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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 28  |  Issue : 1  |  Page : 44-50

Surgical Validation of High-Resolution Ultrasonography in Detection of Missed Tendon and Nerve Injuries after Penetrating Wounds of Hand and Wrist


1 Department of Burns, Plastic and Reconstructive Surgery, Adesh Medical College, Kurukshetra, Haryana, India
2 Department of Burns, Plastic and Reconstructive Surgery, Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India
3 Department of Surgery, Adesh Medical College, Kurukshetra, Haryana, India
4 Department of Radiodiagnosis, Adesh Medical College, Kurukshetra, Haryana, India

Date of Submission19-Nov-2018
Date of Acceptance13-Jan-2019
Date of Web Publication31-Dec-2019

Correspondence Address:
Dr. Mohd Altaf Mir
Department of Burns, Plastic and Reconstructive Surgery, Adesh Medical College, Mohri, Kurukshetra - 136 135, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_86_18

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  Abstract 


Background: To surgically validate high-resolution ultrasonography (USG) in the detection of missed tendon and nerve injuries after penetrating wounds of the hand and wrist. Materials and Methods: Patients with penetrating wounds of the hand and wrist were examined to determine the location of injury, size, and depth of the wound, probable tendons or nerves involved. The selected cases underwent high-resolution ultrasound of the affected part. Injuries detected were noted. The sensitivity, specificity, positive predictive value, and negative predictive values of the high resolution of ultrasound in preoperative detection of tendon and nerve injuries were calculated against the gold standard of intraoperative confirmation. Results: Fifty patients with penetrating injuries to the hand and wrist with the mean age 28.3 ± 4.7 years were admitted. The high-resolution USG of all the 50 patients 33 (66%) were found to have isolated tendon injury and 14 cases were found to have isolated nerve injury, whereas three cases were found to have both tendon and nerve injury. The injuries were compared with injuries confirmed on intraoperative exploration. The calculated sensitivity, specificity, positive predictive value, and negative predictive value of high-resolution USG for diagnosing the tendon injuries were 97.22%, 98.42%, 97.22%, and 98.42%, respectively. The calculated sensitivity, specificity, positive predictive value, and negative predictive value of high-resolution USG for diagnosing the nerve injuries were 85%, 92.85%, 89.47%, and 89.65%, respectively. Conclusion: It is concluded that high-resolution USG is significantly cheaper and dynamic diagnostic modality which can be used to provide additional information for diagnosing tendon and nerve tears and their location and types in cases of penetrating wounds of the hand and wrist.

Keywords: High-resolution ultrasonography, nerve, penetrating wound hand, tendon


How to cite this article:
Mir MA, Ahmad I, Kumar D, Goyal N. Surgical Validation of High-Resolution Ultrasonography in Detection of Missed Tendon and Nerve Injuries after Penetrating Wounds of Hand and Wrist. Turk J Plast Surg 2020;28:44-50

How to cite this URL:
Mir MA, Ahmad I, Kumar D, Goyal N. Surgical Validation of High-Resolution Ultrasonography in Detection of Missed Tendon and Nerve Injuries after Penetrating Wounds of Hand and Wrist. Turk J Plast Surg [serial online] 2020 [cited 2020 Sep 25];28:44-50. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/1/44/274445




  Introduction Top


The wrist and hand are the most important functional parts of the body in daily life activities and are prone to penetrating wounds due to sharp objects with subsequent injury to tendons and nerves.[1],[2] Although these injuries are not life-threatening, the accepted treatment strategy for traumatic injuries is an immediate reconstruction of all injured tissue structures for restoring the function. Hence, early diagnosis of the injured tissue is important for clinical management. Current ultrasonography (USG) systems equipped with linear array transducers have improved the capability of ultrasound to examine superficial organs and tissues. As an easily accessible, rapid, noninvasive imaging technique that also provides dynamic examination, USG is a good imaging modality for examining the musculoskeletal system.[3],[4]

USG can examine the whole length of a tendon, from the forearm to the distal insertion site. Tendons have a typical fibrillar echotexture, which reflects their histological structure of longitudinally oriented bundles of collagen fibers; normal tendons are more echogenic than muscle. Diagnostic findings of a partial tendon rupture include a hypoechoic/anechoic foci within the tendon, tendon swelling, and effusion in the tendon sheath. Nonvisualization of a tendon at the site of injury, the loss of its fibrillar pattern and discontinuity of the tendon with the gap at the rupture site are the signs of complete rupture.[5],[6] The gap between the two ends of the tendon that fills with fluid is helpful for making the diagnosis, especially in the case of a recent injury.[5],[6]

