ARTICLEPEDIATRICS Volume 137 , number 1 , January 2016 :e 20152262

Primary Care Physician Follow-up of Distal Radius Buckle FracturesEric Koelink, MD,a Suzanne Schuh, MD,b Andrew Howard, MD, MSc,c Jennifer Stimec, MD,c Lorena Barra, MD,d Kathy Boutis, MD, MScb

abstractOBJECTIVES: Our main objective was to determine the proportion of children referred

to a primary care provider (PCP) for follow-up of a distal radius buckle fracture who

subsequently did not deviate from this reassessment strategy.

METHODS: This prospective cohort study was conducted at a tertiary care pediatric

emergency department (ED). Eligible children were aged 2 to 17 years with a distal radius

buckle fracture treated with a removable splint and referred to the PCP for reassessment.

We telephoned families 28 days after their ED visit. The primary outcome was the

proportion who received PCP follow-up exclusively. We also measured the proportion who

received PCP anticipatory guidance and those children who reported returning to usual

activities “always” by 4 weeks.

RESULTS: We enrolled 200 children, and 180 (90.0%) received telephone follow-up. Of these,

157 (87.2% [95% confidence interval: 82.3 to 92.1]) received PCP follow-up exclusively.

Specifically, 11 (6.1%) families opted out of physician follow-up, 5 (2.8%) self-referred to an

ED, and the PCP requested specialty consultation in 7 (3.9%) cases. Of the 164 with a PCP

visit, 77 (47.0%) parents received anticipatory guidance on return to activities for their

child, and 162 (98.8%) reported return to usual activities within 4 weeks.

CONCLUSIONS: The vast majority of children with distal radius buckle fractures presented

to the PCP for follow-up and did not receive additional orthopedic surgeon or ED

consultations. Despite a suboptimal rate of PCP advice on return to activities, almost all

parents reported full return to usual activities within 4 weeks.

aDivision of Emergency Medicine, Department of Pediatrics, McMaster University Medical Centre and McMaster

University, Hamilton, Ontario, Canada; bDivision of Emergency Medicine, Department of Pediatrics, cDivision of

Orthopedics, Department of Surgery, and dDepartment of Diagnostic Imaging, The Hospital for Sick Children

and University of Toronto, Toronto, Ontario, Canada

Dr Koelink was involved in the critical development of the research proposal, data collection tools,

and research ethics approval; he oversaw all research operations in patient enrollment, as well

as data collection and entry. Dr Koelink had full access to the data, signifi cantly contributed to the

interpretation of the analyses, and wrote initial drafts of the manuscript. Dr Schuh was primarily

involved in the initial design of the work and development of the research proposal; she also

contributed to interpretation of the results and intellectual input of key study results, and revised

the article critically for important intellectual content. Dr Stimec was involved in the initial design

of the research study and was the content expert in pediatric musculoskeletal radiology; she

independently interpreted the images of all the enrolled cases, contributed to interpretation of

results and intellectual input of key study results, and revised the article critically for important

intellectual content. Dr Howard was primarily involved in the initial design of the study and

development of the research proposal; he also contributed to the interpretation of study results

and revised the article critically for important intellectual content. Dr Barra contributed to the

study methodology and led the logistical operations of patient enrollment; she conducted all

patient follow-up, instituted mechanisms in the study to ensure high follow-up capture, performed

all data entry, and reviewed the manuscript. Dr Boutis is the responsible author and as such has

full access to the data and has fi nal responsibility for the decision to submit for publication. She

To cite: Koelink E, Schuh S, Howard A, et al. Primary Care

Physician Follow-up of Distal Radius Buckle Fractures.

Pediatrics. 2016;137(1):e20152262

WHAT'S KNOWN ON THIS SUBJECT: Distal radius

buckle fractures have an excellent prognosis. They

are often managed by orthopedic surgeons, but

primary care providers (PCPs) may also be able to

reassess these low-risk injuries. Currently, no data

are available on PCP follow-up of this injury.

WHAT THIS STUDY ADDS: The majority of children

with distal radius buckle fractures presented to

the PCP for follow-up and received no additional

orthopedic or emergency department consultation.

