posterior shoulder pain differential diagnosis

Cai, Z., et al., Radiation-induced brachial plexopathy in patients with nasopharyngeal carcinoma: a retrospective study. The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Medical Department of the U.S. Army or the U.S. Army Service at large. Wilderness Environ Med. The items listed in the table above can be present in patients with cervical myelopathy, but they don't necessarily have to be. Cutts Steven, Mark Prempeh and Steven Drew. The presence of antiarrhythmic drugs (especially class Ic or class III antiarrhythmic drugs) or electrolyte abnormalities (such as hyperkalemia) can slow intra-myocardial conduction velocity and widen the QRS complex. Acta orthop. Am J Sports Med. Martin, E., et al., Timing of Surgery in Traumatic Brachial Plexus Injury: A Systemic Review. Am J Cardiol. Robinson et al. Spontaneous recovery is rare with complete axonal discontinuity, manifested by complete absence of CMAPs, absence of motor unit action potentials (MUAPs) despite good effort, and abnormal spontaneous activity.2 With complete conduction block, MUAPs may be absent but distal CMAPs should still be present without significant abnormal spontaneous activity.38 It is important to note that many of the proximal nerves cannot be directly assessed, and root stimulation studies are necessary to detect proximal conduction block. Pain in the posterolateral area of the forearm; Pain sometimes spreads to the dorsal side of the wrist; Parasthesia; Weakness (overuse injuries of the musculoskeletal system) Posterior interosseus nerve syndrome. 45(6): p. 780-95. While subacromial impingement syndrome (SIS) is the most common cause of shoulder pain, rotator cuff (RC) tendonitis is often seen in association with shoulder impingement. The QRS complex is wide, about 150 ms; the rate is about 190 bpm. Occlusal adjustments of the teeth (i.e., grinding the enamel) should not be recommended for the management or prevention of TMD. doi:10.1016/j.arthro.2018.04.027, Aliberti GM, Kraeutler MJ, Trojan JD, Mulcahey MK. Arch Dis Child Fetal Neonatal Ed, 2003. Temporomandibular Disorder: An Underdiagnosed Cause of Headache, Sinus Pain, and Ear Pain. Check for errors and try again. Contemp Oncol (Pozn), 2016. Analysis of outcomes 10 years after trauma reveals that those with brachial plexus injury have lower rates of employment and worse outcome scores.46, Return to play: in athletes, careful evaluation and counseling are required prior to clearing the athlete to return to play.7. Joseph, J.R., et al., Ultrasonography for neonatal brachial plexus palsy. 2008. pp. Sensory nerve action potentials: help anatomic localization, Evoked potentials: Evoked potentials are not necessary in the diagnosis of brachial plexopathy however they may be helpful in ruling out a more central process. This is one VT which meets every QRS morphology criterion for SVT with aberrancy. Plexopathy results from direct axonal damage, demyelination, and microvascular infarction and more indolently because of compression caused by fibrosis, commonly seen following radiation therapy for breast, lung, lymphoma, and head and neck cancer. A 19-year-old female presents with bilateral shoulder pain and instability during volleyball practice. The painful jerk group had a 16% success rate with rehabilitation vs. the painless jerk group which had a 93% success rate with the rehabilitation program. This procedure should be performed only by physicians and dentists with experience in anesthetizing the auriculotemporal nerve region. Its shape means that it offers limited bony support to the joint. vol. Most utilized is the sural nerve. Approximately 50% of patients report a distinct injury that brought on the instability or symptoms they have, yet only 17% report having a dislocation requiring reduction. [1][4] A posterior glenoplasty is used to treat patients with glenoid retroversion greater than 15 degrees. Only 5% to 10% of patients require treatment for TMD, and 40% of patients have spontaneous resolution of symptoms.25 In a long-term follow-up study, 50% to 90% of patients had pain relief after conservative therapy.26 A multidisciplinary approach is successful for the management of TMD. All dislocations should be easily identified on trans-scapular Y views. Effectiveness of rehabilitation after cervical disk surgery: a systematic review of controlled studies. Acute fractures, dislocations, and severe degenerative articular disease are often visible in these studies. Analgesia (usually multiple agents are required, often including an opioid), Immunomodulation (limited evidence suggests that early treatment with high dose prednisone may shorten pain duration and improve functional recovery), Especially for patients with hourglass nerve constriction, Heparin or warfarin may prevent microvascular infarction, Neurolysis may relieve compression caused by fibrosis, Hyperbaric oxygen does not appear to be an effective treatment, Immunomodulators: prednisone and azathioprine (unclear but may increase risk of tumor progression), Rates of spontaneous recover range from 66-92%, Up to 35% of children will have residual shoulder weakness, contracture, or joint deformity, Primarily conservative management: passive range of motion and activity requiring bilateral extremity involvement, this consists of occupational therapy, splinting, and kinesiotaping, Chemodenervation with botulinum toxin type A can be effective in modulating the muscle imbalance that occurs in the affected arm, Nerve graft (commonly performed if no improvement in 3-9mo, evidence is unclear if early nerve grafts results in improved outcome). There is evidencealbeit weakthat supports the use of physical therapy for improving symptoms associated with TMD.31 Techniques may be active or passive (e.g., scissor opening with fingers, use of medical devices) with the goal of improving muscle strength, coordination, relaxation, and range of motion.31 Specialized physical therapy options such as ultrasound, iontophoresis, electrotherapy, or low-level laser therapy have been used in the management of TMD, despite the lack of evidence to support their use.32 Treatment of underlying comorbid conditions results in greater likelihood of success in the management of TMD. In most cases Physiopedia articles are a secondary source and so should not be used as references. Ghizoni, Results and current approach for Brachial Plexus reconstruction. Vidal LB, Bradley JP. Microtrauma can lead to degeneration of anatomical structures that function to stabilize the joint. Am Fam Physician. Younger patients were more likely toredislocate than older patients within the year follow up period of the study. Posterior shoulder instability: approach to rehabilitation. The Diagnosis and Treatment of Heel Pain: A Clinical Practice GuidelineRevision 2010. This is usually performed in the Emergency Department following sedation and appropriate analgesia. 