Ankle fracture

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Ankle fracture
ICD-10 S42.2-S42.4
ICD-9 812
eMedicine emerg/199  orthoped/271 orthoped/199

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammadmain Rezazadehsaatlou[2].


The ankle joint is consisted of 2 different joints:

1: The true ankle joint (Responsible for the dorsiflexion and plantar flexion movements of the ankle joint): It is consisted of three bone:

a: The tibia (medial ankle)

b: The fibula (lateral ankle)

c: The talus (the floor upon which the tibia and fibula rest).

2: The subtalar joint (Responsible for the invertion and evertion of foot):

a: The talus

b: The calcaneus A combination of ankle bones, joint capsule, and ligaments system are responsible for the stability of the ankle joint. syndesmosis of this stabilizing system are Anterior tibiofibular ligament Posterior tibiofibular ligament Transverse tibiofibular ligament Interosseous membrane Generally, there are three sub-groups for the the ankle joint based on the location of the the tibia and fibula:

  • Medial malleolus - inside part of the tibia
  • Posterior malleolus - back part of the tibia
  • Lateral malleolus - end of the fibula

Accordingly, there are thee type of ankle fracture invovlement:

A unimalleolar fracture Involves either the distal fibula (more common) or the distal tibia

A bimalleolar fracture Involves the lateral malleolus and the medial malleolus.

A trimalleolar fracture Involves the lateral malleolus, the medial malleolus, and the distal posterior aspect of the tibia.

Historical Perspective [4][5]

There are no reliable information regarding the historical perspective of the Ankle bone fracture but

In 1758, Percival Pott described three types of ankle fractures based on the number of malleoli involved as: unimalleolar, bimalleolar, and trimalleolar. Despite its ease of use it failed to differentiate stable from unstable types.

In 1949, a Danish physician, Niel Lauge-Hansen created a classification system based on a rotational mechanism of injury and he published his great work in a 1950 issue of Archives of Surgery,

Causes [6][7]

  • Pressure during car accidents
  • Twisted ankle side to side
  • Rotated ankle side to side
  • Rolling ankle in or out
  • Hyper-flextion
  • Hyper-Extention
  • Tripping
  • Falling from a height
  • Jumping from a height

As a person age, two factors cause higher risk of fractures:

  • Weaker bones
  • Greater risk of falling

Stress fractures as a common causes of fractures can be found due to the repeated stresses and strains. Importantly children having more physically active lifestyles than adults, are also prone to fractures. People with any underlying diseases such as osteoporosis, infection, or a tumor affecting their bones having a higher risk of fractures. As mentioned in previous chapters, this type of fracture is known as a pathological fracture. Stress fractures, which result from repeated stresses and strains, commonly found among professional sports people, are also common causes of fractures.

Life-threatening Causes

Common Causes

Common causes of Ankle fracture may include:

Less Common Causes

Less common causes of Ankle fracture include conditions that predisposes to fracture:

Causes by Organ System

Cardiovascular No underlying causes
Chemical/Poisoning No underlying causes
Dental No underlying causes
Dermatologic No underlying causes
Drug Side Effect No underlying causes
Ear Nose Throat No underlying causes
Endocrine No underlying causes
Environmental No underlying causes
Gastroenterologic No underlying causes
Genetic No underlying causes
Hematologic No underlying causes
Iatrogenic No underlying causes
Infectious Disease No underlying causes
Musculoskeletal/Orthopedic Osteoporosis and osteopenia.
Neurologic No underlying causes
Nutritional/Metabolic Osteoporosis and osteopenia.
Obstetric/Gynecologic No underlying causes
Oncologic No underlying causes
Ophthalmologic No underlying causes
Overdose/Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary No underlying causes
Renal/Electrolyte No underlying causes
Rheumatology/Immunology/Allergy No underlying causes
Sexual No underlying causes
Trauma Falling of car accident to on side of Ankle .
Urologic No underlying causes
Miscellaneous No underlying causes

Causes in Alphabetical Order

List the causes of the disease in alphabetical order:

Pathophysiology [8]

The main etiology of the Ankle fracture is thought to excessive inversion stress to the ankle joint. The ankle is more stable and resistant to eversion injuries than inversion injuries Because: The medial malleolus is shorter than the lateral malleolus causing higher range of the invertion than evertion of the talus bone. The deltoid ligament stabilized the medial wall of the ankle joint

On the other hand, the transverse malleolar, Vertical malleolar, and posterior malleolar fractures are associated with an avulsion injury, talar impaction, and other bone and/or ligamentous injury, respectively.