Almost all parents reported a full return to usual

activities within 4 weeks for their child.

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KOELINK et al

A buckle fracture of the distal radius

is the most common type of fracture

in childhood and represents ∼20%

of all pediatric fractures.1 Despite

their high frequency, these fractures

represent very stable injuries with

excellent prognosis.2 As a result,

extensive evidence recommends

their treatment with a removable

wrist splint, rather than the

traditional use of casting.2–8 After

the initial diagnosis and treatment,

most of these fractures are managed

by orthopedic surgeons.9 Given

that intervention by an orthopedic

specialist is rarely required for these

fractures, it may also be appropriate

to have these low-risk injuries

followed up by the primary care

provider (PCP).

However, some studies suggest there

may be knowledge deficits in the

management of this injury by PCPs

because education in musculoskeletal

injuries is often lacking in family

practice and pediatrics residency

training.10–12 Thus, PCP follow-up

may result in unwarranted referrals

to orthopedic surgeons or emergency

departments (EDs), as well as

inappropriate anticipatory guidance

for this injury regarding duration

of splint use or readiness for return

to activities. Because 90% of these

injuries are currently managed by

orthopedic surgeons,9 and there are

no studies demonstrating whether

PCP follow-up is adequate for this

common injury, it is important to

examine the management outcomes

of children with distal radius buckle

fractures referred to the PCP for

follow-up before implementing this

strategy as a practice standard.

The main objective of the present

study was to determine the

proportion of children referred to a

PCP for follow-up of a distal radius

buckle fracture who subsequently

received PCP follow-up and were not

referred to an orthopedic surgeon

or ED physician. Based on the

excellent prognosis of this fracture,2

we hypothesized that ∼90% of

participants would receive PCP

follow-up exclusively for this injury.

METHODS

Study Design and Setting

This prospective cohort study was

conducted in an urban university–

affiliated tertiary care children's ED

in Toronto, Canada.

Study Population

A convenience sample of children

aged 2 to 17 years diagnosed with a

distal radius buckle fracture13 were

enrolled and referred to the PCP for

follow-up. Children were also eligible

if the distal radius buckle fracture

was associated with a distal ulnar

buckle/styloid fracture.2,14 Patients

were excluded if image review

resulted in a different diagnosis.

Other exclusion criteria involved

patients at risk for pathologic

fractures, multiple injuries,

developmental delay affecting

assessment, history of fracture in

the same forearm within 3 months,

and those who could not complete

follow-up due to lack of telephone

access or an insurmountable

language barrier. The study was

approved by the Hospital for Sick

Children Research Ethics Board.

Patient Recruitment

Research assistants present from

8:30 to 2:30 daily screened the

ED electronic tracking system to

identify children presenting with

wrist injuries. In cases confirmed as

having a distal radius buckle fracture

and meeting eligibility criteria, the

research assistant obtained informed

consent and assent where applicable.

Research assistants completed

a study data collection sheet to

capture demographic information,

management, and type of PCP (family

physician, pediatrician, or none). A

PCP is the physician identified by the

family who regularly sees the child

for well-child and sick visits.

At discharge, parents were provided

with an information handout

that discussed the diagnosis and

recommended PCP follow-up in

2 weeks. At the study institution,

follow-up of distal radius buckle

fractures by the PCP is the

standard of care, and thus these

injuries are not routinely referred

to an orthopedic surgeon. Upon

implementation of this practice

standard, there was no education

outreach to the PCPs, and the

management outcomes of this

practice have never been examined.