2020;76(2):119-28. Cioroiu, C. and L.H. 2006;17:164-171. Jon A. Jacobson. Start out by answering the questions below to find out which diagnoses are most probable. Cardiac Rehabilitation Before and After Cardiac Transplantation, Pulmonary Rehabilitation Before and After Pulmonary Transplantation, Pulmonary Rehabilitation in Intrinsic Restrictive Lung Diseases, Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Diseases (COPD), Pulmonary Issues in the Athlete/Exercise Induced Bronchoconstriction, Pulmonary rehabilitation after ventilatory failure, Venous Insufficiency: Rehabilitation Management of Venous Stasis and Postphlebitic Syndrome, Rehabilitation of, and the Effects of Exercise on Peripheral Arterial Diseases, Pressure ulcer management in disorders of the CNS, Lower Limb Amputations: Epidemiology and Assessment, Rehabilitation Management of Prostate Cancer, Brachial Plexopathy: Differential Diagnosis and Treatment, Rehabilitation Management of Hematologic Malignancies and Bone Marrow Transplant (Adults and Pediatrics), Rehabilitation Management of Head and Neck Cancers, Rehabilitation Interventions for Metastatic Bone Tumors, Side Effects of Cancer Treatment (Cancer Surgery, Chemotherapy, Radiation Therapy), Exercise Effects and Fatigue in Cancer Patients, Functional Measures to Track Outcomes for Cancer Rehabilitation, Mixed Connective Tissue Transplants for Face and Hand, Rehabilitation of Patients in Critical Care Settings, ICU Acquired Weakness and Neurocognitive Decline, Age-Associated Changes and Biology of Aging, Endocrine Abnormalities Affecting the Musculoskeletal System, Roots: ventral rami of cervical roots C5-8 and T1*, Trunks: upper (C5-6), middle (C7), and lower (C8-T1), Divisions: 3 anterior divisions and 3 posterior divisions, Roots: Long thoracic (C5-7) and dorsal scapular (C5), Lateral cord: lateral pectoral (C5-7), musculocutaneous (C5-7), lateral antebrachial cutaneous (C5-6), and lateral branch of the median, Posterior cord: upper and lower subscapular (C5-6), thoracodorsal (C6-8), axillary (C5-6), and radial (C5-T1), Medial cord: medial pectoral, medial brachial cutaneous, medial antebrachial cutaneous, ulnar, medial branch of the median (all C8-T1), Supraclavicular: most common site, involves the root or trunk level, Retroclavicular: least common site, involves the divisions, Infraclavicular: involves the cords or terminal branches, hereditary neuropathy to pressure palsy: PMP22 genetic mutation, hereditary neuralgic amyotrophy (NA): a point mutation in the SEPT9 gene on 17q25, Traumatic: up to 70% from motor vehicle accidents and 22%-49% of athletes in contact sports, Compressive: 5.3% in active military (rucksack syndrome), approximately .0001% neurogenic thoracic outlet syndrome, Burner or stinger syndrome: transient and often mild loss of strength or sensation, most often in the C5-6 distribution, secondary to traction, compression injury or direct blow to the brachial plexus without complete avulsion. 1991. pp. 122(1): p. 195-201. Structural abnormalities are shown to attribute to posterior instability of the shoulder. Shoulder pain is defined as chronic when it has been present for longer than six months. Saji, E., I. Kawachi, and M. Nishizawa, [Diagnosis and management of paraneoplastic neurological syndromes]. 2017;47(7):A1A83. BMJ Open. Therefore, onus of proof is on the electrocardiographer to prove that the WCT is not VT. Any QRS complex morphology that does not look typical for right- or left-bundle branch block should strongly favor the diagnosis of VT. [1], In cases of soft-tissue injury, correction of the abnormalities can be performed with open or arthroscopic procedures. 43(11): p. 1943-8. All rights reserved. Case 14: with fracture of greater tuberosity, Case 15: with humeral comminuted fracture, Case 17: inferior dislocation with fracture of proximal humerus, Inferior pseudo subluxation from lipohemarthrosis, younger: 20-30 years (male to female ratio of 9:1), older: 60-80 years (female to male ratio of 3:1). 578-84. 47(7): p. 151-155. 2019;37(4):757-61. 22(4): p. 605-12. This retrospective study was carried out to determine the prevalence of malaria among patients admitted to Hospital Tengku Ampuan Rahimah, Klang, Malaysia, from January 2004 to May 2006. 2006, Philadelphia: Elsevier Health Sciences. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. 2004;17:229-242. 1995; 23: 1-6. The authors thank Katrease Gauer for her assistance with the manuscript. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Jones J, Qureshi P, Lustosa L, et al. Concurrent chemotherapy is associated with increased risk for brachial plexopathy especially with increasing total dose (>50 Gy) and fractional dose (>2 Gy) of radiation. Shoulder osteoarthritis: diagnosis and management. The following observations can be made from the second ECG, obtained after amiodarone: Conclusion: Atrial flutter with LBBB aberrancy with unusual frontal axis and precordial progression. Approximately half of the major joint dislocations seen in emergency departments are of the shoulder 1. The WCT overtakes the sinus P waves starting at the fourth beat, resulting in apparent PR interval shortening. This pattern is pathognomonic of VT, and represents a form of VA dissociation during VT onset. [3][7][9][12]Scapular stabilizers[3][4][7][9][10]and posterior deltoid[7][24] strengthening is also important. Clear rehabilitation protocols have not been defined in the literature for post-brachial plexus repair rehabilitation and close communication between the surgical and rehabilitation teams is essential to optimize outcomes. The etiology of TMD is multifactorial and includes biologic, environmental, social, emotional, and cognitive triggers. Medicine (Baltimore). Shoulder abduction / The items listed in the table above can be present in patients with neck pain, but they don't necessarily have to be. vol. Vereckei, A, Duray, G, Szenasi, G. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. Conclusion: SVT (AVRT utilizing a left-sided accessory pathway) with LBBB aberrancy. 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. doi:10.1016/j.msksp.2018.09.013, Jonsson A, Rasmussen-Barr E. Intra- and inter-rater reliability of movement and palpation tests in patients with neck pain: A systematic review. [1], Operative treatment is contraindicated for patients with voluntary instability due to psychological problems. Think about the soft tissue structures that might be injured, particularly the neurovascular bundle with inferior dislocations. 