Mechanism [9]

In 80% of ankle fractures the foot is in supination position while, in 20% of fractures the foot is in pronation position. The Ankle fracture is caused by a falling or direct trauma to the ankle joint. The form and severity of this fracture depends on the position of the ankle joint at the moment of the trauma. The ankle joint is flexible but the medial side of the ankle joint is rigid because the medial malleolus is attached to the tibia and also the medial collateral ligaments are very strong. Also, lateral wall of the ankle include: the fibula, syndesmosis and lateral collateral ligaments play important rolls in this flexibility. This lateral wall of the ankle allows the talus to move in lateral and dorsal sides easily. The fibula has no weight-bearing roll but it provide a flexible lateral support. The syndesmosis is formed by the anterior and posterior tibiofibular ligaments which is the fibrous connection between the fibula and tibia.

If we imagine the ankle as a ring in which bones and ligaments play an important role in the maintaining the stability of this joint. Meanwhile, if this ring is broken in one place it remains stable but when it is broken in two places, the ring is unstable and it is at the higher risk of fracture. Consequently the ankle is unstable when both the medial and the lateral malleoli are fractured.

Pathophysiology [10][11]

Its known that the Ankle fracture in normal healthy adults can be caused due to the high-energy trauma (e.g., motor vehicle accidents), sport related injuries, falling from height. But it should be noted that the most important Risk factors for insufficiency fractures is chronic metabolic disease such as steoporosis, osteopenia, eating-disordered behavior, higher age, prolonged corticosteroid usage, female gender, lower BMI, history of a recent falling, and prior fracture.

  • The pattern of bone fracture and severity of injury depends on variety of factors such as:
    • Patients age
    • Patients Weight
    • Patients past medical history specifically any bone diseases affecting the quality of bone (such as osteoporosis, malignancies)
    • Energy of trauma
    • Bone quality
    • Position of the specific organ during the trauma
  • The below-mentioned processes cause decreased bone mass density:

Differentiating Ankle fracture from other Diseases [12][13]

In the orthopedic medicine its important to know that the ankle fracture should be evaluated using radiography for both confirming diagnosis and also for evaluating the surrounding tissues.

  • Acute compartment syndrome of ankle joint
  • Ankle Dislocation
  • Soft tissue Injury around the ankle ,
  • Deep Venous thrombosis
  • Thrombophlebitis
  • Foot Fracture
  • Gout
  • Pseudogout
  • Rheumatoid Arthritis
  • Tibia Fracture
  • Fibula Fracture
  • bimalleolar fracture
  • trimalleolar fracture
  • triplane fracture
  • Tillaux fracture
  • Bosworth fracture
  • pilon fracture
  • Wagstaffe-Le Forte fracture
  • Charcot-Marie-Tooth disease: in cases with repeated ankle fractures

Epidemiology and Demographics[14][15]

Of all cases with the ankle injuries only 15% of cases are true ankle fractures. The male-to-female ratio for ankle fracture is 2:1. The frequency of ankle fractures in adults and children is around 100 cases in 100,000 per year and 190 cases in 100,000 per year, respectively.

Risk Factors [16]

There are different risk factors that presidpose patient for the Ankle fracture that include:

  • High-risk contact sports
  • Higher age (elderly adults are higher prone to such fractures)
  • Reduced bone density (osteoporosis)
  • Direct blow
  • Road / traffic accidents
  • Falling
  • Direct trauma to the ankle
  • Taking part in any rough or high-impact sport
  • Street fights, gunshot wounds, and domestic violence, may also cause the Ankle fracture
  • Road traffic accidents.

Classification [17][18][19] [20]

The Ankle fracture may be classified based on the exact location of fracture:

The Weber ankle fracture classification (or Danis-Weber classification) can b used to classify the lateral malleolar fractures.

