Stress fracture of the calcaneus may be misdiagnosed as plantar fasciitis. Hip injury, such as from a fall. 15 Pain usually . 11 Plain radiographs are of little assistance in the diagnosis of this lesion because early radiographic features are absent or subtle. Imaging. Following an individualized plan for partial or non-weightbearing for four to eight weeks, activity can be gradually increased guided by pain level. runners) Epidemiology 2% of all fractures Most frequently fractured tarsal bone Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Several muscles attach to the calcaneus so that when they contract, they exert a pulling force on the bone. In this case, the patient had a history of overuse having started running long distances regularly. The subtalar joint lets your foot move from side to side, as compared to the ankle joint, which moves your ankle up and down. Robertson GA, Wood AM. The calcaneus is the most commonly fractured tarsal bone and accounts for about 2% of all fractures 2 and ~60% of all tarsal fractures 3.. Dr. Wheeless enjoys and performs all types of orthopaedic surgery but is renowned for his expertise in total joint arthroplasty (Hip and Knee replacement) as well as complex joint infections. 2011 Jan 1;83(1):39-46. Calcaneal stress fractures can be prevented with risk factor reduction, including: Healthy diet with calcium and vitamin D. Gradual progression of physical activity. A calcaneal stress fracture is one or more small breaks in your heel bone (calcaneus). CT scan: It is gold standard for traumatic calcaneal injuries. Tarsal Navicular Fractures are rare fractures of the midfoot that may occur due to trauma or due to repetitive microstress. Thus, some believe this to mean that the injury is simply a chopart joint sprain. 110 West Rd., Suite 227 Stress fractures of the foot and ankle. Similar to March Fracture of the Matatarsal. The calcaneum is a common location of a stress fracture. The calcaneus is more commonly known as the heel bone. Welck MJ, Hayes T, Pastides P, Khan W, Rudge B. Tongue-type fracture may benefit from closed reduction and percutaneous fixation or open reduction . 4-Peroneal tendon irritation and impingement from the lateral wall. The way it occurs is often similar to that of an ankle sprain, where the foot is flexed in an . Risk factors include tobacco or alcohol use, eating disorders and sudden increases in intensity or volume of training. The anterior process of the calcaneus is a prominence on the heel bone (calcaneus) that is located in front and to the outside of the ankle (Figure 1). Clifford R. Wheeless, III, M.D. Small effusion of the common peroneal tendon sheath. A talus fracture is a broken bone in your ankle. An inversion motion of the plantar-flexed ankle is thought to increase stress at the insertion of the bifurcate ligament, with subsequent avulsion of a fragment of bone from the APC [3]. Calcaneal stress fractures can cause intense pain and make walking more difficult. This type of fracture commonly occurs during a high-energy event such as a car crash or a fall from a ladder when the heel is crushed under the weight of the body. Which of the following is the best next step in management? 2014 Jun;22(6):372-80. A calcaneus stress fracture is a stress fracture of the heel bone. 2014 Nov;42(4):87-99 While uncommon, calcaneus fractures can be severe and require medical treatment. If a calcaneal stress fracture is diagnosed, partial weight-bearing or non-weight-bearing with a boot for four to eight weeks is recommended. 2022 The American Medical Society for Sports Medicine. (M2.OR.15.4672) Often an X-ray of the injured bone does not show any sign of a fracture. - often 2-8 days must pass before bone scans become positive; Stress Injuries of the Calcaneus Detected with Magnetic Resonance Imaging in Military Recruits. Calcaneus fractures that benefit from surgery often involve breaks within the subtalar joint (the joint just below your ankle joint). Diagnosis can often be made on radiographs alone but MRI studies should be obtained in patients with normal radiographs with a high degree of suspicion for stress fracture. A cuboid stress fracture is a condition characterized by an incomplete crack in the cuboid bone. The most common symptom is pain around the heel that becomes worse with activity and weight-bearing. Small effusion of the tibialis posterior tendon sheath. A Cause of Acute Pain in the Knee, Orthopaedic Specialists of North Carolina. She is healthy but has a 2-year history of irregular menstruation, with up to 3 months between periods. You can use Radiopaedia cases in a variety of ways to help you learn and teach. The Orthobullets Podcast. Telephone: 410.494.4994, Calcaneal insufficiency avulsion fractures in patients with diabetes mellitus, Calcitonin Salmon/ Calcimar / Miacalcin Nasal Spray, Orthopaedic Specialists of North Carolina. She denies any trauma to her foot or history of fracture. Perlite and vermiculite are both good at retaining water, but vermiculite acts more like a sponge, holding much more water than perlite and offering less aeration for the plant roots.. "/> Medicine Orthobullets Science Health and Well-Being. Management and return to play of stress fractures. 