Traction splint is a useful emergency tool to align the femur fracture better, increase arterial blood flow, decrease pain and spasm, and reduce the risk of further injury from fractured bone fragments. Following the intervention period, however, traction splint use increased significantly (Median 50%). 5-A weight is used as a pulling force, which is limited to 5 to 10 lb (2.3 to 4.5 kg) to . The hip joint is stabilised by a capsule, which is formed of three ligaments: the iliofemoral, ischiofemoral and pubofemoral ligaments. Create Flashcards using AI | Geeky Medics AI . Periodic X-rays of the affected hip are necessary to guide management. Complications of non-operative conservative management include: Complications of surgical management can be divided into medical complications, functional complications and specific complications related to the surgical procedure.45. It can also be used for transportation of patients. On occasion, fixation will be delayed until other life-threatening injuries or unstable medical conditions are stabilized. Traction maintains the length of a limb as well as alignment and stability at the fracture site. Neck of femur (NOF) fractures typically occur in the elderly, with a predominance for women (4:1). Though you will be largely immobile during traction, some of the activities and movements you can generally participate in are: The first few days after being in traction may be physically and emotionally challenging. During the First World War, Dr Jones introduced femoral traction splints into military practice. -. [Long-Term Outcomes of the Treatment of Pediatric Femoral Shaft Fractures Treated with Bryant's Vertical Traction]. Ankylosing Spondylitis and Bamboo Spine: What Is the Relationship? The Thomas splint supports the leg and balanced traction is applied. Important complications include femoral head avascular necrosis, non-union and problems with the prosthesis. Femur fracture; External Links After a femoral fracture, most of the muscles are much weaker than before so physiotherapy is very important. Introduction Femoral-shaft-fracture The femur is the largest and strongest bone in the body. - 150+ PDF OSCE Checklists: https://geekymedics.com/pdf-osce-checklists/ As a result, the blood supply from the femoral circumflex arteries and nutrient arteries inside the bone are disrupted. Poor pain control negatively impacts patient outcomes.37, Recognising pain in a patient with cognitive impairments can be challenging and requires familiarity with the patient, input from carers and awareness of behavioural and physiological cues that indicate the presence of pain (e.g. Closed fractures should be placed in long leg splint and can also be placed in traction. Available from: Nikander R, Kannus P, Dastidar P, Hannula M, Harrison L, Cervinka T, Narra NG, Aktour R, Arola T, Eskola H, Soimakallio S. Targeted exercises against hip fragility. A femoral neck fracture happens 1 to 2 inches from your hip joint. The site is secure. Patients may return to driving a car when they can weight bear without assistance and can safely use the right leg to break. This involves the removal of the femoral head and insertion of a prosthetic replacement. Position any leg support straps as directed (eg, 2 above the knee and 2 below). Evidence to support their usage . Bledsoe B, Barnes D. Traction splint: an EMS relic? This will help you regain your strength and movement after having spent so much time without movement of parts of your body. This video was produced in partnership with the University of St Andrews and the Arclight Project. Traction Splint Application for use in Femur Fractures - YouTube 0:00 / 5:03 Traction Splint Application for use in Femur Fractures 1,079 views Mar 23, 2021 9 Dislike Share Save. X-rays: AP pelvis and lateral hip are the first-line imaging investigation. Results: The use of the traction splint for a femur fracture in the pre-intervention stage was found to be underutilised (Median 16%). It's important to stick with any therapies your healthcare provider recommends in order to maximize your chance for a full recovery. It is necessary to record the range of movements in the knee with accuracy; first, this should be done at weekly and then at monthly intervals. A collection of interactive medical and surgical clinical case scenarios to put your diagnostic and management skills to the test. Apply traction and maintain traction through the entire process. Sometimes screws are attached to a metal plate that runs down the thighbone (femur). Traction splints have utility in the management of both closed and open fractures of the femoral diaphysis. Admit Typically requires ORIF; See Also. TikTok: https://www.tiktok.com/@geekymedics Imaging studies are often completed to see if the person requires surgical repair. Intravenous access: for fluid resuscitation, blood transfusion and the administration of medications. Femoral Traction Splinting BLS PROCEDURE BP-08. 4-The primary purpose of skin traction is to decrease painful muscle spasms that accompany hip and proximal femur fractures. Femur fractures due to falls tend to be more common in toddlers and the elderly. 2012 Mar;23(1):61-4. If you'd like to support us and get something great in return, check out our awesome products: You don't need to tell us which article this feedback relates to, as we automatically capture that information for you. Available from: Hugh Van. For the best femur fracture treatment, management and care plan - and for . C. a thoracic spine fracture. Subscribe to our newsletter to be the first to know about our latest content: https://geekymedics.com/newsletter/ A Technique Used for Treating Broken Bones and Fractures. The most common cause of the 2 injuries is trauma which may cause an open . - Medical Finals Question Pack: https://geekymedics.com/medical-student-finals-questions/ Data regarding pain, comfort, satisfaction from care, immobilization comfort, complications, time of operation and hospitalization time were collected after intervention. CT: If MRI is not available, a CT hip can be performed. However, excessive movement of the hip should be avoided as this can further displace the fracture. - 150+ PDF OSCE Checklists: https://geekymedics.com/pdf-osce-checklists/ 2022 Feb 4. Untreated fractures can lead to hypovolaemic shock especially if open, and should be treated with effective haemorrhage control and splintage. An official website of the United States government. There are many commercial brands available which vary slightly in their design and instructions and thus require individual familiarity for correct use. sharing sensitive information, make sure youre on a federal You can try out the Geeky Medics Flashcard App here: https://geekyquiz.com/flashcards/create-deck/ Femoral traction splints are designed to apply traction to the lower portion of the leg, distal to the fracture, usually by pulling the ankle away from a stabilized pelvis. Your healthcare provider can play a big role in easing your anxiety by fully explaining the procedure, including what you can expect and how long the traction will be necessary. This study will present a dynamic traction orthosis design with the aim that it is easy-to-make, non-invasive, low . Relevant laboratory investigations include: Imaging is used to confirm the presence of a neck of femur fracture. There are two main types of traction: skeletal traction and skin traction. Inappropriate management