As a consequence of their relatively superficial location in the wrist, peripheral nerves may be damaged by trauma.[7] The nerve most commonly injured in the upper extremity is the radial nerve, followed by the ulnar and median nerves;[7],[8] however in the region of the hand and wrist the most common nerve to be injured is median nerve, then ulnar nerve, and finally, the radial nerve.[9] The USG findings for injured nerves included disruption or total loss of the normal fascicular pattern of the nerve, local swelling or thickening and decreased echogenicity of the nerve, loss of integrity of the nerve bundle, and neuroma formation at the transected nerve end.[10],[11] Thus, USG can be used to facilitate the preoperative diagnosis and planning of the optimal treatment strategy. We present a report of surgical validation of high-resolution USG in the detection of missed tendon and nerve injuries after penetrating wounds of the hand and wrist.


  Materials and Methods Top


This was a prospective study undertaken between September 2017 and November 2018 in the division of Plastic and Reconstructive Surgery and Division of Radio-diagnosis of our institution. The study has been approved by the departmental ethical committee and has therefore been performed in accordance with ethical standards laid down in 1964 declaration of Helsinki and its later amendments. Patients with penetrating wounds of the hand and wrist were admitted through the outpatient department or emergency room. A detailed history and examination were recorded to determine the location of injury, size and depth of the wound, probable tendons or nerves involved based on the location of the wound and weakness, loss of movement and/or sensation. A complete blood count, kidney and liver function tests, coagulation profile and hepatitis B, C, and human imuno deficiency viral marker testing were performed following informed consent. Anteroposterior and oblique radiographs of the elbow were taken in all cases to rule out fractures. The selected cases underwent high-resolution ultrasound of the affected part on the machine (Toshiba ISTYLE AplioXG) using multifrequency Linear probe 12–18 megahertz (MHz). A detailed and focused ultrasound examination of the injured part was done. Injuries detected were noted. The tendon and nerve injuries were repaired with suitable techniques. All patients were followed up regularly. The data obtained was tabulated on Excel Spread Sheet and subjected to statistical analysis using IBM SPSS version 23 (Armonk, NY: IBM Corp) statistical tool. The sensitivity, specificity, positive predictive value, and negative predictive values of the high resolution of ultrasound in preoperative detection of tendon and nerve injuries were calculated against the gold standard of intraoperative confirmation of tendon and nerve injuries in cases of penetrating wounds of the hand and wrist.


  Results Top


Fifty patients with penetrating injuries to the hand and wrist were admitted from the outpatient and emergency room of the Division of Plastic Surgery of our institution. The age of patients ranges 5–60 years with the mean age 28.3 ± 4.7 years with the maximum number of patients belonging to 21–30 years of age. Of the 50 patients 33 (66%) were males with an average age of 28.6 ± 4.9 years and 17 (34%) were females with an average age of 27.6 ± 4.5 years. The high-resolution USG of all the 50 patients 33 (66%) were found to have isolated tendon injury, and 14 cases were found to have isolated nerve injury, whereas 3 cases were found to have both tendon and nerve injury. The frequency of injury to different tendons reported on high-resolution USG and confirmed intra-operatively is summarized in [Table 1]. Out of 23 injured tendons of flexor digitorum superficialis injuries as reported on high-resolution USG only 21 tendons were actually confirmed intraoperatively. Of the 18 injured tendons of flexor digitorum profundus (FDP) as reported on high-resolution USG all were confirmed intra-operatively; however one more tendon of FDP was found to be injured which was missed and not reported on prior performed high-resolution USG. Out of 3 injured tendons of Flexor carpi ulnaris as reported on high-resolution USG all were actually confirmed intraoperatively. However, 1 more tendon of flexor carpi ulnaris was found to be injured which was missed and not reported on prior performed high-resolution USG. Out of remaining tendons reported as injured, namely, extensor digitorum (5 tendons), extensor carpi radialis brevis (4 tendons), 3 tendons each of extensor policis longus, extensor carpi radialis longus, and extensor digiti minimi, 2 tendons each of flexor policis longus, extensor carpi ulnaris, abductor policis longus, and extensor policis brevis, and 1 tendon each of extensor indices and palmaris longus were all found to be actually injured and confirmed during intra-operative exploration. The calculated sensitivity, specificity, positive predictive value, and negative predictive value of high-resolution USG for diagnosing the tendon injuries were 97.22%, 98.42%, 97.22%, and 98.42%, respectively.
Table 1: Frequency of injury to different tendons reported on high.resolution ultrasonography and confirmed intra-operatively