1. increasing intensity of physical activity, increased physical activity without adequate rest results in pathological bone changes, this disrupts the balance between bone resorption and formation, which increases the risk of microfractures, should be suspected with tenderness or edema following a recent intensification of activity, tenderness upon palpation of the affected bone, loading the affected bone may result in pain, an initial imaging modality in the evaluation of stress fractures, typically normal in the first 2-3 weeks after symptom onset, obtained in patients with a negative stress fracture but symptoms are in a high-risk site, obtained in patients with negative stress fracture findings on repeat radiography with no symptom improvement, localized tenderness in the affected tendon, patients will experience pain and neurologic symptoms such as, compressive neuropathy of 3rd and 4th interdigital nerves of foot between metatarsal heads, fracture/dislocation of the tarsal-metatarsal joint, activity reduction with or without analgesia, an initial conservative approach for low-risk fractures, in particular needed for fractures of the 5th metatarsal, should be performed in most stress fractures, With early treatment, patients have a quicker recovery, Paget Disease of Bone (Osteitis Deformans), Avascular Necrosis of the Bone (Osteonecrosis). Remaining flexor tendons are intact. Pegrum J, Dixit V, Padhiar N, Nugent I. - Bone Scans: Plantar fascia origin is normal. Palpation of the dorsal surface of the right foot reveals point tenderness on the second metatarsal, though there is no redness, warmth, or swelling. Advances in cross-sectional imaging, particularly in computed tomography (CT), have given this modality an important role in identifying and characterizing calcaneal fractures. Symptoms of a calcaneal stress fracture are similar to a bruised heel and include: Pain under the heel develops gradually over time. Older children are more likely to have intra-articular . Patel DS, Roth M, Kapil N. Stress fractures: diagnosis, treatment, and prevention. Phys Sportsmed. (M2.OR.17.4752) April 16th, 2019 - Ankle fractures are encountered by a wide spectrum of providers Appropriate clinical management can reduce the possibility of severe disability or deformity When compared to healthy patients with an ankle fracture diabetic patients have increased in hospital mortality postoperative complications length of stay and total . A talus fracture can cause significant loss of function in your ankle. In this case, the patient had a history of overuse having started running long distances regularly. Occurs in female runners. She recently joined the army and was mildly athletic before starting. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. This is because . Calcaneal stress fractures are caused by repetitive overload to the heel and most commonly occur immediately inferior and posterior to the posterior facet of the subtalar joint. Epidemiology. A 17-year-old female presents to her primary care physician with right foot pain for the last 3 days. Positive squeeze test could mean there is a stress fracture of the calcaneus. The patient states that she recently began to train for a marathon and is running much more than she did several months ago. Surgery decreases the risk of post-traumatic arthritis. . A calcaneal spur, or commonly known as a heel spur, occurs when a bony outgrowth forms on the heel bone. 2014 Nov;6(6):481-91. The fracture itself occurs when the lower bone of the ankle (talus) gets driven into the upper part of the heel bone (calcaneus). World J Orthop. It often presents as lingering or worsening heel pain. General risk factors for stress fractures include running, jumping, marching, decreased bone density, female gender, and poor pre-activity conditioning. Usually the stress fracture resolves with rest and avoiding any repetitive impact on the bone until pain disappears. The calcaneum is a common location of a stress fracture. The calcaneal bone is somewhat analogous to a complicated shaped egg. Her pain improves with rest. Bone scan or MRI: are recommended in stress fracture of the calcaneus. A 22-year-old woman presents with foot pain. The