Weber ankle fracture classification (or Danis-Weber classification)
  • Usually transverse
  • Under the level of the talar dome
  • Tibiofibular syndesmosis is intact
  • Deltoid ligament is intact
  • Medial malleolus maybe affected
  • Usually stable if medial malleolus intact
  • Stage 1 - Tension on the lateral collateral ligaments cause

the rupture of the ligaments


avulsion of the lateral malleolus below the syndesmosis.

  • Stage 2 - Oblique fracture of the medial malleolus.
Ankle-fracture-weber A
Ankle-fracture-weber A
  • Usually spiral
  • Distal extent at the level of the talar dome
  • Tibiofibular syndesmosis usually is intact
  • Deltoid ligament may be injured
  • Medial malleolus maybe fractured
  • Variable stability dependening on the medial structures
  • May require ORIF
  • Stage 1 - Rupture of the anterior syndesmosis
  • Stage 2 - Oblique fracture of the fibula (the true Weber B fracture)
  • Stage 3 - Rupture of the posterior syndesmosis or - fracture of the posterior malleolus
  • Stage 4 - Avulsion of the medial malleolus or - rupture of the medial collateral bands
  • Above the level of the ankle joint
  • Tibiofibular syndesmosis is injured
  • Deltoid ligament is injured
  • Medial malleolus maybe fractured
  • Fracture may arise as proximally as the level of fibular neck and not visualized on ankle films, requiring knee or full-length tibia-fibula radiographs (Maisonneuve fracture)
  • Unstable:
  • Usually requires ORIF
    • Stage 1 - Avulsion of the medial malleolus or - ligamentous rupture
    • Stage 2 - Rupture of the anterior syndesmosis
    • Stage 3 - Fibula fracture above the level of the syndesmosis (this is the true Weber C fracture)
    • Stage 4 - Avulsion of the posterior malleolus or - rupture of the posterior syndesmosis

The Lauge-Hansen classification system is also for the ankle injuries based on injury mechanisms. This classification system uses two words:

  • The first word describes the position of the foot during the injury such as: supination and pronation.
  • The second word describes the direction of the deforming force such as abduction, adduction, or external rotation.

Accordingly, at least 13 different patterns have been described:

Grade Sequence
Supination-Adduction Stage 1: With no medial malleolar fracture (Weber A)

Stage 2: With oblique or vertical medial malleolar fracture

Supination-External rotation

(40-70% of injuries)

Stage 1: Tear or avulsion of the anteroinferior tibiofibular ligament is torn or avulsed

Stage 2: The talus displaces and fractures the fibula in an oblique or spiral fracture, starting at the joint (Weber B)

Stage 3: Tear of the posteroinferior tibiofibular ligament or fracture posterior malleolus

Stage 4: Tear of the deltoid ligament or transverse avulsion fracture medial malleolus

Pronation-Abduction stage 1: Deltoid ligament disruption or transverse medial malleolus fracture

stage 2: Posterior malleolus fracture

stage 3: Oblique fibular fracture (Weber C)

Pronation-External rotation stage 1: Deltoid ligament rupture, which may appear occult or as medial mortise widening, or  transverse avulsion fracture of the medial malleolus

stage 2: Involvement of the AITFL with extension into the interosseous membrane results in widening of the distal tibiofibular distance

stage 3: A spiral or oblique fibular fracture (>6 cm) at the level or above the talotibial joint (Weber C) stage 4: Involvement of the posterior inferior tibiofibular ligament (PITFL), or posterior malleolus fracture

AO/OTA classification of tibial malleolar fractures

AO/OTA classification of tibial malleolar fractures
Infrasyndesmotic 44-A1



isolated fibula fracture

fibula fracture with a medial malleolar involvement fibular fracturewith a posteromedial involvement

Transsyndesmotic 44-B1



isolated fibula fracture

fibula fracture with a medial involvement fibula fracture with a medial injury and the posterolateral rim involvement (Volkmann’s fragment)

Suprasyndesmotic 44-C1



simple diaphyseal fibula fracture

wedge or multifragmentary diaphyseal fibula involvement proximal fibula fracture


Osteoporosis is an important risk factor for human affecting human bone especially in men with the age of older than 50 years old and postmenopausal and women.