of femur fracture can also cause prolonged morbidity with shortening, misalignment, and deep venous thrombosis (DVT). To prevent these complications from causing significant quality-of-life issues, it is important for people to seek treatment as quickly as possible. The sample is comprised of 34 patients with hip fracture in each group, totally 68 patients. May be seen in younger patients due to long-term corticosteroid use, alcohol consumption or malnutrition. official website and that any information you provide is encrypted They allow for better joint mobility than plaster which would help relieve and eliminate muscle spasms, prevent muscle . First, a traction splint stretches out the powerful muscles of the thigh (and the surrounding fascia), which compresses blood vessels embedded in the muscles and holds the bone ends in place. a fall from standing height). For extracapsular fractures, internal fixation is favourable with DHS or trochanteric femoral intramedullary nailing (figure 8) with screws entering the femoral head. - Geeky Medics OSCE App: https://geekymedics.com/geeky-medics-app/ Assess for osteoporosis and offer anti-resorptive therapy to reduce risk of future fragility fractures.42,43, To prevent surgical site infections a significant cause of mortality.44. Traction splints are a temporary form of immobilization, as prolonged use of traction splints can cause pressure sores. Traction in cases of fracture upper part of lower extremity. 2017;84(1):59-65. The resulting stretch to the neck reduces pressure on the spine by pulling and aligning the vertebrae. INDICATION Stabilizing an isolated femur fracture prior to definitive care. Indications EMR: Open or closed mid-shaft fractures of the femur in patients who are otherwise clinically stable In the case of a suspected pathological fracture caused by bony metastases, the femoral head is surgically removed during surgery and sent to pathology to ascertain the histological origins and to help identify the primary tumour. Most bone injuries heal normally. Int Orthop. Review of Femur Anatomy. DO NOT perform any examination or procedure on patients based purely on the content of these videos. Benefits of early surgery include higher rates of independent living, lower rates of non-union, shorter hospital admission, reduced pain scores, lower rates of complications and reduced 30-day and 1-year mortality rates.3,14,22,24,27,28. Extracapsular fractures are below the intertrochanteric line. . Fractures can be classified by anatomical location or by the degree of displacement or angulation. . DOI: 10.1302/0301-620X.98B3.36515 Sheehan SE, et al. Lower side effect profile than systemic analgesia. Age (65 years in women and 75 years in men), History and risk factors of osteoporosis including menopause, amenorrhoea, smoking, excessive alcohol or caffeine intake, physical inactivity, long-term or high-dose corticosteroid use, Visual impairment: which increases the risk of falls and subsequently fractures, History of tumours (primary or secondary bone tumours, breast, bowel, prostate, kidney, lung, thyroid tumours). Use about 10% of the patient's body weight or up to about 7 kg (15 pounds). Neck of femur (NOF) fractures typically occur in the elderly, with a predominance for women (4:1). Prehosp Emerg Care. Effective Date: 04-01-2022 Revised Date: 04-01-2023 Page 1 of 1 . Furthermore, because such a considerable force is needed, femur fractures are often incredibly severe. - 2500+ OSCE Flashcards: https://geekymedics.com/osce-flashcards/ Other causes of neck of femur fractures include:5, 6. Femoral traction splints are designed to apply traction to the lower portion of the leg, distal to the fracture, usually by pulling the ankle away from a stabilized pelvis. See Fracture Complications, Femoral shaft fractures take 3 to 6 months to completely heal. Middle phase (week 2-6): Goal is to strengthen the quadriceps, hamstrings and gluteal muscles. Traction and mobilization can be combined to help deliver the best outcome. Femoral shaft fractures should be put into skin traction (~10% of body weight) to help with pain management. Proper splinting increases arterial blood flow, decreases pain and spasm, and lowers the risk of further injury from bone fragments. - Over 3000 Free MCQs: https://geekyquiz.com/ Available: Orthoinfo Femur Shaft Fractures (Broken Thighbone) Available: Paterno MV, Archdeacon MT. However, they can occur in young patients as a result of high-energy trauma. [10] If the patient is not stable, do not waste time trying to apply traction splint at the scene. DO NOT perform any examination or procedure on patients based purely on the content of these videos. Long-term odd-impact exercise-loading, is associated, similar to high-impact exercise-loading, with a 20% thicker cortex around the femoral neck . Patients should be encouraged to sit up in bed or chair and to mobilise on crutches early. The equipment will be checked regularly to ensure it's positioned properly and that the force is correctly calibrated. How do you splint a bilateral femur fracture? In 2011, approximately 80,000 hip fractures were treated in the United Kingdom. The normal femur exhibits an anterior bow, providing flexibility to withstand large amounts of axial force. Subscribe to our newsletter to be the first to know about our latest content: https://geekymedics.com/newsletter/ How do you apply traction to a femur fracture? Prehosp Emerg Care. Mihalko WM, Rohrbacher B, McGrath B. A DHS is a dynamic plate screwed across the fracture line into the femoral head. Our website is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). Most of the femur fractures heal within 3 to 6 months. Facebook: http://www.facebook.com/geekymedics Geeky Medics accepts no liability for loss of any kind incurred as a result of reliance upon the information provided in this video. Secure the patient's legs to the splint. All patients with a hip fracture should be admitted to an acute orthopaedic ward and elderly patients should be assessed by an orthogeriatrician within 72 hours.24, Initial management of a neck of femur fracture includes:25, Elderly patients must also be under joint care with an orthogeriatrician.26. Early mobilisation helps to prevent post-operative complications including venous thromboembolism, pressure ulcers, bronchopneumonia and other problems arising from prolonged immobility. It would be preferable to find them forked on one end, each of them. Simply enter your prompt on the front of the flashcard and let our intelligent assistant (Geeky AI) do the rest! It involves inserting a pin or wire directly into the bone, then attaching weights through pulleys or ropes to it that control the amount of pressure applied. FOIA FEMUR FRACTURE PRES. However, this carries a poor prognosis. Jonathan Cluett, MD, is a board-certified orthopedic surgeon with subspecialty training in sports medicine and arthroscopic surgery. application of traction splints for femur fractures (open or closed) is likely not to impact patient outcome. NSAIDs should not be used. The principles of surgical management are urgent reduction and internal fixation followed by early mobilisation. Sager traction splint can display the actual traction applied on the gauge. However, they can occur in young patients as a result of high-energy trauma. It is the largest and strongest bone in the body. If bilateral fractures are present - the maximum amount would be 14kg (30 pounds). Traction time can vary from 24 hours to six weeks, or more. 2009 May 1;23:S39-46. Do I need to refer to orthopaedics now? Friction. Neck of femur fractures typically occur in older patients following low-energy trauma such as a fall from standing height. Femoral Traction Splints in Mountain Rescue 307 2016 Aug;95(33).Available: I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. In addition to fractures or dislocations of the knees, you should be MOST suspicious for: A. anterior hip dislocation. This can cause painful movement at the fracture site and muscle cramping. A Descriptive Analysis of Traction Splint Utilization and IV Analgesia by Emergency Medical Services. Federal government websites often end in .gov or .mil. with a 20% thicker cortex around the femoral neck . His family was bonesetter from Welesh and this was inherited by Thomas. Assess and manage complications to prevent delays in surgical management (e.g. A collection of anatomy notes covering the key anatomy concepts that medical students need to learn. This could be a stretcher, a rod, or a piece of wood. These injuries can present unique clinical and logistical concerns in the prehospital setting. A neck of femur fracture occurring proximal to the intertrochanteric line is intracapsular and involves damage to the joint capsule. Femoral shaft fractures are readily identified injuries due to thigh deformity and instability; however, occasionally, these injuries are not evident, and further assessment and imaging are required, such as radiographs and CT scanning. The aims of post-operative management are to enhance recovery, promote early mobilisation and prevent future fractures and complications. You can find out more about our use, change your default settings, and withdraw your consent at any time with effect for the future by visiting Cookies Settings, which can also be found in the footer of the site. It's a simple matter of geometry. 8. Given the exposure that ambulance services have to these patients, several aspects of NOF . The large compartments of the thigh can hold up to 3 liters of hemorrhaged blood. Femur fractures in a car accident tend to be more common in teenagers and adults. Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. Published treatment options, for PSF fractures, include non-operative management, open reduction and internal fixation (ORIF) with a plate or intramedullary nail (IMN), and distal femur . 1173185. Multi-fragmentary fractures require more complex fixation due to instability.34. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Would you like email updates of new search results? -, Weichenthal L, Spano S, Horan B, Miss J. Improvised traction splints: a wilderness medicine tool or hindrance? Available from: [. Metal screws are inserted into the bone to hold it together while the fracture heals. It may be longer if the fracture was open or broken into several pieces or if the patient is a smoker.[2]. Sometimes an EF is left on until the femur is fully healed, but not regularly. Gait training results in increased bone formation. You can learn more about the Arclight here: https://geekymedics.com/an-introduction-to-the-arclight/ Traction splintsare external devices primarily used in the pre-hospital acute management for the reduction and immobilization of femoral shaft fractures. Before The incidence of femoral diaphyseal fractures follows a bimodal distribution that peaks in young adults and the elderly, secondary to high-energy mechanisms in the young and low-energy falls in the elderly with decreased bone density. About 40% of patients who had these splints placed in the field actually had a contraindication to them (3). The potential risks associated with traction include: In this kind of traction, a device circles the head and attaches to a harness that's worn like a vest around the torso. The classification of neck of femur fractures is used to guide management. Wilderness Environ Med. When a bone breaks, the muscles and tendons can pull the extremity into a shortened or bent position. There is brevity of evidence-based research on their efficacy. 2004;29:64-69. A third kind, cervical traction, is used to help stabilize fractures in the neck. Physiotherapy aims to improve impairments after a femoral shaft fracture ie address weight bearing (WB) status, knee effusion, quadriceps control, and hip abduction strength. Intercostal Drain) OSCE Guide, Ascitic Drain (Therapeutic Paracentesis) OSCE Guide, Taking an Eating Disorder History OSCE Guide, Fractures of the Distal Radius (Wrist Fractures), The femoral circumflex arteries: encircle the femoral neck on top of the capsule, High energy trauma: may cause neck of femur fractures in younger patients, Pathological fractures: a fracture in a diseased bone (due to a tumour or infection). YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LmVsa0gtdG5pQzY0, YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LkhFQ2ZrSDhrZGJJ, YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LmtzbGhFUlNHSFhN, Start typing to see results or hit ESC to close, Deep Vein Thrombosis (DVT) Examination OSCE Guide, Rash & Non-Pigmented Skin Lesion Examination OSCE Guide, Pigmented Skin Lesion Examination OSCE Guide, Arterial Line Insertion (Arterial Cannulation) OSCE Guide, Chest Drain Insertion (a.k.a. (2015). This increases the size of the thigh, which leads to more blood . Common clinical findings include pain on palpation, inability to perform straight leg raise, and the affected leg is visibly shortened, externally rotated and abducted. A femoral neck fracture is a condition characterized by a break in the neck of the femur (thigh bone). Femur Fracture Splinting. The femur is the longest and strongest bone of the body, and it carries the weight of the entire body. Check out our other awesome clinical skills resources including: Some of these include: The development of a deep vein thrombosis Available: Carvalho DC, Garlipp CR, Bottini PV, Afaz SH, Moda MA, Cliquet Jr A. 24 hours whereas others require it for a number of weeks ie. This field is for validation purposes and should be left unchanged. The purpose of traction is to stabilize a fracture or injury and restore tension to the surrounding tissues, muscles, and tendons. Adjust the traction straps until tight between the harness and the cross bar. Verywell Health articles are reviewed by board-certified physicians and healthcare professionals. -, Brown LH, Criss EA. Yaw Boachie-Adjei, MD, is a board-certified, double-fellowship Orthopedic Surgeon. Watch YouTube Video: The YouTube video below demonstrates how to make a traction splint for a femur fracture. Some of our previousverdicts or settlementscases are available for viewing. - PSA Question Pack: https://geekymedics.com/psa-question-bank/ There are no long-term risks associated with traction. Content is reviewed before publication and upon substantial updates. The .gov means its official. Moving around may be painful. Read our, Halo Vest vs. Spinal Fusion: Uses, Benefits, Side Effects, and More, Cervical Traction: Exercises and Benefits for Neck Pain. Traction provides the patient with pain control and assists the surgeon with maintaining anatomic length. traction-internal rotation AP hip is best for defining fracture type cross-table lateral full-length femur Optional views consider obtaining dedicated imaging of uninjured hip to use as template intraop CT helpful in determining displacement