35(1): p. 84-91. van der Holst, M., et al., Outcome of secondary shoulder surgery in children with neonatal brachial plexus palsy with and without nerve surgery treatment history: A long-term follow-up study. [4] The patient may have tenderness with palpation at the posterior glenohumeral joint line. Her serum potassium was 7.1 mEq/dl, and with aggressive treatment of hyperkalemia, her ECG normalized. Ninad S. Karandikar, MBBS, Michael J. Burns, MD. 39(6): p. e1188-e1192. Even with these parameters, opioids should be used cautiously because of the potential for dependence.51, Medications that have limited or no effectiveness for the treatment of TMD include tramadol (Ultram), topical medications (e.g., capsaicin [Zostrix], lidocaine, diclofenac52), and newer antidepressants (e.g., selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, monoamine oxidase inhibitors).37. 83. Diagnosis is made clinically with presence of increased anterior and posterior humeral translation, a sulcus sign, and overall increased external rotation. His ECG showed LBBB during sinus rhythm (left panel in Figure 6). Most affected individuals recover, but some will have persistent pain or weakness, believed to be caused by peripheral myelin cross-reacting antibodies and complement, often, but not always, associated with recent parvovirus or Bartonella henselae infection,1,24 immunization, surgery, and childbirth. The QRS complex is identical to the prior WCT, which was atrial flutter with 2:1 conduction. The Licensed Content is the property of and copyrighted by DSM. [4]They may also present with weakness of the rotator cuff muscles and scapular stabilizers. 40(6): p. 562-7. Am J Sports Med. 2014: p. 726103. 4. Wilson, T.J., K.W. doi:10.1007/s00586-019-06270-0, Tederko P, Krasuski M, Tarnacka B. doi:10.1016/j.arthro.2015.10.022, Minns Lowe CJ, Moser J, Barker K. Living with a symptomatic rotator cuff tear 'bad days, bad nights': a qualitative study. Arch Phys Med Rehabil. (OBQ06.69) Am J Sports Med. Published 2013 Sep 26. doi:10.1136/bmjopen-2013-003452, Badran A, Davies BM, Bailey HM, Kalsi-Ryan S, Kotter MR. Is there a role for postoperative physiotherapy in degenerative cervical myelopathy? - Clinical News The Journal of Emergency Medicine is an international, peer-reviewed publication featuring original contributions of interest to both the academic and practicing emergency physician.JEM, published monthly, contains research papers and clinical studies as well as articles focusing on the training of emergency physicians and on the practice of emergency Horizontal Instability of the Acromioclavicular Joint: A Systematic Review. Circulation. The jerk test is useful in predicting the success & prognosis for nonoperative treatment of posteroinferior shoulder instability. What is the most appropriate initial treatment? A Systematic Review [published online ahead of print, 2018 Dec 26]. [4] If a patients main complaint is vague shoulder pain, the clinician may first need to rule out injuries such as a SLAP or rotator cuff tear. Neurosurg Clin N Am, 2009. [1][3]Bottoni et al. Olecranon bursitis is a common cause of posterior elbow pain and swelling. The patient is able to hyperextend the elbows and knees to 12 degrees, can place both palms on the floor with knees fully extended, and hyperextend the small finger MCP joint past 90 degrees. 1173185, Figure 1. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Anterior dislocation will result in the humeral head being displaced deep into the far field (away from one's probe), whereas posterior dislocations will result in the humeral head being located in the near field (presuming the usual posterior position of one's transducer). Figure 8: WCT tachycardia recorded in a male patient on postoperative day 3 following mitral valve repair. Pain worse with exertion. Bilateral glenohumeral corticosteriod injections and physical therapy, Bilateral subacromial corticosteriod injections and physical therapy, Bilateral staged arthroscopic labral repair and capsulorrhaphies. differential diagnosis and treatment options. 28. The only treatment option for a dislocated shoulder is a prompt reduction. doi:10.3109/09593985.2011.598220, Martetschlger F, Warth RJ, Millett PJ. 7(14): p. 18887-95. Imaging may be necessary to determine which structures are involved in the instability and is crucial for surgical interventions, as surgery is only successful if it is lesion specific. Obstetrics & Gynecology, 2020. The glenoid is a saucer-shaped extension of the scapula. The authors of this study looked at data collected for 89 shoulders with posteroinferior instability with a positive posterior clunk during the jerk test. 42(3): p. E14. Findings on Imaging that affect likelihood of this diagnosis . A recent publication about patient reported outcomes of health-related quality of life after neonatal brachial plexus suggests that physical limitations, followed by social health, and to a lesser degree, emotional health remain significant long-term issues in these patients.42, Depression: Rates of depression are higher among those with traumatic brachial plexus injury, commonly reported around 30%, which may also reflect a high rate of concurrent TBI.43 Indeed, traumatic brachial plexopathy has been associated with anger, frustration, pain, unemployment, social isolation, and change in body image.44 Importantly, like back pain literature, patients with comorbid depression and brachial plexus injury have poorer outcomes in rehabilitation.43, Marriage status: In one study of 34 patients who had undergone surgical treatment for brachial plexus injury a mean of 7 years prior, 47% were married at the time of the survey and 65% of participants had been married at least once. For complete dissociation, this would require that the VT rate would fortuitously have to be at an exact multiple of the sinus rate. A 13-year-old baseball pitcher presents with persistent pain of the right shoulder over the last 2 years. The Archives of Physical Medicine and Rehabilitation publishes original, peer-reviewed research and clinical reports on important trends and developments in physical medicine and rehabilitation and related fields.This international journal brings researchers and clinicians authoritative information on the therapeutic utilization of physical, behavioral and Prevention: relies on physical and occupational therapy with patient/family adherence to range of motion programs. Mechanical injury to the myelin sheath or axon itself resulting from traction, compression, or transection. In post-ganglionic injury, it is prudent to wait for 34 months for spontaneous improvement to occur. 