Based on the US Preventive Services Task Force (USPSTF) there are three groups of patients need to be screened for the osteoporosis:

  • ·       Men with no history of osteoporosis
  • ·       Women with the age of 65≤ year old, with no previous history of pathological fracture due to the osteoporosis
  • ·       Women with the age of <65 years, with 10-year fracture risk of not less than a 65-year-old white woman (who has not any other risk factor)

Accordingly women older than age of 50 are the main target for the osteoporosis screening. There is no specific recommendation to screen men for the osteoporosis.

The USPSTF recommendations from 2002 included:

Meanwhile, there are two major modalities for the osteoporosis screening:

  1. ·       Dual energy x-ray absorptiometry (DXA) of the hip and lumbar spine bones
  2. ·       Quantitative ultrasonography of the calcaneus

*It should be noted of the two above mentioned modalities for screening the ultrasonograhy is preferred to the DXA due to its lower cost, lower ionizing radiation, more availability.

After the primary evaluation of the osteoporosis, the further evaluation are required in some cases such as:

·       Women with normal bone density or mild osteopenia: T-score of greater than −1.50 – should have screening for 15 years.

·       Women with moderate osteopenia: T-score of −1.50 to −1.99 – should have screening for 5 years.

·       Women with advanced osteopenia: T-score of −2.00 to −2.49 - should have screening for 1 year.

Natural History, Complications and Prognosis [22][23]

Natural History[24]

In cases with untreated Ankle fracture the malunion and deformity of arm can be occurred.

Complications [25]

The overall complication rate in the treatment of Ankle fracture were found in around 40% of cases:

  1. Neurovascular compromise: such as Ulna nerve damage
  2. Compartment syndrome
  3. Chronic disability of the DRUJ
  4. Physeal Injury
  5. Malunion of the radius
  6. Nonunion
  7. Infection
  8. Refracture following plate removal
  9. Neural injury
  10. Instability of the DRUJ
  11. Loss of Motion (Stiffness)
  12. Posttraumatic Arthritis
  13. Heterotopic Ossification

Prognosis [26]

Successful treatment of Ankle fracture depends on the on-time interventions such as: accurate diagnosis and appropriate treatment and referral. Complex open fractures with soft-tissue injuries have a worse prognosis than isolated closed ankle fractures.


The diagnosis of a Ankle fracture should be confirmed using a radiographic examination.

History and Symptoms [27]

The related signs and symptoms include:

  • Deformity
  • Skin lacerations
  • Open fractures
  • Erythema
  • Edema
  • Stiffness
  • Decreased range of motion
  • Tenderness
  • Loss of function of the leg
  • Difficulties in detection of pulses
  • Nerve damage

In the physical exam the orthopedic surgeon should check the vascular status and amount of swelling in the ankle. In MULTI-trauma patients or in comatose or obtunded patients a tense compartment with neurological signs or stretch pain should be considered as the compartment syndrome, and the compartment pressures should be measured and monitored. Normally the pain and soft-tissue swelling are found at the injury site. This injury should be confirmed using a radiographic evaluations.

Physical Examination[28][29][30]

The related signs and symptoms include:

  • Edema of the ankle
    • Most of the time the edema will be a non-pitting edema
    • Depends on the edema extent, it may even lead to compartment syndrome in the anterior and internal compartment of the ankle
  • Bruising
    • As a manifestation of internal injury to the local vessels by trauma or fractures bone
  • Decrease in range of motion of the ankle
    • Movement of the ankle will be painful if possible at all
  • Tenderness
  • Deformity
    • Fractured bone deformity may be touchable in the internal side of the ankle if the fracture is displaced

In the physical exam the orthopedic surgeon should check the vascular status and amount of swelling in the ankle. In polytrauma patients or in comatose or obtunded patients a tense compartment with neurological signs or stretch pain should be considered as the compartment syndrome, and the compartment pressures should be measured and monitored.

Physical examination of patients with Ankle fracture is usually remarkable for swelling, tenderness, bruises, ecchymosis, deformity and restricted range of motion of the ankle.

Appearance of the Patient

  • Patients with Ankle fracture usually appears normal unless the patients had a high energy trauma causing the open wound fracture.