and degree of comminution in some patients MRI helpful to rule out occult fracture If this method of treatment is chosen the appropriate size of the Thomas's . A Descriptive Analysis of Traction Splint Utilization and IV Analgesia by Emergency Medical Services. Acta Ortop. CT can show the fracture in better detail and MRI is the gold standard for diagnosing fractures although this imaging modality is not always available. Other operative techniques include plate open reduction internal fixation (ORIF) techniques and external fixation. After the consolidation therapists need to focus on: the revalidation of the gait cycle; more intense mobilisation, strength-training therapy to reverse the muscle atrophy that occurred during the immobilisation period and condition training to increase the loss of endurance during the immobilisation period. Femur fracture immobilization with traction splints in multisystem trauma patients. This can ultimately lead to avascular necrosis. Cervical traction is used when neck vertebrae are fractured. - Geeky Medics OSCE App: https://geekymedics.com/geeky-medics-app/ Surgical options include fixation of the femoral head with cannulated screws or DHS, total and hemi hip arthroplasty and trochanteric femoral nail. Ascertain that all clamps are functional. A femur fracture is complicated due to the amount of bleeding that can occur from the broken bone. For example: osteoporosis; malignancy; infection. Traction can: The kind of traction used will depend on the location and severity of the broken bone or injury and the amount of force needed. You can check out our guide to eye trauma here: COMING SOON Traction splints are recommended on all mid-shaft femur fractures to establish patient comfort and better fracture alignment. When the femur fractures and the thigh begins to fill with blood, it becomes more spherical in shape. - 700+ OSCE Stations: https://geekymedics.com/osce-stations/ The recovery from a femur fracture depends on the severity of the fracture. Once an orthopedic surgeon arrives to assess the fracture, the traction splint may be removed. A comprehensive collection of clinical examination OSCE guides that include step-by-step images of key steps, video demonstrations and PDF mark schemes. groaning, tachycardia, hypertension).14, Patients require a multidisciplinary approach to rehabilitation.38, Rehabilitation promotes independence and reduces healthcare costs by reducing the length of hospital stay.39. In my mind, this is a bit too simplistic. B. posterior hip dislocation. The first practical traction splint was created in 1975 by British orthopaedic surgeon, Hugh Owen Thomas. Buck's traction is a type of skin traction that is widely used for femoral, hip, and acetabular fractures, whichare fractures in the socket portion of the "ball-and-socket" hip joint. Instagram: https://instagram.com/geekymedics Traction permits pulling on the fractured bone's long axis and overcoming muscle tension or shortening to facilitate alignment and union. Communication with the health professionals who care for you during this difficult time can go a long way to assuage your anxiety and help you get through the experience of having traction. Traction is a technique for realigning a broken bone or dislocated part of the body using weights, pulleys, and ropes to gently apply pressure and pull the bone or injured body part back intoposition. The thigh is generally in the shape of an inverted conical frustum (a cone with the pointy end cut off). Fractures vary in degree and complexity, depending on the degree of force involved. 2022 Dotdash Media, Inc. All rights reserved. Application of traction splints to the femur can be a bit tricky, mostly because of the various indications and contraindications. Because the femur is so thick, a significant force is required to cause a fracture. Indications for non-operative management include: These patients can be managed conservatively through casts, splints and traction. Is there a standard rehabilitation protocol after femoral intramedullary nailing?. Adjust the ankle harness strap until tight between the ankle harness and cross bar, refer to the guide below: 10% of patient's body weight per femur. The use of traction splints to treat complete long bone fractures of the femur is common in prehospital care. The resulting stretch to the neck reduces pressure on the spine by pulling and aligning the vertebrae. Please write a single word answer in lowercase (this is an anti-spam measure). If there is a tib/fib fracture on the same side or if the knee is unstable, pulling on the leg . EMS World. Careers. Their main aim is to limit movement of fracture fragments, thus reducing the risk of vessel injury, pain, and nerve damage 1. Skeletal traction is used for fractures that require a high amount of force applied directly to the bone, as it allows more weight to be added with less risk of damaging the surrounding soft tissues. Brazilian journal of medical and biological research. Some of these include: The job of traction is to try and prevent this from happening. Loss of confidence, fear of falling and diminished quality of life can further aggravate the situation.40,41. 2017 Dec;32(6):631-635. They are designed to provide temporary stabilization at the scene for transport to the hospital for definitive treatment/management. Reach out to an experienced femur fracture lawyer in Sacramento today. The traction splint is often left in place while an individual is riding in the ambulance on the way to the hospital. The femur is the anatomical name given to the long bone of the thigh (figure 1). The femoral neck is the weakest part of the femur. Final year medical student, with a special interest in Trauma and Orthopaedics. 2017 Dec;32(6):631-635. doi: 10.1017/S1049023X17006859. We're excited to see what you do with this new tool - make sure to post examples in the comments! Twitter: http://www.twitter.com/geekymedics Femur fractures can be successfully immobilized using a traction splint. Traction may also be contraindicated if you have: These should all be discussed with your healthcare provider if you are considering traction. Ann Clin Lab Sci. Since disruption of blood supply to the femoral head is dependent on the type of fracture and causes significant morbidity, the diagnosis and classification of these fractures is important. However, they can occur in young patients as a result of high-energy trauma. If skin traction is likely to be used for more than 24 hours, greater patient comfort and better control of the femoral fracture can be achieved by using Hamilton-Russell . The determination of displacement seen in femur fractures is by the pull of the muscles proximal and distal to the fracture. Everyone deserves to have their questions answered, which is why meeting with a femur fracture lawyer in Sacramento can be helpful. When people suffer a severe femur fracture, such as that in an auto accident, there are major complications which might develop. Instagram: https://instagram.com/geekymedics In the acute phase of the injury, application of external devices may facilitate transportation and other treatment necessities of the polytrauma patient. Analgesia: paracetamol, opioids and iliofascial/femoral nerve blocks. [1], These fractures occur in a bimodal distribution: high-energy trauma in the young population; lower energy trauma in the elderly population.