Follow-up

All study radiographs were reviewed

by a pediatric radiologist specializing

in musculoskeletal injuries within

72 hours. Discordant interpretations

from the ED interpretation and

respective changes in management

were reported to the family. All

enrolled families were contacted by

telephone at day 28 after the ED visit

to allow adequate time for contact

with the PCP. This time frame also

allowed adequate recall of events by

parents.15 For those with continued

symptoms, weekly telephone calls

were made after day 28 until patients

reached full recovery. We chose

telephone contact (versus in-person

contact) to maximize compliance

with follow-up2,16 and to remove

the impact that a hospital visit may

have on PCP and/or other physicians’

visits. Other rigorously designed

studies support the use of parental

recall via telephone follow-up with

respect to reports on physician visits

within the time frame used in this

study.,17,18

Families were asked about the

following details related to the index

fracture: clinical status, pain (never,

occasionally, often, or always) and

return to usual activities (always,

most of the time, some of the time,

not very often, or never); type (if

any) of physician follow-up; parent

management of splint usage and

return to activities; and physician

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PEDIATRICS Volume 137 , number 1 , January 2016

visits and diagnostic imaging taken

after the ED visit, with respective

changes in diagnosis/treatment.

Families were also asked about their

satisfaction with PCP follow-up and

PCP-recommended time frames

for splint usage and return to usual

activities.

Outcomes

The primary study outcome was

the proportion of participants

referred to the PCP for follow-up

of a distal radius buckle fracture

who, after ED discharge, received

PCP follow-up and did not have

visits to other physicians for this

injury (ie, exclusive PCP follow-up).

This outcome is clinically relevant

as a measure of physician ability

and willingness to manage the

injury without additional specialty

consultation, and it also measures the

feasibility of this follow-up strategy

for parents. Although follow-up

of this fracture was not routinely

accepted at the study institution's

orthopedic clinic, follow-up of

distal radius buckle fractures are

routinely accepted into several other

orthopedic clinics in the study region;

thus, PCPs do have the option of

referring these children to fracture

clinics at a different hospital.

As secondary outcomes, we also

reported the frequency of each

type of deviation from exclusive

PCP follow-up. To explore PCP

management of these injuries, the

following factors were examined:

(1) mean number of physician

visits; (2) proportion of children

who received repeat radiographs

at the PCP visit; (3) comparison of

physician-recommended timelines

on splint usage and return to

activities versus those applied by

the parents; and (4) variables that

may be independently associated

with lack of anticipatory guidance

on return to activity provided at the

PCP visit (pediatrician versus family

physician; age ≤5 years versus >5

years; radius and ulna fractures

versus isolated radius fracture). We

also examined the proportion of

children with a poor or prolonged

recovery, defined as pain/limitation

of activity >6 weeks13,19 and re-injury

that leads to re-fracture. To establish

the convenience and satisfaction with

PCP follow-up, the mean distance of

a PCP clinic from the family home

versus the mean distance of the

hospital from the family home was

determined. We also determined the

proportion of families who reported

being “very satisfied/satisfied”

with PCP follow-up for this injury

as measured by using a 5-point

categorical scale.

Data Analyses

Based on PCP knowledge of

managing these injuries,7,10,20,21 we

estimated that 90% of participants

would receive follow-up with the PCP

exclusively. Therefore, assuming a

primary outcome proportion of 0.90

and a 95% confidence interval (CI)

precision of ±0.05 yields a minimum

number of 158 patients (PASS, 2011;

NCSS, LLC, Kaysville, UT).

Descriptive statistics were used to

summarize responses. Proportions

were compared by using a χ2 test.

Logistic regression was used to

determine the association between

variables and the binary outcome

of anticipatory guidance on return

to activities given in follow-up or

the lack thereof. All variables were

entered into a full (ie, saturated)

multivariable logistic regression

model. Odds of anticipatory guidance

for a given variable were reported

with respective 95% CIs. All analyses

were completed by using SPSS

version 20 (IBM SPSS Statistics, IBM

Corporation, Armonk, NY).

RESULTS

Patients

During the study period, 297 children

were diagnosed with a distal radius

buckle fracture, 247 met enrollment

criteria in the ED, and 223 (90.3%)

consented to participate (Fig 1).

There were no significant differences

in the mean age (P = .34) or gender

(P = .12) of children who consented

to participate versus those who

declined. Upon image review, 23

(10.3%) of the 223 enrolled children

were found to have ED physician

diagnostic errors.