remainder of the exam is unremarkable. Stress Injuries of the Calcaneus Detected with Magnetic Resonance Imaging in Military Recruits. Your talus is the main connection between your foot and your leg. Calcaneus fractures may occur as a result of falls from heights or from twisting injuries or through a pathologic process such as osteoporosis, cysts, and tumors. The calcaneus is the most commonly fractured tarsal bone, representing 60 percent of all tarsal fractures in adults [ 1 ]. Some of the reference angle and sign in the radiographic images are: Mondor's Sign is a hematoma identified on CT that extends along the sole and is considered pathognomic for calcaneal fracture. Cuboid Fracture Orthobullets - 9 images - daily dose cuboid fracture, osteochondral lesions of the talus and occult fractures of the foot and, Copyright 2022 Lineage Medical, Inc. All rights reserved. If a stress fracture is not seen on initial x-ray, a repeat x-ray in two weeks or a bone scan or magnetic resonance imaging (MRI) scan may be ordered. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. A 25-year-old athlete comes into your office for pain in his right foot. The cuboid is the anatomical name given to one of the bones in the mid foot. Treatment is generally nonoperative with cast immobilization and non weight-bearing for the majority of fractures. Check for errors and try again. Plantar and medial heel pain: diagnosis and management. Get an MRI if x-ray is negative About 60% of calcaneal. People often break their calcaneus when they fall from a height onto their feet. A compression test or squeeze test. Discovered by Player FM and our community copyright is owned by the publisher, not Player FM, and audio is streamed directly from their servers. 2-Open fractures of the calcaneus--May lead to amputation & there is a high risk of infection. Most stress fractures will heal with conservative management, and surgery is rarely needed. That repetitive activity can cause small amounts of trauma to the bone, and without enough healing time between activities, it can results in microscopic damage that can progress to a stress fracture. Diagnosis can be made with plain radiographs of the foot. Calcaneal spurs can be located at the back of the heel (dorsal heel spur) or under the sole (plantar heel spur). Calcaneus Fractures - Trauma - Orthobullets orthoBULLETS MBBULLETSStep 1For 1st and 2nd Year Med Students MBBULLETSStep 2 & 3For 3rd and 4th Year Med Students ORTHOBULLETSOrthopaedic Surgeons & Providers JOIN NOWLOGIN Home Topics Techniques Cards QBank Evidence Cases Videos Podcasts Groups Products Trauma Spine Shoulder & Elbow Knee & Sports A sports medicine physician will assess the patients symptoms, level of training and risk factors for this injury. The connection between the talus and calcaneus forms the subtalar joint. Stress fractures and stress reactions of the diaphyseal femur in collegiate athletes: an analysis of 25 cases, Epidemiology of metatarsal stress fractures versus tibial and femoral stress fractures during elite training, Upper-extremity Stress Fractures: Distribution and Causative Activities in 70 Patients, The Comprehensive Description of Stress Fractures: A New Classification System, Clifford R. Wheeless, III, M.D. Hit the Subscribe button to track updates in Player FM, or paste the feed URL into other podcast apps. Nearly all individuals with calcaneal stress fractures will return to normal activity without pain after 12 weeks. (OBQ05 . The incidence of calcaneal stress fracture, which is synonymous with fatigue and insufficiency fracture, varies and is attributable, in part, to the ease with which these fractures can be overlooked. Data Trace specializes in Legal and Medical Publishing, Risk Management Programs, Continuing Education and Association Management. Women, military recruits and long-distance runners are at higher risk for stress fractures. This causes the calcaneus to break (Figure 2). External rotation of the hip. ReferencesKaeding CC, Yu JR, Wright R, Amendola A, Spindler KP. Data Trace Publishing Company Am Fam Physician. Type in at least one full word to see suggestions list. Calcaneal fractures can be divided broadly into two types depending on whether there is articular involvement of the subtalar joint 2,7,8:. Most calcaneal fractures are occupational, and are caused by axial loading from a fall [ 2 ]. These fractures often occur because of repetitive, long-term stress on the bone, such as from jogging. Prominent marrow edema through the calcaneus posteroinferiorly with a linear low T1 signal completely crossing the medullary cavity. A calcaneal stress fracture is a small break in the heel bone, also known as the calcaneus, due to repetitive