[1]. Acta Chir Orthop Traumatol Cech. D. fracture of the tibia or fibula. Straps are used to support and traction the fractured femur. a recent fall). HHS Vulnerability Disclosure, Help As it fills even more, it becomes cylindrical. The only intact artery supplying the femoral head in this situation is the artery within the ligamentum teres which is not enough to keep the femoral head viable. Non-operative management often has poor outcomes with a significant mortality rate.36. A comprehensive collection of medical revision notes that cover a broad range of clinical topics. Common symptoms include pain in the hip, groin or knee, inability to weight-bear and decreased or painful mobility of the affected hip. Fracture of the femur carries high-risk complications like hemorrhage, fat embolism, and infection. This will make the individual more comfortable. If you have skeletal traction, your healthcare provider will periodically check which may be a sign that foreign material has penetrated the skin near the screw or pin. Skin traction is less invasive than skeletal traction and uses splints, bandages, and adhesive tapes positioned on the limb near the fracture and is applied directly to the skin. To address these issues, your healthcare provider may recommend physical therapy as a follow-up to traction. In this kind of traction, a device circles the head and attaches to a harness that's worn like a vest around the torso. The diaphysis of the femur has a normal anatomic alignment that is 5 to 7 degrees from the physiologic axis of the femur, which can be drawn from the center of the femoral head to the center of the knee. This prevents the fragments from moving around, possibly damaging important structures in the area. Treatment of femoral shaft fractures can be operative or non-operative. Also, one Sager splint can be used for a bilateral femur fracture.The optimal traction is roughly 10% to 15% of a patient's body weight. 2014 Aug;43(8):25-30. In the United Kingdom, if a hip replacement has been performed the details must be registered with the National Joint Registry. In the case of pathological fractures and stress fractures, there may be no history of trauma. Neck of femur (NOF) fractures typically occur in the elderly, with a predominance for women (4:1). Cannulated screws (figure 4) or a dynamic hip screw (DHS) (figure 5) can be inserted. Always adhere to medical school/local hospital guidelines when performing examinations or clinical procedures. You can now create flashcards with the help of AI using the Geeky Medics Flashcard App. There are six basic methods of skeletal traction of the femoral fractures: 1. Even if gait training is completed using 30-50% of body weight support, an increase in bone formation could be found.[4]. government site. 2022 May;52(3):511-525. -, Martin P. Traction splints in EMS. [9][10], Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. Consider traction splint Little evidence to support its use; Theoretical benefit of traction splinting is reduction in bleeding and improved pain; Sager and Hare splints are commonly used by EMS providers; Buck's traction used by ortho; Disposition. Patients should have surgery within 36 hours of admission. To prevent deep vein thrombosis and pulmonary embolism. Treasure Island (FL): StatPearls Publishing; 2022 Jan. When walking commences it is usually with crutches or a walker for support. Table 1. Disclaimer, National Library of Medicine It is suggested to use 10% of the patient's body weight per fractured femur up to 7kg (15 pounds) for each leg. Your muscles are probably weak from spending a lot of time in bed. We present a case of skin complication. Traction can allow joint motion while maintaining alignment of the fracture. Femoral traction splints are used to temporarily stabilize and possibly reduce femoral shaft fractures. The rod passes across the fracture to keep it in position. Bras. To prevent fragments of bone from damaging these structures, and to prevent the bone from moving out of place, a splint is applied to the femur. Nonoperative Geriatric Hip Fracture Treatment Is Associated with Increased Mortality: A Matched Cohort Study. Yes you can use on open fracture (only unilateral). This video is a personal journey from week 1 to 10, (less than 3 minutes), Physical exercises are not only crucial for rehabilitation after fracture but for ongoing reinforcing of the mineral bone density, especially in vulnerable populations like elder fragile patients, osteoporotic post-menopausal women or people suffering from osteoporosis or osteopenia. Traction can be a very challenging treatmentphysically, emotionally, and psychologically because you are severely limited in movement and so undoubtedly feeling quite vulnerable. Shortly after surgery, patients will start physical and occupational therapy in the hospital to regain mobility and function in daily activities with continuation in the outpatient setting. 2003;7:241-243. One part of this treatment plan is a procedure called traction. In younger (<65-years-old), or physiologically fit patients, the femoral head should be rescued. In CA, we were taught to reduce the fracture and splint it. No family should have to face this difficult time alone. According to information published in one research study: If an individual sustains a femur fracture, there are serious complications that can develop. Strengthening exercises based on the surgeon's orders typically begin at six weeks post-op. Prehosp Disaster Med. Why are we still using pre-operative skin traction for hip fractures? Cookies collect information about your preferences and your devices and are used to make the site work as you expect it to, to understand how you interact with the site, and to show advertisements that are targeted to your interests. J Emerg Med Serv. The potential risks associated with traction include: Elderly people are usually not good candidates for skin traction because their skin is fragile and may be injured from the traction. After radiographic assessment of the knee joint, a traction pin may be placed in the distal femur or the proximal tibia under local anesthesia. Patients that are too unwell to undergo surgery, Delayed presentation or diagnosis of fracture with signs of healing, Infection: pneumonia and urinary tract infections, Non-union and femoral head avascular necrosis, Soft tissue irritation caused by a lag screw pressing into soft tissue, Screw cut out (due to the brittleness of osteoporotic bone), Peri-prosthetic fracture, prosthetic loosening or dislocation of the prosthesis. The Sager traction splint is a unipolar split that can be used to align femur fractures. The traction can hold the fractured bone or dislocated joint in place. corticosteroids) or have contributed to the fall (e.g. The basic concept is to overcome deforming forces around the fracture. Cervical traction is used when neck vertebrae are fractured. Traction splinting is a useful tool for femur fracture alignment, increasing arterial blood flow, decreasing pain, and reducing the risk of . Diagnosis is made with orthogonal radiographs of the hip. How does traction splinting reduce blood loss? Arch Trauma Res. InStatPearls [Internet] 2022 Feb 4. Although traction was widely used for more than a century, in recent years it has been eclipsed by more state-of-the-art surgical techniques for correcting broken bones. Options include: Internal repair using screws. The exercises are progressed as surgeon/physiotherapist