Of the remaining 200 enrolled

children, 109 (54.5%) were male,

and the mean ± SD age was 8.4 ±

3.4 years. Specifically, 33 (16.5%)

were aged 2 to 4 years, 65 (32.5%)

were aged 5 to 7 years, 63 (31.5%)

were aged 8 to 10 years, 25 (12.5%)

were aged 11 to 12 years, and 14

(7.0%) were aged ≥14 years. There

were 183 (91.5%) patients who

demonstrated skeletal immaturity

(open physes) on radiographs. In

this cohort, 191 (95.5%) identified

a regular PCP; 110 (55.0%) used a

pediatrician. A total of 66 (33.0%)

participants had buckle fractures of

the ulna as well as the distal radius.

Telephone follow-up was successful

in 180 (90.0%) of the 200 enrolled

children.

Orthopedic Referral, ED Visits, and No Physician Follow-up

Of the 180 children with distal radius

buckle fractures who received the

study telephone follow-up, 157

(87.2% [95% CI: 82.3 to 92.1])

received exclusive PCP follow-up (Fig

2). Specifically, 11 (6.1%) families

opted out of any physician follow-up

due to a reported lack of need; 5

(2.8%) self-referred to an ED for a

second opinion; and the PCP referred

7 (3.9%) children for further ED care

(3 for a broken splint) or orthopedic

consultation (4 for a second opinion).

None of the families who received

a second opinion by the ED or an

orthopedic surgeon were given a

different diagnosis or management.

If we assume that all 20 patients lost

to follow-up either did not receive

a PCP visit or received orthopedic/

ED consultation, the proportion of

those who received exclusive PCP

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KOELINK et al

follow-up would be 157 of 200

(78.5% [95% CI: 72.3 to 83.6]).

Of the 23 patients with ED physician

diagnostic errors, 7 children had

no fractures and were advised that

splinting and follow-up were no

longer required. The remaining 16

injuries represented subtle examples

of more complex fractures. Fourteen

of these were greenstick fractures

of the distal radius metaphysis

(2 minimally displaced at ≤15

degrees; 12 nondisplaced) that

were managed with a removable

splint for the duration of therapy.

There were also 2 cases of minimally

displaced Salter-Harris type II

fractures of the distal radius that

were immobilized with a cast and

healed to anatomic alignment by 6

months. Figure 3 presents the ED

radiographs of the children with the

highest degree of displacement. In

this subset of 16 cases, there was no

further displacement on follow-up

radiographs, and parents reported a

full return to baseline activities by 4

weeks.

Resource Use of PCP Visits

Of the 164 patients with distal radius

buckle fractures with PCP follow-up,

123 (75.0%) visited their PCP once

after the index ED visit, 35 (21.3%)

visited twice, and 6 (3.7%) were

seen 3 times. In addition, 126

(76.8%) children followed up with

their PCP at 2 to 3 weeks after the

ED visit, 15 (9.1%) were seen within

1 week, and 23 (14.0%) were seen

in 4 to 5 weeks due to scheduling

issues. Seven (4.3%) patients had

repeat wrist radiographs ordered by

the PCP.

Splint Use and Return to Activities

Parents reported <3 weeks of

splint usage in 112 (68.3%) of 154

cases (Fig 4). According to parental

report, duration of splint use was

not discussed by the PCP with 77

(47.0%) parents. However, the

reported frequency of splint usage in

the group that did not receive specific

physician advice on this topic was

not significantly different from that

reported by parents who did receive

specific PCP advice on duration of

splint use (P = .72). In contrast, the

proportion of parents who opted for

splint use for ≤3 weeks was 72.9%

versus 54.0% of physicians who

recommended this time frame to

parents (P < .0001).

4

FIGURE 1Patient enrollment. aExclusions total >50 because some patients had >1 exclusion criterion.

FIGURE 2Follow-up of children diagnosed with a distal radius buckle fracture in the ED.

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PEDIATRICS Volume 137 , number 1 , January 2016

When asked about their PCP-

recommended time to return to

normal activities, 87 (53.1%) families

stated lack of specific advice about

this issue (Fig 5). There were no

differences in reported return to

activities in patients who received

physician advice versus those who

did not (P = .79). Family physicians

versus pediatricians were more

likely to provide activity anticipatory

guidance on return to activities (odds

ratio [OR]: 2.1 [95% CI: 1.1 to 4.1]).