20(1): p. 67-72. Sensory nerve action potentials are more sensitive than compound motor unit action potentials to determine axonal loss in brachial plexopathy. Common in contact sports and the most common reported peripheral nerve injury in American Football, occurring in 59-70% of all players. Conclusion: VT due to bundle branch reentry. Editor/authors are masked to the peer review process and editorial decision-making of their own work and are not able to access this work in Data Sources: An OvidSP search was completed using the key terms temporomandibular joint disorders, temporomandibular disorders, headache, diagnosis, acupuncture, treatment, occlusal splints, occlusal adjustment, pharmacotherapy, randomized controlled trials, meta-analysis, botulinum toxin, differential diagnosis, biofeedback, cognitive behavior therapy, physical therapy, and classification. Boome, Brachial plexus lesions associated with dislocated shoulders. * Expert opinion **Based on a level of evidence below systematic review or meta-analysis The items listed in the table above can be present in patients with adhesive capsulitis, but they don't necessarily have to be. found good results in patients with posterior instability secondary to trauma after an open or arthroscopic procedure. This is one VT where the QRS complex morphology exactly mimics that of SVT with aberrancy. Cranial nerve abnormalities should not be attributed to TMD.14 A clicking, crepitus, or locking of the TMJ may accompany joint dysfunction. 14. Of the affected patients, 55% carry a point mutation in the SEPT9 gene on 17q25.24 Neuralgic amyotrophy is a rare disorder that has a reported incidence of 2-3 per 100,000. Supportive patient education is the recommended initial treatment for TMD.28,29 Adjunctive measures include jaw rest, soft diet, moist warm compresses, and passive stretching exercises. Emerg Med J. Yousem, and V. Chaudhry, Role of magnetic resonance neurography in brachial plexus lesions. The QRS morphology suggests an old inferior wall myocardial infarction, favoring VT. Occlusal adjustments (i.e., grinding enamel surfaces to improve dentition) have no benefit in the management or prevention of TMD.61. doi:10.23736/S1973-9087.20.05820-7, Lemeunier N, Jeoun EB, Suri M, et al. Treatment of instability of the shoulder with an exercise program. Jivan, S., et al., The influence of pre-surgical delay on functional outcome after reconstruction of brachial plexus injuries. 1987; 15: 175-178. 136(4): p. 725-730. It is the most commonly dislocated large joint; indeed,the most commonly dislocated joint in the body 5. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. However, careful observation shows VA dissociation (best seen in lead V1) with slower P waves. 126 (4): 235-40. Phys Sportsmed. The major morbidity associated with untreated massive rotator cuff tears in this age group requires a clinician to ensure actively that these injuries are not missed. Return to work following a distal biceps repair: a systematic review of the literature. Goldberger, ZD, Rho, RW, Page, RL.. Approach to the diagnosis and initial management of the stable adult patient with a wide complex tachycardia. 2008. pp. Strengthening should progress to include full range and diagonal and spiral patterns including PNF patterns. Citations may include links to full text content from PubMed Central and publisher web sites. The patients were split into two groups to receive nonoperative treatment: pain present with jerk test vs. painless jerk group. Which of the following is true regarding closure of the rotator interval in patients undergoing arthroscopic shoulder stabilization? Exam reveals bilateral anterior shoulder apprehension and relocation, positive jerk test, and a 2cm sulcus bilaterally. Barman, A., et al., Traumatic brachial plexus injury: electrodiagnostic findings from 111 patients in a tertiary care hospital in India. (2004)Painful jerk test: a predictor of success in nonoperative treatment of posteroinferior instability of the shoulder. doi:10.2340/16501977-2639, Rosas S, Krill MK, Amoo-Achampong K, Kwon K, Nwachukwu BU, McCormick F. A practical, evidence-based, comprehensive (PEC) physical examination for diagnosing pathology of the long head of the biceps. 3. Resources, including psychology, vocational rehabilitation, ergonomics, and driver training, can be included as necessary. Association Among Pelvic Girdle Pain, Diastasis Recti Abdominis, Pubic Symphysis Width, and Pain Catastrophizing: A Matched CaseControl Study . She denies any injuries. Outcomes and rehabilitation after surgery: To date, outcome reporting for brachial plexus surgery has largely centered on motor recovery and typically has not included measures of function or non-musculoskeletal recovery. Radiographs are normal and an MRI arthrogram is seen in Figure A. There has been a limited number of studies investigating the effectiveness of onabotulinumtoxinA (Botox) in the management of TMD.53 Early small randomized controlled trials have shown promising results for the improvement of painful myofascial symptoms.5456 However, a recent Cochrane review (four studies, N = 233) found inconclusive evidence to support use of onabotulinumtoxinA for myofascial pain.57 Only one of the four studies demonstrated benefit with this modality. 48(7): p. 609-17. A single click during opening of the mouth may be associated with an anterior disk displacement. Heart Rhythm. There are errant pacing spikes (epicardial wires that were undersensing). Kim SH, Park JC, Park JS, Oh I. Gibson et al. Systematic reviews have shown conflicting results on the preferred occlusal device for relieving TMD symptoms.59,60 Dental consultation should be obtained to determine the optimal occlusal device. Midha, R., Epidemiology of brachial plexus injuries in a multitrauma population. 3(1): p. 1-11. The recognition of variable intensity of the first heart sound (variable S1) can similarly be another clue to VA dissociation, and can help make the diagnosis of VT. Childs Nerv Syst, 2016. (2006) Archives of orthopaedic and trauma surgery. When a WCT abruptly becomes a narrow complex tachycardia with acceleration of the heart rate, SVT (orthodromic atrioventricular reciprocating tachycardia using an accessory pathway on the same side as the blocked bundle branch) is confirmed (Coumels law). A 56-year-old woman with end-stage renal disease presented with dizziness and altered mental status. Pain4,11,17,18, weakness4, paresthesia4,11,17,18, Symptoms in dermatomes4,11,17 of constant behavior11, Numbness/hypoesthesia in dermatomes4,11,17, Placing the hand on the head relieves pain3, Difficulty raising the arm because of weakness4. The QRS complex in lead V1 shows an Rr morphology (first rabbit ear is taller than the second), favoring VT (Table IV). Kiviluoto O, Pasila M, Jaroma H, Sundholm A. Immobilization after primary dislocation of the shoulder. 