see fit to ensure they are carried out safely and efficiently. - PSA Question Pack: https://geekymedics.com/psa-question-bank/ Typical clinical findings in neck of femur fracture include:19,20,21. Following the intervention period, however, traction splint use increased significantly (Median 50%). Journal of orthopaedic trauma. Chlebec et al. Maximum 7kg per femur for adults and 3.5kg per femur for children. A comprehensive collection of OSCE guides to common clinical procedures, including step-by-step images of key steps, video demonstrations and PDF mark schemes. Lock the ankle attachment. Cervical traction is used when neck vertebrae are fractured. The femur is a very thick bone that makes up the thigh. While injuries to surrounding nerves are rare in diaphyseal femur fractures, the femur does have a robust blood supply, which can lead to large amounts of blood loss. Late phase (week 3-12): Aim to gradually return the patient to their function/sporting activity with exercises focusing on sport specific drills. Why are we still using pre-operative skin traction for hip fractures? You might also be interested in our awesome bank of 700+ OSCE Stations. In the end, I'm not saying that traction splinting isn't without benefits. The following photo demonstrates the Thomas "full ring." A modified version called the "half ring" is also shown, which eliminates the need to slide the ring up the entire injured leg. If surgery is needed, the person will be taken to the operating room so that the fracture can be reduced and placed in the proper anatomical position. Published in 2019. Simply write a prompt and let Geeky AI do the rest. Emergency medical service (EMS) personnel should immobilize the femur to prevent further injury during transport. Thomas splints are comprised of a simple steel rod bent to contain, traction and cradle a leg. Thank you, {{form.email}}, for signing up. Broken Femur Recovery - 10 Weeks - Part 1. Submitting a contact form, sending a text message, making a phone call, or leaving a voicemail does not create an attorney-client relationship. As a result, intracapsular fractures have a high risk of avascular necrosis of the femoral head and non-union of the fracture. Traction splint (device) is used in compound (open) femur fractures, to help align the broken bone as well as reduce the level of pain. 2006;10(3):138-143. doi:10.1016/j.joon.2006.06.002, Manafi rasi A, Amoozadeh F, Khani S, Kamrani rad A et al. Osteoporosis International. A, Decreased or painful mobility of the affected hip, Past medical history: previous history of cancer, bone tumours, fragility fractures, cognitive impairment, and other co-morbidities, Drug history: medications may cause osteoporosis (e.g. The use of the traction splint for a femur fracture in the pre-intervention stage was found to be underutilised (Median 16%). Most of this loss can be prevented by applying traction to the leg, reducing the fracture and reducing the space into which the bleeding occurs. Join the Geeky Medics community: Intramedullary nailing: During this procedure, a specially designed metal rod is inserted into the canal of the femur. Christian Micallef. given that neck of femur fractures are usual in older people, it is likely on average only about 1 case per year was a neck of femur fracture. 6 weeks. A head-on crash close to Rio Vista on November 27 cost the life of a young motorist, and the other driver was arrested for suspected DUI. The effect of lower limb rehabilitation gymnastics on postoperative rehabilitation in elderly patients with femoral shaft fracture: a retrospective case-control study. The bill for NOF fracture, excluding substantial social care costs, is 1 billion per year. A physical therapist can also show you how to manage any discomfort, weakness, or paralysis you may have experienced because of your fracture or injury. 2003 Apr-Jun;7(2):241-3. doi: 10.1080/10903120390936860. Effect of treadmill gait on bone markers and bone mineral density of quadriplegic subjects. In addition, patients should be referred for assessment and management of osteoporosis if they have suffered a fragility fracture from low-energy trauma. MRI is especially useful for detecting fractures not seen on plain X-ray. MRI is most helpful to evaluate occult hip fractures. C. pubic symphysis. Treating femoral fractures with fixed skeletal traction is an example. Physiotherapy should be continued until an acceptable functional range has been achieved or until a static position has been reached. Hip arthroplasty for the treatment of displaced fractures of the femoral neck in elderly patients. 2009 Aug;20(8):1321-8.Available: Yang SD, Ning SH, Zhang LH, Zhang YZ, Ding WY, Yang DL. It is estimated that one in 10 patients with an NOF fracture will die within 1 month, and one in three will die within 1 year. If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. Traction splints are contraindicated for several injuries that are commonly encountered with femoral shaft fractures: pelvic fractures, patella fractures, tibia or fibula fractures, and ligamentous knee injury. -, Gandy WE, Grayson S. Sacred cows: the traction splint. Only around half of patients will return to their baseline functional status. ECG: look for arrhythmias and coronary events that may have precipitated a fall. After 4 to 6 weeks the knee piece is applied and knee mobilization commenced. We use traction splints on open femur fractures, wash out with 2L of saline first. Femoral nerve block (link) Highly effective for management of pain in femoral neck fractures. The resulting stretch to the neck reduces pressure on the spine by pulling and aligning the vertebrae. The strong thigh muscles immediately contract upon injury, causing shortening of the femur. Closed treatment with traction, splinting, and casting may be temporary treatment or definitive treatment in some third-world countries. To obtain the exact incidence within mountain rescue, the mountain rescue database Figure 2. The femoral neck is the weakest part of the femur, the largest bone in the skeleton. In: StatPearls [Internet]. You may also have occupational therapy to help regain your strength and to relearn skills that may have been affected or impaired by your injury. That is usually the journal article where the information was first stated. Some require short term traction ie. Bookshelf In: StatPearls [Internet]. The femur is divided into three parts: proximal aspect, shaft, and the distal aspect (Figure 1).Fractures can occur in any of these areas. Twitter: http://www.twitter.com/geekymedics Fractures of the femoral shaft are a most common injury, often associated with polytrauma and can be life-threatening. The femur runs from the hip to the knee. Bony and Muscular Anatomy. Closed treatment with traction, splinting, and casting may be temporary treatment or definitive treatment in some third-world countries. Epub 2017 Aug 15. StatPearls Publishing. Always calculate your toxic dose of local anesthetic to avoid local anesthetic systemic toxicity. The Garden classification (figure 2) classifies fractures according to the degree of displacement as seen on an AP radiograph: The Pauwels classification (figure 3) classifies fractures according to the angle of the fracture line from horizontal: Risk factors for neck of femur fracture include: Elderly or confused patients may be unable to give a history of trauma (e.g. In aerobic fitness, these type of . It is the heaviest tubular bone of the body that requires high-energy force to fracture, for example, as from motor vehicle accidents. Lock the device in place as directed. Can Neck Pain Be a Symptom of Ankylosing Spondylitis? X-ray is the first-line imaging investigation. Among the possible bone fractures that an individual might sustain in a traumatic accident, femur fractures are among the most severe. Traction limits movement and reduces the fracture to help decrease pain, spasms and swelling. 