Vital Signs






  • Cardiovascular examination of patients with Ankle fracture usually normal




  • Genitourinary examination of patients with Ankle fracture usually normal


  • Neuromuscular examination of patients with Ankle fracture is usually normal
  • However, some patients may develop neuropraxia of the branch of the Ulnar nerve resulting in decreased sensation of thumb, index and middle finger.

Laboratory Findings[31]

There is a limited laboratory tests useful in the diagnosis of bone fractures such as the Ankle fracture. Meanwhile, aged men and women may have some abnormalities in their laboratory findings suggestive of osteoporosis.

Laboratory tests for the diagnosis of osteoporosis are:

  • Complete blood count (CBC)
  • Serum total calcium level
  • Serum Ionized calcium level
  • Serum phosphate level
  • Serum alkaline phosphatase level
  • Serum 25-(OH)-vitamin D level

X Ray[32]

The orthopedic surgeon should consider to have at least two radiographic projections (ie, anteroposterior [AP] and lateral) of the ankle. These show the fracture, the extent of displacement, and the extent of comminution. The orthopedic surgeon should pay serious attention toward finding any foreign bodies in open fractures and gunshot injuries. Also imperative is to include the elbow and wrist joint in the radiographs of Ankle fracture to ensure that the distal radioulnar joint injuries are not missed.

CT [33][20]

  • CT-scan in the case of the Ankle fractureis the best modality if you can not have an exclusive diagnosis by X-ray itself can not be made.

MRI [34]

  • Magnetic resonance imaging (MRI) is an expensive technique that should not be used routinely.
  • MRI is a powerful diagnostic tool to assess the abnormalities of the bone, ligaments and soft tissues associated with the Ankle fracture, but it is known as a limited utility in radioulnar injuries and is not indicated in uncomplicated ankle fractures.
  • Meanwhile, the MRI can be useful in in following mentioned evaluations:
  • Evaluation of occult fractures
  • Evaluation of the post-traumatic or avascular necrosis of carpal bones
  • Evaluation of tendons
  • Evaluation of nerve
  • Evaluation of carpal tunnel syndrome

Other Imaging Findings[35]

There are no other imaging findings associated with Ankle fracture

Other Diagnostic Studies[35]

There are no other Diagnostic studies associated with Ankle fracture

Treatment [36]

Immediate stabilization of patients is the first step. Then the radial fracture and the DRUJ stabilization is recommended in these cases. Open ankle fractures considered as a surgical emergency. Ankle fracture occurs in younger patients who are skeletally immature; the normally they treated using a closed reduction and casting. Since closed reduction and cast application have led to unsatisfactory results. Then, Almost always the open reduction are necessary for the Ankle fracture. There are controversies regarding the indications for intramedullary nailing of ankle fractures.

Non-Operative Treatment [37][38]

  • The first step in managing a patient with a fracture is to stabilize the patient if he/she is unstable due to blood loss, etc by giving them intravenous fluids and giving them some painkillers if the pain is severe.
  • In children, the usual plan is to attempt closed reduction followed by cast immobilization. In adults, treatment with immobilization in a molded long arm cast can be used in those rare occasions of a non-displaced fracture of the ankle joint. If the fracture shifts in position, it may require surgery to put the bones back together.
  • Rigid immobilization is suggested in preference to removable splints in nonoperative treatment for the management of the Ankle fracture
  • For all patients with Ankle fracture, a post-reduction true lateral radiograph is suggested.
  • Operative fixation is suggested in preference to cast fixation for fractures with post-reduction radial shortening greater than 3 mm, dorsal tilt greater than 10º, or intra-articular displacement or step-off greater than 2 mm.
  • Patients probably do not need to begin early wrist motion routinely after stable fracture fixation.
  • Adjuvant treatment of Ankle fracture with vitamin C is suggested for the prevention of disproportionate pain
  • Lateral epicondylar fractures should be immobilized for 7 days with patients elbow flexed at 90º, with the supinated ankle , and the extended wrist for relaxing the extensor muscles.

Complications of Non-surgical therapy[37]

Failure of non-surgical therapy is common:

  • Re-displacement to its original position even in a cast
  • Stiffness
  • Post traumatic osteoarthritis leading to wrist pain and loss of function
  • Other risks specific to cast treatment include:

Surgery [39][40][41]

Returning to the normal physical activity after Ankle fracturecan take weeks to months of therapy under supervision an orthopedist. Meanwhile, a physiotherapy can be helpful for patient to achieve the normal wrist and elbow function caused by the immobilisation. All adult Ankle fracture should be considered to be treated with open reduction and internal fixation (ORIF).