However, young age (≤5 years versus

>5 years) and fracture of both radius

and ulna were not likely to provide

guidance (OR: 1.0 [95% CI: 0.4 to

2.4]; OR: 1.1 [95% CI: 0.5 to 2.2],

respectively). Of the 75 families who

received PCP anticipatory guidance

advice, 59 (78.7%) opted for return

to activities in <3 to 4 weeks versus

38.3% of the PCPs who reportedly

recommended this time frame (P <

.0001).

Clinical Recovery and Parental Satisfaction

In the 164 children with distal radius

buckle fractures and PCP follow-up,

162 (98.8%) reported recovery to

usual activities within 4 weeks; 2

patients had occasional pain until

6 weeks after injury. Parental

satisfaction was reported as follows:

117 (71.3%), very satisfied; 39

(23.8%), satisfied; 5 (3.1%), neither

satisfied/unsatisfied; 2 (1.3%),

unsatisfied; and 1 (0.6%), very

unsatisfied. The mean distance from

a patient's home to the PCP was 7.8 ±

9.6 km, and the respective distance to

the treatment hospital's orthopedic

clinic was 12.7 ± 14.5 km, a mean

difference of 4.9 km (95% CI: –7.2 to

–2.6).

DISCUSSION

This study showed that the majority

of children with distal radius

buckle fractures were followed up

exclusively by the PCP. Despite the

suboptimal rate of PCP anticipatory

guidance on splint use and return

to activities, parents reported a full

return to usual activities within 4

weeks, which represents an expected

time frame for this injury.2

Considerable practice variation

exists in the care of distal radius

buckle fractures after the index

ED visit. Approximately 99% of

pediatric orthopedic respondents in

a US-based survey reported these

fractures to be at “very low/low risk”

for future complications, but 90%

still recommended an orthopedic

reassessment of this fracture.9 In

Canada, ∼50% of patients with

these injuries are referred from the

ED to the PCP for follow-up.22 The

present study's findings support the

premise that PCP care represents a

safe and feasible follow-up option

for this low-risk fracture. Despite

previous reports that parents

5

FIGURE 3Injuries misdiagnosed as a distal radius buckle fracture by the ED physician. A, Greenstick fracture of distal radius. B, Salter-Harris type II fracture of the distal radius.

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KOELINK et al

may prefer care by orthopedic

surgeons,20 our study found that

parents reported a high degree of

satisfaction with PCP follow-up, and

PCP offices were significantly closer

to patients’ homes. Importantly,

most of the patients who saw a PCP

only required 1 visit, and very few

had repeat imaging. This finding

contrasts with the practice in some

orthopedic clinics in which several

visits and repeat radiographs seem to

be common,23,24 leading to increased

health care costs, loss of patient

and provider time, and exposure to

potentially unnecessary radiation.23

Approximately 10% of injuries

diagnosed by the ED physician as

distal radius buckle fractures were

subtle examples of more complex

injuries. Other studies have found

a similar frequency and type of

misdiagnosis by ED physicians

when considering this injury.2,7

Nevertheless, healing of these more

complex injuries is excellent because

the distal radius has one of the

highest capacities for remodeling.25

An intervention by an orthopedic

surgeon is rarely required,25–27

and these fractures can generally

be safely treated by using a splint.

However, these injuries may require

longer immobilization and different

anticipatory guidance.13 Because

diagnostic errors in radiograph

interpretation by the ED physician can

result in a change in management,28–33

we recommend a robust quality

assurance system for ED physician

image interpretation34 to ensure

errors are recognized and acted on.

Only approximately one-half of

participating parents reported

receiving PCP recommendations

with respect to 2 key elements of

anticipatory guidance: duration of

splint usage and return to normal

activities. This relatively low rate

6

FIGURE 4Splint usage reported by parents.

FIGURE 5Return to activities reported by parents.

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PEDIATRICS Volume 137 , number 1 , January 2016

of PCP advice may be related to the

limited PCP expertise in this area.