18. It is important to differentiate root avulsion from brachial plexus injury for treatment and prognostication as complete root avulsions are incapable of regeneration and are not amenable to surgical repair.1, Neonatal brachial plexopathy may be associated with glenohumeral joint dysplasia, joint contractures (shoulder, elbow, supination), posterior shoulder dislocation, or length discrepancies.27,28. Such abnormal spontaneous activity represents spontaneous depolarization of a muscle fiber in the setting of any kind of denervation. Patients will present with poorly localized pain with possible clicking in the shoulder. Mosby Inc. (2002) ISBN:0323011896. The effectiveness of rehabilitation for nonoperative management of shoulder instability: a systematic review. Knee Surg Sports Traumatol Arthrosc. Am J Sports Med. These findings would favor SVT. 138(4): p. 364-9. It must be acknowledged that there are many clinical scenarios where different criteria will provide conflicting indications as to the etiology of a WCT. 91(7): p. 1729-37. ISRN Orthop, 2014. Lippincott Williams & Wilkins. The QRS complex in rhythm strip V1 shows an RR configuration, but with the second rabbit ear taller than the first; this favors SVT with aberrancy. Therefore, the finding of deep Q waves during a WCT favors VT. Often, single wide complex beats that are clearly VPDs may be present during sinus rhythm on prior ECGs or other rhythm strips; if the QRS complex morphology of the WCT is identical to that of the VPDs, VT is likely. 99-B(2): p. 255-260. The QRS complex down stroke is slurred in aVR, favoring VT. Management of posterior shoulder instability in the athlete. Pain deep in the glenohumeral joint localized posteriorly23*, Shoulder joint line tenderness and joint effusion23*, Pain, crepitus, and reduced range of motion with shoulder abduction and external rotation23*. 2004, Philadelphia: Elsevier Health Sciences. (2001) ISBN:1853171190. 89-98. 53(3): p. 337-50. van Alfen, N., Clinical and pathophysiological concepts of neuralgic amyotrophy. 68(5): p. 416-24. For specific dislocation types please refer to the following articles: Sex distribution is bimodal and relative incidence is dependent on patient age. "Anterior Shoulder Dislocation". The hallmark of VT is ventriculoatrial (VA) dissociation (the ventricular rate being faster than the atrial rate), the following examination findings (Table II), when clearly present, clinch the diagnosis of VT. Torchia ME, Bradley JP. doi:10.1177/0269215518766229, Hawkins SC, Williams J, Bennett BL, Islas A, Kayser DW, Quinn R. Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection. Ferrante, M.A., The thoracic outlet syndromes. doi:10.1016/j.msksp.2017.06.002, Ricciardi L, Scerrati A, Olivi A, Sturiale CL, De Bonis P, Montano N. The role of cervical collar in functional restoration and fusion after anterior cervical discectomy and fusion without plating on single or double levels: a systematic review and meta-analysis. 2005, Treatment Timeline for Post-Surgical Rehabilitation. When performed correctly, complication rates are low. Dev Med Child Neurol, 2004. A northwest frontal axis during WCT strongly favors VT (since neither RBBB nor LBBB aberrancy results in such an axis). I. [6]. Simank HG, Dauer G, Schneider S, Loew M. Incidence of rotator cuff tears in shoulder dislocations and results of therapy in older patients. Journal of the American Academy of Orthopaedic Surgeons, 2019. doi:10.1016/j.apmr.2015.09.003, Karikari I, Ghogawala Z, Ropper AE, et al. This material may not be published, broadcast, rewritten or redistributed in any form without prior authorization. [1]Depending on the mechanism of injury, patients may report a traumatic incidence leading to dislocation & reduction of the shoulder or a more insidious onset often from repeated overuse. Figure 4: A 57-year-old woman with palpitations for many years and idiopathic globally dilated cardiomyopathy was admitted for incessant wide complex tachycardia. Select the button below to go to the rotator cuff tear examination page to confirm the diagnosis with special tests. Select the button below to go to the acromioclavicular joint examination page to confirm the diagnosis with special tests. Return to Sport After Surgical Treatment for Anterior Shoulder Instability: A Systematic Review. Engle RP, Canner GC. Managing posterior shoulder instability result-oriented techniques. In 2013, the International Research Diagnostic Criteria for Temporomandibular Dysfunction Consortium Network published an updated classification structure for TMD (eTable A). Bone Joint J, 2017. Copyright 2022 American Academy of Family Physicians. It is useful to determine whether the dislocation is acute, chronic or recurrent. doi:10.1177/0363546519831013, Katsuura Y, Bruce J, Taylor S, Gullota L, Kim HJ. Theshoulder dislocation(more accurately termed a glenohumeral joint dislocation) involves separation of the humerus from the glenoid of the scapula at the glenohumeral joint. It is atrial flutter with grouped beating. The items listed in the table above can be present in patients with neck pain, but they don't necessarily have to be. Benzodiazepines are also used, but are generally limited to two to four weeks in the initial phase of treatment.40,44 Longer-acting agents with anticonvulsant properties (i.e., diazepam [Valium], clonazepam [Klonopin], gabapentin [Neurontin]) may provide more benefit than shorter-acting agents. The posterior delt specifically has been shown to respond to EMG training and this should be utilized as appropriate. 37(2): p. 135-43. Borenstein, D., S. Wiesel, and S. Boden, Low Back and Neck Pain: Comprehensive Diagnosis and Management. [4] Also, patients with PSI may test positive for subacromial impingement because the tests place the shoulder in positions that can be painful for both diagnoses. 2016;33(2):130-3. From proximal to distal, its elements are the following: * Anomalous innervation is also possible. Norell, Microvasculitis and ischemia in diabetic lumbosacral radiculoplexus neuropathy. Clin Neurol Neurosurg, 2007. Am J of Cardiol. (2005)Recurrent Posterior Shoulder Instability. Condition . 2020;10(2):195208. [1][2][3]Translation that is not symptomatic is considered laxity. European Heart J. vol. Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. In other words, the VT morphology shows the infarct location because VT most often arises from the infarct scar location. Numbness of the upper extremity11, Difficulty raising the arm because of weakness11. - Multidirectional Shoulder Instability (MDI), Glenohumeral Joint Anatomy, Stabilizer, and Biomechanics, Traumatic Anterior Shoulder Instability (TUBS), Humeral Avulsion Glenohumeral Ligament (HAGL), Posterior Shoulder Instability & Dislocation, Luxatio Erecta (Inferior Glenohumeral Joint Dislocation), Glenohumeral Internal Rotation Deficit (GIRD), Brachial Neuritis (Parsonage-Turner Syndrome), Glenohumeral Arthritis (Shoulder Arthritis), Shoulder Arthroscopy: Indications & Approach, Valgus Extension Overload (Pitcher's Elbow), Lateral Ulnar Collateral Ligament Injury (PLRI), Elbow Arthroscopy: Indications & Approach. There is a positive anterior and posterior load and shift test with a positive sulcus sign. Yang, Depression and Anxiety in Traumatic Brachial Plexus Injury Patients Are Associated With Reduced Motor Outcome After Surgical Intervention for Restoration of Elbow Flexion. A 16-year-old swimmer has pain and weakness in her dominant shoulder with overhead use. 44(5): p. 655-60. Another source of orofacial pain should be suspected if pain is not affected by jaw movement. 6. Electromyography is critical for localizing the injured portion(s) of the brachial plexus. Joint Bone Spine, 2001. Groothuis, and N. Van Alfen, Neuralgic amyotrophy: An update on diagnosis, pathophysiology, and treatment. Subacromial decompression surgery (including acromioplasty)36, Pain over the lateral deltoid muscle and upper arm4, Pain but no significant loss of range of motion with shoulder abduction4,37. Van Eijk, J.J., J.T. The efficacy of nerve grafts after traumatic brachial plexopathy diminishes with time after 8 weeks. Impingement (tendinopathy, bursitis, PASTA) Age usually 35-55; if younger and really looks like impingement, think instability [7][10][24]To help focus muscular activity on dynamic stabilizers biofeedback can be useful. Commonly affects the infraclavicular plexus.1,11, Traction or compression injury most commonly of C5-7 nerve roots associated with shoulder dystocia and excessive lateral flexion of the head and neck, malpositioning, and increased birth weight. 65(4 Suppl): p. A189-96. The temporomandibular joint (TMJ) is formed by the mandibular condyle inserting into the mandibular fossa of the temporal bone. A 70-year-old woman with prior inferior wall MI presented with an episode of syncope resulting in lead laceration, followed by spontaneous recovery by persistent light-headedness. Bottoni CR, Franks BR, Moore JH, DeBerardino TM, Taylor DC, Arciero RA. Defining posterior shoulder instability (PSI) is therefore difficult, not only defining it within this continuum but differentiating it from other shoulder pathologies. Copyright 2020. Disabil Rehabil, 2015. and J.E. What procedure can eliminate a sulcus sign? 2020;12(2):136143. 2008. pp. Musculoskeletal imaging, the requisites. The following historical features (Table I) powerfully influence the final diagnosis. [1][3], In cases of bony abnormalities, open procedures to correct the bony structures include a posterior glenoplasty, bone-block, or rotational osteotomy of the proximal humerus. 3rd ed. Eur J Phys Rehabil Med. Weinberg, J., S. Rokito, and J.S. Of note, these authors found that motor function and functional status did not correlate with employment.45, The presence of brachial plexus injury in polytrauma is of poor prognostic significance. Acta Neurochir, 2017. 9. Klumpke palsy: C8-T1 with Horner syndrome. Early arthroscopy, labral repair and debridement may be of use, especially in young patients with anterior dislocation in which there is a high (up to 85%) rate of recurrence 3. vol. Rasulic, L., et al., Outcome After Brachial Plexus Injury Surgery and Impact on Quality of Life. Feinberg, J.H., et al., The Electrodiagnostic Natural History of Parsonage-Turner Syndrome. 1 (2009): 2-7. Clinical presentation of plexopathy typically delayed from time of radiation by months to years, depending on type of plexopathy (early transient radiation-induced plexopathy v. delayed radiation-induced plexopathy). Mullins, G.M., et al., Non-traumatic brachial plexopathies, clinical, radiological and neurophysiological findings from a tertiary centre. doi:10.1080/00913847.2018.1413920, Uppal HS, Evans JP, Smith C. Frozen shoulder: A systematic review of therapeutic options. Huemer, M, Meloh, H, Attanasio, P, Wutzler, A. Clinicians should assess for malocclusion (e.g., acquired edentulism, hemifacial asymmetries, restorative occlusal rehabilitation), which can contribute to the manifestation of TMD. PM R, 2010. 2019;27(12):38033812. Figure 9: After starting intravenous amiodarone, this ECG was obtained. Postoperative: compressive injury, often of the upper plexus, caused by patient positioning, less commonly a mechanical or ischemic injury caused by axillary anesthetic block, transaxillary arteriography, or postoperative hematoma. All of the following are characteristic features of a generalized connective tissue disorder EXCEPT: Left 5th finger passive extension beyond 90, Abducted thumb to reach the ipsilateral forearm (thumb-to-forearm test) of the right hand, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, 2018 Chicago Sports Medicine Symposium: World Series of Surgery, Complex Posterior and MDI: All My Tricks - Scott W. Trenhaile, MD (CSMS #9, 2018), 2018 Winter SKS Meeting: Shoulder, Knee, & Sports Medicine, Video Spotlight: Arthroscopic Treatment of Multidirectional Instability - Felix Savoie, III, MD (1.16, 2018 Winter SKS), Multi-directional Shoulder Instability (MDI), Shoulder & ElbowMultidirectional Shoulder Instability (MDI). J Plast Reconstr Aesthet Surg, 2009. Oncotarget, 2016. He denies trauma and admits to popping his shoulders in and out voluntarily since the age of 8. x Postoperative pain management is a significant challenge in patients undergoing Nuss repair for pectus excavatum chest wall deformity [1,2]. Adapted from Robinson et al. There is precordial (positive) concordance, favoring VT. Lead aVR shows a broad Q wave, favoring VT. Imaging Findings in Posterior Instability of the Shoulder. Lee, J., S. Laker, and M. Fredericson, Thoracic outlet syndrome. It is important to note that all the analyses that help the clinician distinguish SVT with aberrancy from VT also help to distinguish single wide complex beats (i.e., APD with aberrant conduction vs. VPD). Assess for specific deficits in the following: There are no required laboratory analyses in the work-up of brachial plexopathy however basic laboratory assessments may be helpful in ruling out alternative causes of weakness or in looking for triggers of NA. Fritsch BA, Taylor DC. Exp Brain Res. The items listed in the table above can be present in patients with shoulder impingement syndrome, but they don't necessarily have to be. Poor results have been reported following operative intervention to treat recurrent posterior instability with nonanatomic techniques. PubMed comprises more than 34 million citations for biomedical literature from MEDLINE, life science journals, and online books. The differential diagnosis of cough is wide ranging and includes many diseases the cause is determined by clinical features, there may be visible mucus and a cobblestone appearance to the posterior oropharyngeal wall and local upper airway structures. Am J Sports Med. Pain in the neck, shoulder, and upper extremity. A WCT that occurs in a patient with a history of prior myocardial infarction can be safely assumed to be VT unless proven otherwise. 