External fixation: For severe open fractures Open reduction and internal fixation: For distal Ankle fracture which depending on each patients condition the following may be needed:

Nerve placement Bone grafting Osteotomy Arthrodesis

Operation [42][43]

  • There are a variety of methods and implants useful to stabilize the Ankle fracturee, ranging from closed reduction and percutaneous pin fixation to the use of intra-medullary devices.
  • However, the most common fixation methods to treat complex Ankle fracture include external fixation, and open reduction and internal fixation.

External Fixation With or Without Percutaneous Pin Fixation

  • Ankle spanning external fixation employs ligamentotaxis to restore and maintain length, alignment, and rotation of bone.
  • Reduction is typically obtained through closed or minimally open methods and preserves the fracture biology.
  • The addition of percutaneous pins enhances the ability to reduce and stabilize fracture fragments.

Complications of External Fixation

Open reduction and internal fixation with plates and screws

  • This is the most common type of surgical repair for Ankle fracture
  • During this type of procedure, the bone fragments are first repositioned (reduced) into their normal alignment.
  • The bones held together with special screws and metal plates attached to the outer surface of the bone.

Complications of open reduction and internal fixation with plates and screws =

  • Infection
  • Damage to nerves and blood vessels
  • Synostosis
  • Nonunion

Pain Management [44][45]

Pain after an injury or surgery is a natural part of the healing process.

Medications are often prescribed for short-term pain relief after surgery or an injury such as:

  • opioids
  • non-steroidal anti-inflammatory drugs (NSAIDs)
  • local anesthetics

Be aware that although opioids help relieve pain after surgery or an injury, they are a narcotic and can be addictive.  It is important to use opioids only as directed by doctor.

Interventions [46]

The following options can be helpful for patients to rehabilitate after their fracture :

  • Joints mobilization
  • compression bandage
  • Soft tissue massage
  • Exercises and Activity modification

Postoperative Rehabilitation [47]

  • Complex Ankle fracture warrant individualized immobilization and rehabilitation strategies.
  • Because most multifragmentary Ankle fracture are the result of high-energy injuries, a prolonged period of wrist immobilization and soft-tissue rest may be beneficial and has not been shown to affect clinical outcomes.
  • The ankle is typically immobilized for 6 weeks post-operatively in a splint with Full weight bearing commences at approximately 3 months post-operatively after consolidation of the fracture is noted on radiographs.
  • The presence of varying degrees of ankle stiffness is inevitable and may result from poor pain control, lack of effort in controlled mobilization, edema, concomitant ipsilateral lower extremity fractures, or peripheral nerve injuries. Early stretching and mobilization of the intrinsic and extrinsic tendons of the hand is important to prevent finger stiffness. Edema control can be initiated with compression gloves, digital massage, and active and passive ROM of the ankle. A home exercise program or outpatient occupational therapy is started immediately post-operatively to maintain full range of motion of the ankle and limit the development of intrinsic muscle tightnes

Primary Prevention [48][49]

There are various preventive options to reduce the incidence of the Ankle fracture

  • Using ankle guards during practicing sports (skating, biking)
  • Using ankle guards during driving motorbikes
  • Avoid falls in elderly individuals
  • Prevention and/or treatment of osteoporosis
  • Healthy diet

Secondary Prevention [50]

It should be noted that the Post-menopausal women specially older than the age of 65 are at the higher risk of osteoporosis consequently these type of patients at greater risk for the pathological fractures .

So the Calcium and vitamin D supplementation play important role in increasing the bone mineral density (BMD) consequently decrease the risk of fracture in these type of patients. Also, avoiding excessive alcohol and quitting smoking play important role in this regard.

Detecting osteoporosis

Pharmacological therapy [51]

Life style modifications[52]


Template:WH Template:WS

See also

  • triplane fracture
  • Tillaux fracture
  • Bosworth fracture
  • pilon fracture
  • Wagstaffe-Le Forte fracture
  • Maisonneuve Fracture


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