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The frequency of injury to different nerves reported on high-resolution USG and confirmed intraoperatively is summarized in [Table 2]. Out of 9 injuries of the median nerve as reported on high-resolution USG all were actually confirmed intraoperatively. However, 1 more patient with median nerve injury was found intraoperatively which was missed and not reported on prior performed high-resolution USG. Out of 7 injuries of ulnar nerve as reported on high-resolution USG, only 5 ulnar nerves injuries were confirmed intraoperatively, in the remaining 2 cases ulnar nerves were found to be intact intra-operatively. Moreover, two more patients with ulnar nerve injury were found intraoperatively which were missed and not reported on prior performed high-resolution USG. Hence, the number of injured ulnar nerves is same, i.e., 7, for high-resolution USG findings and intraoperative findings but the point to be noted is that there are 2 false negative and 2 false positive results. Out of 3 injuries of radial nerve as reported on high-resolution USG all were confirmed intra-operatively. The calculated sensitivity, specificity, positive predictive value, and negative predictive value of high-resolution USG for diagnosing the nerve injuries were 85%, 92.85%, 89.47%, and 89.65%, respectively.
Table 2: Frequency of injury to different nerves reported on high.resolution ultrasonography and confirmed intra-operatively

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Case representation

We represent here two cases of penetrating wounds of hand and wrist with tendon and nerve injuries.

Case 1

A 27-year-old female presented with penetrating wound left-hand palm by knife at home, longitudinal high-resolution sonogram of the left 3rd digit shows hypoechogenicity with a total loss of continuity in the tendon of FDP just proximal to the distal interphalyngeal joint diagnosing complete tear [Figure 1]. There is only minimal retraction of the proximal end. The intraoperatively confirmed completely transected FDP tendon of the 3rd digit. In addition, FDP of the same digit was also observed intraoperatively. Both the tendons were repaired with modified Kessler suture technique [Figure 2].
Figure 1: High resolution sonography showing complete tear of flexor digitorum profundus tendon of 3rd digit of left hand in case 1

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Figure 2: Intra-operative image showing completely transectected flexor digitorum superficialis and flexor digitorum profundus tendon of the 3rd digit in case 1

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Case 2

A 24-year-old male carpenter presented with penetrating wound right wrist and distal arm zone 4 and 5 with broken glass at work, longitudinal high-resolution ultrasound scans shows ovoid hypoechoic lesion (neuroma) arising from the media nerve, with maintained continuity of the remaining nerve fibers suggestive of partial tear with neuroma formation [Figure 3]. Intraoperatively, the findings were confirmed, neuroma excised and nerve reconstruction was performed [Figure 4] and [Figure 5].
Figure 3: High resolution sonography showing posttraumatic neuroma of median nerve in case 2

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Figure 4: Intraoperative image showing posttraumatic neuroma of median nerve in case 2

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Figure 5: Intraoperative image of excision of median nerve neuroma and repair in case 2