15. The interval from the pacing spike to the captured QRS complex progressively gets longer, before a pacing spike fails to capture altogether; this is consistent with Pacemaker Exit Wenckebach. Neurology, 1999. It is unclear whether it is due to a compensatory motion or a contributor to instability. Rotator cuff tear and glenohumeral instability : a systematic review. Although there are articles describing the following physical therapy treatment and this treatment is commonly accepted as best practice, a systematic review by Gibson et al found little definitive, empiric evidence to substantiate their effectiveness,[21]but concludes that conservative physical therapy treatment should be the first-line treatment especially for those patients with isolated dislocations. Physical Therapy. J Hand Surg Am, 2010. Temporomandibular disorders (TMD) are characterized by craniofacial pain involving the joint, masticatory muscles, or muscle innervations of the head and neck.1 TMD is a major cause of nondental pain in the orofacial region. Clin Sports Med, 2003. 27(19): p. 705-716. Rarely, diabetic patients can experience brachial plexopathy as a result of microvasculitis induced ischemic nerve damage, usually seen in conjunction with lumbosacral plexopathy.25, Hereditary NA presents similarly to idiopathic NA (previously described), but it is frequently recurrent and increased in incidence in certain familial lineages. Muscle Nerve, 2016. [1]. Any cause of rapid ventricular pacing will result in result in a WCT. Although invasive, surgical treatments have shown benefit in alleviating TMD symptoms and increasing joint mobility.63,64 Referral to a dentist is indicated for patients with poor dental health, dental caries, malocclusions, or dental wear patterns that may be contributing to TMD symptoms. (OBQ18.164) Absence of these findings is not helpful, since VT can show VA association (1:1 VA conduction or VA Wenckebach during VT). This website uses cookies to improve your experience while you navigate through the website. Population-based studies show that TMD affects 10% to 15% of adults, but only 5% seek treatment.2,3 The incidence of TMD peaks from 20 to 40 years of age; it is twice as common in women than in men and carries a significant financial burden from loss of work.4 Symptoms can range from mild discomfort to debilitating pain, including limitations of jaw function. When VT occurs in patients with prior myocardial infarction, the QRS complex during VT shows pathologic Q waves in the same leads that showed pathologic Q waves in sinus rhythm. Select the button below to go to the shoulder impingement syndrome examination page to confirm the diagnosis with special tests. If the patient is conscious and cardioversion is decided upon, it is strongly recommended that sedation or anesthesia be given whenever possible prior to shock delivery. Many patients with VT, especially younger patients with idiopathic VT or VT that is relatively slow, will not experience syncope; on the other hand, some older patients with rapid SVT (with or without aberrancy) will experience dizziness or frank syncope, especially with tachycardia onset. J Hand Surg Eur Vol, 2015. Essentials of Assessment History. [27]Rhythmic stabilization can be used to promote proper muscle firing and enhance stability. Vascular: these exam maneuvers are primarily useful in evaluating for vascular etiologies of brachial plexopathy, including vascular thoracic outlet syndrome (TOS). Aberrancy, ventricular tachycardia, supraventricular tachycardia, right-bundle branch block (RBBB), left-bundle branch block (LBBB), intraventricular conduction delay (IVCD), pre-excited tachycardia. This is achieved by rapid propagation along the common bundle of His, the right and left bundle branches, the fascicles of the left bundle branch, and the Purkinje network. Traumatic injuries are more common in males aged between 15 and 25 years.5 Like traumatic spinal cord injury, these injuries are most often associated with motor vehicle and often motorcycle collisions.6 In adults, the most common cause of brachial plexus injury is trauma, either by compression or traction.3. 2017;40(8):597608. 7. 2020;29(5):10021009. Evans-Jones, G., et al., Congenital brachial palsy: incidence, causes, and outcome in the United Kingdom and Republic of Ireland. Unusual presentations (e.g., MI without chest pain) are more likely in women, elderly, and/or diabetic patients. These cookies will be stored in your browser only with your consent. Physiother Theory Pract. J Hand Surg Eur Vol, 2011. 2008; 37: 693-707. 22(3): p. 493-500, viii. Formal theory. In the hemodynamically stable patient, obtaining an ECG with specially located surface ECG electrodes can be helpful in recognizing dissociated P waves. [1], In patients with posterior instability with a traumatic aetiology, operative treatment is recommended because conservative treatment is usually unsuccessful. Adventitious sounds of the jaw (e.g., clicking, popping, grating, crepitus) may occur with TMD, but also occur in up to 50% of asymptomatic patients.1 A large retrospective study (n = 4,528) conducted by a single examiner over 25 years noted that the most common presenting signs and symptoms were facial pain (96%), ear discomfort (82%), headache (79%), and jaw discomfort or dysfunction (75%).13 Other symptoms may include dizziness or neck, eye, arm, or back pain. J Orthop Sports Phys Ther. This is one SVT where the QRS complex morphology exactly mimics that of VT. Weimer, Update on Chemotherapy-Induced Peripheral Neuropathy. 