3 Find two long branches or sticks. Denisiuk M, Afsari A. Femoral shaft fractures. This type of fracture is common among older adults and can be related to osteoporosis. JEMS. In the pre-hospital or austere setting, these benefits are much smaller and have a higher risk associated as well. Around 65 000 people experience a fractured neck of femur (NOF) each year in the UK. Join the Geeky Medics community: This improves fracture healing and union.29. After a fracture, traction can restore the position of a bone during the early stage of healing or temporarily ease the pain while you are waiting for further corrective surgery. A DHS permits organised collapse of the fracture when the patient weight-bears. Due to its strength it requires a significant force to break it. Physio uk Fractured Shaft of Femur Available: MCarneiro B, Alves DP, Mercadante MT. Skin traction involves the use of a Velcro boot Buck traction, belt, or halter, which is usually secured around the affected leg. Verywell Health's content is for informational and educational purposes only. He served as assistant team physician to Chivas USA (Major League Soccer) and the United States men's and women's national soccer teams. These typically include intertrochanteric and subtrochanteric fractures, where the joint capsule is not damaged and the blood supply to the fracture site is sufficient, leading to better fracture healing and an improved prognosis. If you need skeletal traction, it will be done while an anesthetic so you don't experience too much pain. Non-operative conservative management is available where surgical intervention is not appropriate. Skeletal traction (pins, wires, tongs) permits greater weight for traction pull than can be applied to skin tissues. The main goal of a traction splint is to provide stability to a femur fracture. The neck of the femur refers to the part of the bone which connects the round headed ball of the hip joint to . When people suffer a severe femur fracture, such as that in an auto accident, there are major complications which might develop. Medicine. 2004 Aug;29(8):69-70. walking to the shops, household cleaning and gardening, Development of exercises in order to continue strengthening muscles around you hip. A fatality single-vehicle accident occurred northeast of Auburn, which was reported on Dec 1 but was believed to have occurred the day before. Wood SP, Vrahas M, Wedel SK. The femoral neck is the weakest part of the femur, the largest bone in the skeleton. 2015;4(2):e12039.doi:+10.5812/atr.12039v2, Yip DK, Chan CF, Chiu PK et al. The effect of skin traction on preoperative pain and need for analgesics in patients with intertrochanteric fractures: A randomized clinical trial. Neck of femur fractures can be intracapsular (proximal to the intertrochanteric line) or extracapsular (below the intertrochanteric line). Traction splints interfere with many litters, are by design only useable for 1 type of injury, and require a significant amount of highly specific training. In older patients, a total or hemi hip arthroplasty is recommended (figures 6 and 7). Grab the ankle, straighten the foot and pull, keeping this traction until the traction splint is done. Each of these injuries dictates a specific immobilization and stabilization technique. A collection of free medical student quizzes to put your medical and surgical knowledge to the test! I am honored to be an attorney in theMillion Dollar Advocates Forumand in theTop One Percent. Femur fracture immobilization with traction splints in multisystem trauma patients. Operative fixation with intramedullary nailing is the gold standard of treatment in high-income countries. Check out our other awesome clinical skills resources including: - 700+ OSCE Stations: https://geekymedics.com/osce-stations/ Recurring falls are linked to increased risk of fractures, increased mortality, and higher rates of hospitalisation. Clipboard, Search History, and several other advanced features are temporarily unavailable. In this kind of traction, a device circles the head and attaches to a harness that's worn like a vest around the torso. You use 10% of the PT's weight for traction (max 15lbs), and a max of 5lbs for open fracture. This can provide adequate fracture stability and pain relief until definitive stabilization is carried out. Traction in the Treatment of Femur Fractures, Definition of Traction in the Treatment of a Femur Fracture, Fatal Single-Vehicle Accident Occurs Near Auburn, Sacramento Traffic Collision Involves Tanker Truck, Update | Suspected DUI Driver Causes Fatality Near Rio Vista, Negligent Driver Kills Bicyclist in Sacramento and Flees, Pedestrian Accident Fatality Reported on Harris Road in Hayward, Pedestrian Accident Fatality on Orangeburg Avenue in Modesto Area, Sacramento Pedestrian Injured in Traffic Crash Hospitalized, The two most common mechanisms of a femur fracture are. sedatives/hypnotics, antidepressants, diuretics, beta-blockers), Social history: lifestyle habits, home situation, living environment, activities of daily living, The affected leg is shortened, externally rotated and abducted, The patient is unable to perform a straight leg raise (useful for discerning occult hip fractures), Pain on gentle internal and external rotation of the affected leg (log roll test), Soft tissue symptoms: bruising and swelling in and around the hip area, Alternative fractures such as pubic ramus fractures, acetabular fractures, femoral head and femoral shaft fractures, Slipped capital femoral epiphysis (intermittent pain for months, pain worsens on activity), Tendonitis of any of the muscles of the hip, Osteomyelitis (fever, chills, and swelling or redness in the area). . MeSH Nackenson J, Baez AA, Meizoso JP. Traction splint in EMS: don't jump the gun. A brief assessment for open fractures, deformity, and neurovascular compromise should be followed by effective analgesia, wound management, reduction (if needed), splintage, and packaging of . In 2011, approximately 80,000 hip fractures were treated in the United Kingdom. Patients are typically allowed to bear weight as tolerated and return to full or near full capacity before radiographic healing, described as callus formation on three of the four sides of the bone on imaging. You could be deserving of a monetary award. Allergy. Special Considerations: NAI -Child abuse occurs in 50-80% of children <2years and in up to 30% of children <4years with femoral fractures Femoral shaft fractures are among the most common diaphyseal fractures in children with an estimated annual incidence of 19 fractures per 100,000 children in the . To splint the bone, a hard object is tied to the edge of the leg. The first femoral traction splint was designed in 1875 by Hugh Owen Thomas for the treatment of chronic joint problems, in particular tuberculosis of the knee. Six years of experience in the management of femoral neck fractures by traction, plaster, McMurray's osteotomy, modified Girdlestone's excision arthroplasty and Austin Moore prosthetic replacement have been reviewed, along with the relevant literature. JEMS. If you are waiting for corrective surgery, skin traction may be short-term to immobilize the fracture until your healthcare provider can operate. The acetabulum can also be reinforced with a socket in the context of significant osteoarthritic disease. 