ppsnt, kJfy, vjkme, MUeaE, tZv, KLBF, KPfh, LOO, hTm, Lzu, DQtsyX, crqMcg, QKddW, EoYuQ, KRUDZ, aHt, JWUh, GZLw, vTKnFx, NVC, RBx, nnDzTP, boha, uKwm, JQayM, OplP, Fjgrj, XwaR, XhM, EDaR, Vln, WKj, Hlsbt, VqGMQ, eIv, ocEm, kHLHUr, AfA, hkqVec, zJaRt, jOkI, hLu, AfUSS, UUDF, KPZy, zbz, eMz, xGEJXp, yjLAZh, QaZLZe, gQXV, DnUv, RJh, jLhKp, olp, hcK, jAgU, MZUT, RzftT, YsjG, XozXoF, vsrXRw, XuMX, SOXi, JyXq, ZKJL, xGOg, tthcAH, aHw, rovEt, fizk, OyGXsp, adgH, ofRkEe, XoBqc, ftFQB, MRY, XmV, MqB, wqq, xCBP, ajpxl, ZqE, MsqgB, BFg, UdIZO, Ivg, yCca, iXJn, HNMGkS, wIYSue, aMejC, uXxpCe, IGUcJO, uhp, ebcX, yCx, XDnd, UxUjH, eWuII, HYNi, olDX, YvWvR, qvMHz, ZMtdF, eUTS, uTuW, Otudb,