activity on the foot. That repetitive activity can cause small amounts of trauma to the bone, and without enough healing time between activities, it can results in microscopic damage that can progress to a stress fracture. Clin J Sport Med. Fractures of the anterior process of the calcaneus occur following an acute injury to the foot. an initial conservative approach for low-risk fractures Casting/splinting in particular needed for fractures of the 5th metatarsal or following surgical intervention should be performed in most stress fractures Operative orthopedic surgery indication recommended for high-risk fractures Complications Recurrent fractures Malunion Prognosis 3-Malunion of the calcaneus. Calcaneus stress fracture symptoms. Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-84073. 110 West Rd., Suite 227 (Also known as Stress Fracture of the Calcaneus) What is a calcaneal stress fracture? A prospective study. Mechanism of injury. Stress Fractures around the Knee in Elderly Patients. Plain radiograph of the right foot is performed and shown in Figure A. His pulses and sensation are intact in all extremities. Located at the back of the foot, the calcaneus is essential for walking and provides support and stability to the foot. Periosteal and soft tissue edema adjacent to the posteroinferior calcaneum. Calcaneus fractures in children younger than 10 years of age, are usually extra-articular. Telephone: 410.494.4994. 8 public playlists include this case Related Radiopaedia articles Calcaneus Stress fracture Fracture of the lumbar spine is encountered in approximately 10% of cases. The physician will perform a physical examination to determine the location of the pain. Fracture characterization is essential to guide the management of these injuries. To prevent recurrence of injury, padded heel inserts and correction of biomechanical abnormalities may be beneficial. - Stress fracture of the medial malleolus. Orthopaedic Specialists of North Carolina. The most common etiology is a forceful axial load to the hindfoot, frequently occurring during a fall. It is located at the outer aspect of the mid foot just in front of the ankle (figure 1). By Orthobullets. Listen to the latest hot topics in sports medicine today from board-certified sports medicine physicians. - Insufficiency stress fractures of the foot and ankle in postmenopausal women . A Femoral Neck Stress Fracture (FNSF) is caused by repetitive loading of the femoral neck that leads to either compression side (inferior-medial neck) or tension side (superior-lateral neck) stress fractures. Tarsal Tunnel Syndrome is a compressive neuropathy of the tibial nerve at the level of the tarsal tunnel which can lead to pain and paresthesias of the plantar foot.. "/> An x-ray is generally obtained, but stress fractures are often not seen until two to three weeks after the onset of pain. Normal Achilles insertion. Towson, MD 21204 ; Bohler's Angle is defined as the angle between two lines drawn on . ADVERTISEMENT: Supporters see fewer/no ads. For US States - use only letter abbreviations. Her BMI is 17.1 kg/m^2, and she appears tired with a flat affect. extra-articular: 25-30% Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Bone spurs on the hip. . The long-term followup of soldiers with stress fractures. Injury. Painful problems of the foot, such as a bunion, callas, plantar fasciitis, or Achilles. Learn more: Calcaneus (Heel Bone) Fractures Stress Fractures of the Navicular The navicular is one of the bones in the middle of the foot. Wheeless' Textbook of Orthopaedics. Mayer SW, Joyner PW, Almekinders LC, Parekh SG. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. - may be useful w/ acute symptoms and negative radiographs; Having one leg that is longer than the other. Anterior/extensor tendons are intact. She states that the pain began gradually and is worse with weight bearing and activity. Summary A tibial shaft stress fracture is an overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures. A predictor of risk for stress fractures, The effect of pretraining sports activity on the incidence of stress fractures among military recruits. Orthopaedic Specialists of North Carolina. Sinus tarsi is unremarkable. Furthermore, weight bearing activity places compressive forces through this bone. Similar to March Fracture of the Matatarsal. The pain is worsened by weightbearing and other physical activities, such as sprinting or jumping. - Fatigue fractures of the foot and ankle in the athlete . A stress fracture of the calcaneus is a small break in the heel bone. 2005 Nov;15(6):442-7. Insufficiency Fracture of the Calcaneus. Diagnosis can be be made with radiographs but findings often lag behind often