2010; 21: 32-37. Noland, S.S., et al., Adult Traumatic Brachial Plexus Injuries. Although there are a number of predisposing focators for PSI, their relative importance remains poorly understood. Prop 30 is supported by a coalition including CalFire Firefighters, the American Lung Association, environmental organizations, electrical workers and businesses that want to improve Californias air quality by fighting and preventing wildfires and reducing air pollution from vehicles. [3] Some patients with PSI may also have a sulcus sign, which is considered an indication of inferior shoulder instability. Soft-Tissue etiologies that can contribute to structural abnormalities include, but are not limited to: [1][3][4][5], Bony abnormalities that are associated with posterior instability of the shoulder are:[1], The importance of scapulothoracic dysfunction inPSI is poorly understood. It consists of 3 bone structures: humerus, scapula, and clavicle.These bones make a total of 3 synovial joints: glenohumeral, sternoclavicular, and acromioclavicular joints. Peterson L, Renstrm P. Sports injuries, their prevention and treatment. There are impressively tall, peaked T waves, best seen in lead V3, as expected in hyperkalemia. 36(9): p. 747-59. [6] If a plain radiograph reveals there may be bony abnormalities then Computerized Tomography (CT) scans are recommended for their ability to better delineate bone quality and glenoid morphology. Samuels, B.L., et al., Brachial plexopathy after intraarterial cisplatin. Ali, Z.S., et al., Upper brachial plexus injury in adults: comparative effectiveness of different repair techniques. 1992; 74: 890-896. 42(3): p. 371-6. World Neurosurg. Approximately 25% of adults who have a brachial plexus injury will suffer from severe neuropathic pain that can last for years.3 Neuropathic pain secondary to brachial plexopathy may respond to the following medications: Non-pharmacologic pain management alternatives include the following: Slings and cautious positioning may be helpful in cases of flail arm to prevent secondary nerve and limb injury. The Annals of The Royal College of Surgeons of England 91, no. 2005; 33: 996-1002. (2004) The effectiveness of rehabilitation for nonoperative management of shoulder instability: a systematic review. 2018;38:128147. Doctors will take your history of pain and also perfrom Physical examination test that help to find the cause of sciatica pain. 2020;48(2):504510. 21(1): p. 13-24. Electrolyte disorders (such as severe hyperkalemia) and drug toxicity (such as poisoning with antiarrhythmic drugs) can widen the QRS complex. 89-98. Lesion-specific surgery has improved clinical results, particularly when the surgery is performed arthroscopically. Millett PJ, Gobezie R, Boykin RE. The items listed in the table above can be present in patients with sternoclavicular joint pathology, but they don't necessarily have to be. Diagnostic Confirmation: Are you sure your patient has Wide QRS Tachycardia? Thoracic pain is also common with cancer metastases so prior to any manual therapy be sure to rule out cancer as a cause of pain. [4][7][12]In addition to the routine anterior-posterior and lateral radiographs, it is recommended that patients also get an Axillary view, as it reveals the most diagnostic information for a posterior dislocation or subluxation. 2019;52(1):jrm00009. Young MS. Electromyographic biofeedback use in the treatment of voluntary posterior dislocation of the shoulder: a case study. doi:10.1016/j.jmpt.2017.07.002, Li S, Sun H, Luo X, et al. Computed tomography is superior to plain radiography for evaluation of subtle bony morphology. Preston, D. and B. Shapiro, Electromyography and Neuromuscular Disorders. Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Posterior dislocations can be difficult to identify on an AP view only (as may be obtained in the setting of a secondary survey of a trauma), as the humeral head moves directly posteriorly and congruency may appear to be maintained (at least at first glance). Posterior shoulder instability is a fairly rare condition and is often a diagnosis of exclusion. Dyck, P.J. doi:10.1097/MD.0000000000009625, Vavken P, Bae DS, Waters PM, Flutie B, Kramer DE. Phrenic nerve injury may occur in conjunction with traumatic and non-traumatic plexopathies and may present as hemi-diaphragmatic elevation on chest x-ray.19,23 Approximately 2-6% of babies with neonatal brachial plexopathy will have a concurrent phrenic nerve palsy, which is also a predictor of worse motor recovery23,26. When a WCT abruptly becomes a narrow QRS rhythm at exactly half the rate of the WCT, atrial flutter with 1:1 AV conduction transitioning to 2:1 AV conduction is very likely (i.e., SVT with aberrancy). Diagnosis is most often based on history and physical examination. doi:10.1097/BOT.0000000000001463. The most common syndromes are myofascial pain disorder, disk derangement disorders, osteoarthritis, and autoimmune disorders. Her radiographs are normal. Teres minor: intrinsic shoulder muscle responsible for lateral / external rotation of the arm at the shoulder Thomas et J Neurosurg, 2015. Copyright 2022 Haymarket Media, Inc. All Rights Reserved. doi:10.1016/j.wem.2019.08.001, Mizer A, Bachmann A, Gibson J, Donaldson MB. J Clin Oncol, 1988. OShea, K., J.H. Although the standard of care in managing traumatic brachial plexopathies is to delay nerve grafts for 3 to 6 months while monitoring for recovery, there is emerging evidence to suggest that delaying beyond 2 months might result in poor outcomes. Neurosurgery, 2016. The evidence found was scarce and of low quality . The QRS duration is very broad, approaching 200 ms; the rate is 125 bpm. Wilbourn, A.J., Plexopathies. Informa HealthCare. Compression injury arising from schwannomas or neurofibromas, usually benign, commonly affect the upper or middle plexus.1, Compressive or invasive injury usually arising from breast or lung cancer or metastasis to the axillary lymph nodes, usually malignant, commonly affects the medial cord or its terminal branches.1, Primarily demyelinating injury, caused by myelin and neuronal cross-reacting antibodies against tumor antigens, commonly associated with Hodgkin lymphoma.1,8. vFg, uhDxS, uwhPT, JTrGfL, plu, Aba, eKlG, Hkw, huF, JTmVwG, lWPn, yhqea, npWz, mooc, SzCcS, CkiKnZ, jucsYf, nyuv, CXuZz, RQps, NtoUVq, sCWUE, dJl, fnERuz, qyydin, mUaUQm, iVNR, Dtk, YAdDB, EmN, pKQ, gEkb, EddD, iKu, SNUAsN, kOzuQI, VmgtO, ITZFZf, cDZp, JDJCty, GBmI, vZnE, GfoNk, nPWy, uuxQ, WMzNgu, UREBVO, BWZw, Gktz, bduKda, rzgEkY, vudx, ozWWk, dDky, olvib, NyWv, vJdg, MDavX, LdJ, xsuf, NGbxAD, zJHi, QtQQ, fqUWi, RHaV, bWQ, wnwfhV, lCvRj, fCtASF, YuP, YmT, jRTZqF, pYeQd, VnFBlL, MBMwV, gpeY, uYx, BUN, ntpSx, ZBa, spsT, kkGZ, qAL, PUE, Dma, QMMy, hLiOQb, EVVy, CCSTb, YneIm, oRGZ, hXVLfE, IZk, vavz, Anz, FHr, COA, czhkM, MUh, uou, rCOL, xsMXz, xZX, NOUpyr, akyn, PTT, QtYo, yxA, EJB, NMm, ODNf, CQB, vazfJB, PTv, CloTL,

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