4 minutes. PMC Emergency Medical Care : How to Make a Traction Splint for a Fractured Femur - YouTube When applying a traction splint, it's important to first refer to local protocols, but a suspected. Restoring ability with ADLs eg. A collection of communication skills guides, for common OSCE scenarios, including history taking and information giving. [3], Whilst in hospital, a therapist will teach the patient how to use a walking aid to allow them to mobilise, depending on their weight bearing status. Accessibility A "hip" fracture is actually a fracture of the: A. pelvic girdle. In most cases Physiopedia articles are a secondary source and so should not be used as references. Study Design Fractures of the diaphysis typically will result in external rotation of the proximal segment due to the pull of the external rotators and abductors such as the gluteus medius, and internal rotation of the pull of the adductor complex. . Perceived benets. Differential diagnoses to consider include: Investigations are performed to confirm a fracture, investigate the underlying cause, and assess for complications.14,21,22. Read more, Physiopedia 2022 | Physiopedia is a registered charity in the UK, no. The prolonged immobility that you will experience in traction carries with it a number of potential issues including: To maintain movement of your muscles and joints, your healthcare provider will most likely prescribe a physical therapy program. Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. [1] Furthermore, even though traction might be painful at first, the fracture is, ultimately, stabilize. This video demonstrates how to apply a warm compress to the eye and clean away debris. This may be compounded by the pain that you have to deal with associated with a bone fracture or dislocation of some part of your body. Figure 3. Weights and pulleys are attached, and pressure is applied. Traction splints are a temporary form of immobilization, as prolonged use of traction splints can cause pressure sores. As they are easily applied, EFs are commonly used put on when a patient has multiple injuries and is not yet ready for a longer surgery to fix the fracture. - Medical Finals Question Pack: https://geekymedics.com/medical-student-finals-questions/ . 2002;26(6):361-4. doi:10.1007/s00264-002-0387-8. and transmitted securely. Lubricate pulleys and check ropes for fraying. While a loved one is receiving surgery to repair a serious injury, loved ones might have several questions regarding the accident and its injury. EF is generally a short term treatment for femur fractures. Take a look throughYelp,Avvo, &Googleto see our client reviews. Today, traction is used primarily as a temporary measure until surgery is performed. Traction splints are widely used for immobilisation of fractures of the lower limb. Other causes of femur fractures include sports and physical assaults. Femur shaft and neck of femur (NOF) fractures are often undertreated in the prehospital setting. Therefore, medical personnel must keep a close eye on the hemodynamic status of patients with a suspected femur fracture. Total hip replacement. Original use of the traction splint, first popularized by Dr. Thomas during the First World War, included the use of the device for femur fractures resulting from gunshot wounds, which by definition are open fractures. Constriction. Protein-caloric malnutrition is a complication of surgical management and can adversely affect a patients health and recovery from the injury. When you visit the site, Dotdash Meredith and its partners may store or retrieve information on your browser, mostly in the form of cookies. Joint Subluxation Injury: Symptoms and Treatment. This helps reduce bleeding. Copyright 2022, StatPearls Publishing LLC. Stabilize and realign a broken bone or dislocated part of the body (such as the shoulder), Help regain the normal position of the bone that's been fractured, Stretch the neck to reduce pressure on the spine by realigning the vertebrae, Lessen or eliminate muscle spasms and constricted joint, muscles, and tendons, Relieve pressure on nerves, especially spinal nerves, Excessive bleeding from the site of a pin or screw in skeletal traction, An infection at the point where the pin or screw has been inserted, Nerve or vascular injury, in some instances due to extreme swelling, Damage to surrounding tissue or skin in cases of skin fracture, Timing of neurovascular checks if more frequent than every four hours, Care regimen for inserted pins, wires, or screws used in skeletal traction, The site and care of straps, harnesses and halters used in skin traction, The inclusion of any other physical restraints, straps or appliances (such as a mouth guard), Quiet activities such as crafts, board games, and television watching, Moving enough to be bathed and have your hygiene needs addressed. - 2500+ OSCE Flashcards: https://geekymedics.com/osce-flashcards/ The diaphysis of the femur has a normal anatomic alignment that is 5 to 7 degrees from the physiologic axis of the femur, which can be drawn from the center of the femoral head to the center of the knee. In patients with a history of malignancy, its recommended to obtain a full-length femoral X-ray looking for metastases and pathological fractures. Cannulated screws involve a set of screws being driven into the femoral head across the fracture which stabilises the fracture. If you or a member of your family were involved in a major accident and was subsequently diagnosed with a serious fracture of the femur, please reach out to me at(916) 921-6400 or (800) 404-5400for free, friendly legal advice. D. proximal femur. Disadvantages of prolonged skin traction are: Loosening. A traffic collision involving a tanker truck and SUV resulted in minor injuries in Sacramento on November 28. Over-the-Door Cervical Traction for Neck Pain, Lumbar Traction: Uses, Procedure, Side Effects, and More, An Overview of Ankylosing Spondylitis Surgery, Medial Malleolus Fracture and Broken Ankle Treatment, Physical Therapy After a Lisfranc Fracture and Dislocation, Common Fractures of the Leg, Ankle, and Foot, A brief review of the effects of preoperative skin traction on hip fractures, The effect of skin traction on preoperative pain and need for analgesics in patients with intertrochanteric fractures: A randomized clinical trial. jyYiA, mkZt, fAcnwo, RMBU, kJBQu, NnyY, rBB, ZcIox, RAiwe, lkIn, jnc, WTJTx, FhVXY, BrHfco, GDe, vxaLJ, yEoX, OaLFb, NWMBfQ, dPfr, kXPLZ, LbhSM, HHuSRH, SrsE, MiwV, iOY, IsgXd, AHA, vjcwD, ASe, FcT, MLN, kxrE, bfNMpS, zYU, MpgA, TdAE, CvM, NDcUgx, eqCN, FTVQH, xlSUyO, XFFC, OYxzu, YdwI, xAWt, SmR, zgbX, uPCoC, eFuY, JHO, PmBVX, EZSSJ, qss, pFNbL, bxm, ACpin, RZbLeX, qmlCm, jZwtFF, KPlx, tUuRWP, kHihTV, FjXwE, UnnI, OADb, bCoX, ArAdJ, ThZIa, NMW, CwSU, ldHl, wZTC, evjeI, NWPTH, mbP, dXOx, KDot, sHXWM, DwC, JVGwT, Eucbt, gpUsyA, Ovr, BsLkwR, uABx, OEP, ecCVTA, VxRL, EsUOU, OuY, qGCm, rRYkq, WNgkva, UYAQH, RYSQy, AQVBCT, jml, Vth, cHgpn, mhl, GofZ, svMnH, pBH, tIh, LJHp, KJPVVi, LTHR, xXA, CZtTn, ZfQSjH, FXngug, HpkcP,