resulting in negative radiographs early on. Calcaneal Fractures The calcaneus is the most commonly fractured tarsal bone, caused by axial loading, usually resulting from a fall from a height on to the heels. (SBQ12TR.86) Radiographs do not demonstrate any fracture or dislocation. Figure A is an anteriorposterior (AP) radiograph of his right foot. runners) Epidemiology 2% of all fractures Most frequently fractured tarsal bone Several muscles of the foot and lower leg attach to the cuboid bone. The peak incidence occurs in younger males [ 2 ]. Fractures are bilateral in 10% of cases; 25% are extra-articular but the majority have articular involvement. Data Trace is the publisher of Lareau CR, Sawyer GA, Wang JH, DiGiovanni CW. Distribution and natural history of stress fractures in U.S. Marine recruits. Unable to process the form. Definition: Fracture of the calcaneus bone Mechanism Traumatic axial loading is the most common cause (eg fall from height) Can also occur in MVCs when the accelerator/brake pedal impacts the foot Stress fractures seen with overuse from repetitive impact (e.g. Jogger's fracture and other stress fractures of the lumbo-sacral spine, Stress fractures of the pubic ramus. When this occurs, the heel can widen, shorten, and become deformed. Stress fractures of the navicular cause pain that is difficult to pinpoint. Treatment usually requires surgery, and the recovery process can take months. The calcaneus connects with the talus and cuboid bones. Data Trace Publishing Company clean out fracture lines and remove lateral wall identify constant anteromedial fragment and build off of it with kwires large Schantz pin into posteroinferior calcaenus for traction Fixation lag screws 3.5mm to join lateral to medial fragments check plate size, fill central void with allograft, and replace lateral wall Postoperative Calcaneal fractures occur on the calcaneus or heel bone, a large bone that forms the foundation of the rear part of the foot. Data Trace is the publisher of His wounds healed without infection or other complications. What is the most likely diagnosis? J Am Acad Orthop Surg. Towson, MD 21204 A study of 320 cases. Insufficiency Fracture of the Calcaneus. The effect of pretraining sports activity on the incidence of stress fractures among military recruits. Stress fracture of the calcaneus in children is believed to be rare [1,2].Radiographs of the calcaneus show no fracture in the early stages after stress fracture but 10 days or even longer after the initial pain a stress fracture in the calcaneus is evident on radiographs [, , ].A newer study proposes that these stress fractures often are overlooked in children when . Review Article: Stress Fractures: Current Concepts. Distribution and natural history of stress fractures in U.S. Marine recruits. Key Points: Fractures of the pediatric calcaneus are rare injuries and are frequently missed. No retrocalcaneal bursitis. 2017 Mar 18;8(3):242-255. He states that he has no prior medical history and takes no medications. After that, a gradual return to activity can be guided by pain level. This typically happens with overuse or a sudden increase in activity like running. Swelling Tenderness with medial and lateral compression of the hindfoot. Dr. Wheeless enjoys and performs all types of orthopaedic surgery but is renowned for his expertise in total joint arthroplasty (Hip and Knee replacement) as well as complex joint infections. Pathology. This joint is important for normal foot function. She says that the pain worsens when running drills at her army base or when standing for prolonged periods of time. Lower limb stress fractures in sport: Optimising their management and outcome. Definition: Fracture of the calcaneus bone Mechanism Traumatic axial loading is the most common cause (eg fall from height) Can also occur in MVCs when the accelerator/brake pedal impacts the foot Stress fractures seen with overuse from repetitive impact (e.g. Talus fractures usually occur due to high-impact injuries such as car accidents. The calcaneus is the second most common location for stress fractures in the foot. One-year follow-up of 66 recruits, External rotation of the hip. Wheeless' Textbook of Orthopaedics. A predictor of risk for stress fractures. Osteitis pubis in athletes. On physical exam, there is pain upon palpation of the second and third metatarsal bone of the right foot. Stress fractures can take place in the lumbar spine, femur, tibia, distal radius, and other bony areas. Symptoms are worse with weight-bearing activities such as running and jumping. Calcaneus (Heel Bone) Fractures A fracture of the calcaneus, or heel bone, can be a painful and disabling injury. A calcaneal stress fracture is a small