A recent survey of pediatricians

across Canada and the United States

found that ∼45% of respondents

reported perceived knowledge

deficits in anticipatory guidance

of minor common pediatric

fractures.20 Although ∼70% of these

respondents supported PCP office

management of this injury, they

anticipated benefit from further

related education. Interestingly,

most parents removed the splint and

returned their children to activities

by 3 to 4 weeks, regardless of the

PCP advice on this matter. The latter

finding is consistent with the data

reported by Plint et al,2 in which

families were advised to use the

splint as needed, and ∼95% were

no longer using it by 4 weeks. Given

the excellent prognosis of this injury,

lack of reported complications, and

the conservative physician guidance

compared with choices influenced

by patient symptoms, PCPs would

likely benefit from further related

education while assuming primary

responsibility of follow-up of these

injuries.

This study has limitations. There was

no orthopedic surgeon comparator

group, limiting comparisons of PCP

versus orthopedic surgeon follow-up

outcomes. Nevertheless, our study

has value in demonstrating the

feasibility of PCP follow-up without

the need for further specialty

consultation for this injury. Our

outcomes were susceptible to the

accuracy of parental recall and were

not corroborated with physician

records; functional recovery in

particular was subject to parental

interpretation and not validated by

a scale35 or health care professional.

Our results may not be generalizable

to areas in which many patients

lack a PCP. However, ∼5% of our

patients opted out of any follow-up

care due to reported lack of need,

a finding also present in other

studies examining this population.2,7

Although there is 1 study supporting

no physician follow-up of distal

radius buckle fractures,36 future

research examining this strategy

may be warranted. Our reported

rate of misdiagnosis may differ

from other ED settings with

different levels of expertise in

pediatric musculoskeletal image

interpretation.

CONCLUSIONS

The vast majority of children with

distal radius buckle fractures

presented to the PCP for follow-up

and received no additional

orthopedic surgeon or ED

consultation. Many parents did not

receive PCP anticipatory guidance

on splint use and return to activities.

Furthermore, when PCPs did provide

this guidance, their timelines were

more conservative than patient-

guided choices. The latter 2 findings

suggest that PCPs may benefit

from further education in this area,

which echoes the desire for more

education on office management of

minor pediatric fractures previously

reported by PCPs.20

ACKNOWLEDGMENTS

The authors acknowledge the

Pediatric Research Academic

Initiative at SickKids Emergency

(PRAISE). This research would

not have been possible without

the superb efforts of the program

manager, Johanna Crudden, and

the participating PRAISE research

assistants.

7

ABBREVIATIONS

CI:  confidence interval

ED:  emergency department

OR:  odds ratio

PCP:  primary care provider

lead and provided most input into the intellectual content of the research proposal, developed all data collection forms, performed all the analyses, and had the

most major role in the interpretation of results. She contributed most signifi cantly to the initial drafts and critical revisions of the manuscript and gave fi nal

approval of the submitted version. All authors gave fi nal approval of the submitted version.

DOI: 10.1542/peds.2015-2262

Accepted for publication Sep 28, 2015

Address correspondence to Kathy Boutis, MD, MSc, Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8. E-mail: kathy.boutis@sickkids.ca

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2016 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to disclose.

FUNDING: The Hospital for Sick Children funded the research support received via the Pediatric Research Academic Initiative at SickKids Emergency (PRAISE)

program.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.

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KOELINK et al

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DOI: 10.1542/peds.2015-2262 originally published online December 10, 2015; 2016;137;Pediatrics 

Kathy BoutisEric Koelink, Suzanne Schuh, Andrew Howard, Jennifer Stimec, Lorena Barra and

Primary Care Physician Follow-up of Distal Radius Buckle Fractures

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DOI: 10.1542/peds.2015-2262 originally published online December 10, 2015; 2016;137;Pediatrics 

Kathy BoutisEric Koelink, Suzanne Schuh, Andrew Howard, Jennifer Stimec, Lorena Barra and

Primary Care Physician Follow-up of Distal Radius Buckle Fractures

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