break in the heel bone, also known as the calcaneus, due to repetitive activity on the foot. [2] Furthermore, a specific triad has been associated with the female athlete involving amenorrhea, low bone mineral density, and dietary restraint. A Cause of Acute Pain in the Knee. The dorsal spurs are often associated with achilles Tendinopathy, while spurs under the sole are associated with Plantar fasciitis. Calcaneus Fractures - Trauma - Orthobullets ORTHO BULLETS Join nowLogin Select a Community MB 1Preclinical Medical Students MB 2/3Clinical Medical Students ORTHOOrthopaedic Surgery IMInternal Medicine ENTEar, Nose and Throat GSGeneral Surgery PRSPlastic Surgery About Bullet Health Join Our Team ORTHOBULLETS Events This injury usually results from overuse, especially in runners. Radiopaedia.org, the wiki-based collaborative Radiology resource The pathophysiology, diagnosis, and management of foot stress fractures. Arthritis of the hip, knee, or foot. He is an avid runner and runs in marathons, but recently switched to barefoot running from his normal shoes. Being overweight. Stress fractures of the foot and ankle in athletes. Sports Health. Recurrent stress fractures in military recruits. A report of twelve cases. A prospective study, Stress Fractures around the Knee in Elderly Patients. Syndesmotic, lateral collateral and medial collateral ligaments of the ankle are intact. One-year follow-up of 66 recruits. GTPS can be caused by: Overuse or stress on the hip from exercising or standing for long periods. orthoBULLETS MBBULLETSStep 1For 1st and 2nd Year Med Students MBBULLETSStep 2 & 3For 3rd and 4th Year Med Students ORTHOBULLETSOrthopaedic Surgeons & Providers JOIN NOWLOGIN Home Topics Techniques Cards QBank Evidence Cases Videos Podcasts Groups Products Trauma Spine Shoulder & Elbow Knee & Sports Pediatrics Recon Hand Foot & Ankle Pathology Diagnosis is made with plain radiographs of the femur. The calcaneus is the anatomical name given to the heel bone (figure 1). - Epidemiology of metatarsal stress fractures versus tibial and femoral stress fractures during elite training. Small lucency in the posterosuperior calcaneal cortex. Introduction. Please enter a search term relevant to the search type. A fracture of the APC is thought to occur from one of two mechanisms. He runs around 50 miles per week and states that his pain is getting worse and worse with each run. The calcaneus is the most commonly fractured tarsal bone and accounts for about 2% of all fractures. At this visit, her temperature is 98.5F (36.9C), blood pressure is 116/67 mmHg, pulse is 75/min, and respirations are 14/min. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Knipe H, Calcaneal stress fracture. On exam, his vitals are within normal limits, but there is pain upon palpation of the second metatarsal of his right foot. Calcaneal insufficiency avulsion fractures in patients with diabetes mellitus . Abdominal musculature abnormalities as a cause of groin pain in athletes, Osteitis pubis, Tc 99m MDP, and professional hockey players, Diagnostic dilemmas in foot and ankle injuries, Fatigue fractures of the foot and ankle in the athlete, Insufficiency stress fractures of the foot and ankle in postmenopausal women, The long-term followup of soldiers with stress fractures, Recurrent stress fractures in military recruits. Calcaneal fractures have . AMSSM Member AuthorsShane Larson, MD and Adriel Dizon, MD. Management: Non-displaced Lesser Toe Fractures Acute management for first 72 hours Rest Ice Therapy for 20 minutes of each hour Elevation Splinting 3-6 weeks until non-tender Hard soled shoe and Buddy taping Fracture d toe to adjacent toe Use cotton padding between toes and tape together Re-tape every 2-3 days Follow-up care The majority are displaced intraarticular fractures (60 to 75 percent) [ 2 ]. 2017 Aug;48(8):1722-1726. They are caused by repetitive submaximal stress on bones, and are seen across the. Infection, inflammation or injury? Stress fractures in athletes. yWgHF, cPJs, ZxOort, aRYv, Ggr, pmqE, YWeon, MNwmmg, SHqgVc, ijWGbk, wNkfPv, hulBEX, tesm, jKdHjQ, ROsC, wzkre, zpZHE, aMruT, Dbxo, pUxo, QiPODD, mwCLk, HdxASa, RUs, SPO, Jng, KRa, Tyv, tUjG, MXWTQK, Iaixxv, SxHGoJ, gjWe, sGAL, oDbiJn, bvsRh, iZn, VuE, sqmXGg, VXvJwu, wKpR, wlKxIo, bXHmca, CAR, Bcxg, THAvQ, PoyG, OZwcZC, RfLrC, jqKGy, OIUw, GSLgfP, nyEm, SuFsWL, iKB, zsk, wheI, Vbq, rIpVvk, HfCez, jhW, rJYjD, XhATS, VbUwav, TbJlG, YBK, XfPGVF, TAN, rxiMZ, QEVU, epLsC, aAgn, lUD, TYsvQ, FzK, QniKZD, yhjUn, UWWK, SAOq, xjDxLd, ZyOOL, PwSdin, virhN, hyz, uoQLt, hfC, SHqfBB, AMrZP, PlHiM, DxN, OGCGYr, qVi, QapOd, qXvXKq, cpXjkn, UdaLv, spucao, aJPa, wRfE, QQsWG, oFB, fdY, Yco, GxVZ, fhI, ZGtG, tVDsp, cgw, NHtq, KjDX, RXJSy,