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  Discussion Top


The penetrating wounds of the wrist and hand are often due to sharp objects with subsequent injury to tendons and nerves which sometimes may be missed on clinical examination and therefore may result in functional deficits. Hence, early diagnosis of the injured tissue is important for clinical management. Current USG systems equipped with linear-array transducers have improved the capability of ultrasound to examine superficial organs and tissues. As an easily accessible, rapid, noninvasive imaging technique that also provides dynamic examination, high-resolution USG is a good imaging modality for examining the musculoskeletal system[3],[4] Tendon injuries are the second most common injuries in hand after fractures.[12] Most injuries are direct injuries to the tendons, but less frequent indirect traumas may cause damage to the tendon, tendon sheath, and pulley system.[13] The recognition of a tendon rupture is usually based on the physical examination and history. An acute loss of motion, a patient's report of hearing a popping sound during the injury and the final position of the finger generally demonstrates a tendon rupture. However, imaging is necessary for diagnosis, especially in complicated cases. USG has been used as a diagnostic tool for tendon injuries since the 1990s. Höglund et al.[14] detected the rupture of recently repaired tendons using USG in 1991. Corduff et al.[15] used USG imaging to assess the state of healing of zone 1 flexor tendon repairs in 1994. USG can examine the whole length of a tendon, from the forearm to the distal insertion site. Tendons have a typical fibrillar echotexture, which reflects their histological structure of longitudinally oriented bundles of collagen fibers; normal tendons are more echogenic than muscle. The operator should be careful when evaluating a tendon with USG, as a slightly oblique angle of the USG beam in the longitudinal or transverse planes causes a false reduction in the echogenicity, known as anisotropy, which is more likely to occur when the tendon is curved or when a nonlinear array transducer is used. This may lead to misdiagnosis.[16] Diagnostic findings of a partial tendon rupture include a hypoechoic/anechoic foci within the tendon, tendon swelling, and effusion in the tendon sheath. Nonvisualization of a tendon at the site of injury, the loss of its fibrillar pattern and discontinuity of the tendon with the gap at the rupture site are the signs of complete rupture.[5],[17] The gap between the two ends of the tendon that fills with fluid is helpful for making the diagnosis, especially in the case of a recent injury. Occasionally, these gaps become filled with mixed echogenic material in relatively late presentations, which is interpreted as fibrinous tissue. This appearance may lead to the misdiagnosis of an intact tendon in the cases.[17] As a result of an inactive flexor system and injuries to other soft tissues of the digits, the tendons can sometimes adhere to the surrounding scar tissue. An adhered flexor tendon appears to be continuous at the repair site, with no evidence of a gap, but the tendon is thickened and enclosed by mixed echogenic tissue, which is interpreted as fibrosis in these cases. All 50 patients with signs and symptoms of clinically proven tendon injuries were subjected to high-frequency USG examination and a detailed and focused ultrasound examination of the injured part was done. The injured tendons as reported on high-resolution USG were intraoperatively correlated, care was also taken to identify missing injuries which USG failed to detect. The total of 199 tendons were examined in the duration of the study, out of which the number of tendons which were reported as injured on high-resolution USG were 72 and the number of tendons which were reported as intact were 127. There were 2 false positive (2 of Flexor digitorum superficialis) and 2 false negative (1 each of FDP and flexor carpi ulnaris) results of USG findings as compared to intraoperative findings. Out of the 72 injured tendons as detected during surgery, 56 were found to be complete tears and 16 were found to be partial tears. In a summary, out of 72 tendon injuries found at surgery, high-resolution USG was able to detect only 70 of them and radiologists wrongly reported 2 tendon injuries on high-resolution USG, which were not found intra-operatively. Hence with 2 false positive and 2 false negative high-resolution USG findings, the sensitivity, specificity, positive predictive value and negative predictive value of USG in detecting tendon injuries preoperatively with surgical exploration as reference standard, came out to be 97.22%, 98.42%, 97.22%, and 98.42%, respectively. Regarding retraction and localization of the proximal end of the ruptured tendons, in our study high-resolution USG was able to correctly locate the proximal end in only 40 of the 56 complete tears (71.4%). Very few studies have been conducted previously, studying the role of high-frequency USG in penetrating tendon injuries. However, our results significantly correlated with those studies. Zhang et al.[18] conducted a study entitled “Value of High-Frequency USG in Diagnosis and Surgical Repair of Traumatic Finger Tendon Ruptures (2012)” where preoperative high-frequency ultrasound examination yielded excellent diagnostic accuracy for zone 2 flexor tendon injuries. Types of ruptures (complete or partial) and the location of the distal end of the ruptured tendon diagnosed by preoperative USG were consistent with surgical findings in all cases (95/95, 100%) of the study group, whereas the concordance rate between clinically diagnosed ruptures and surgical findings was only 34.4% (31/90) in the control group (P = 0.02). Another study by Ravnic et al.[19] entitled “Diagnosis and localization of flexor tendon injuries by surgeon-performed ultrasound: A cadaveric study (2011)” where correct diagnosis of flexor tendon injury was made in 78 of 81 tendons (96.2% success) and correct localization of the proximal tendon stump was made in 39 of 50 lacerated tendons (78% success). In the study entitled “Penetrating Volar Injuries of the Hand: Diagnostic Accuracy of US in Depicting Soft-Tissue Lesions” by Soubeyrand et al.[20] which was published in the year 2008, USG correctly depicted all of the 17 tendon injuries with no false positive or false negative results. Thus the sensitivity, specificity, positive predictive value, and negative predictive values were all calculated to be 100%. The reason for slightly lower values of these statistical parameters in our study could be the late presentation of most of the patients included in our study group, as in delayed presentation tears become filled with mixed echogenic material, which is interpreted as fibrinous tissue leading to misdiagnosis. Again the same reason; the late presentation of the patients leading to the filling of the tears with mixed echogenic material may be attributed to the decreased frequency of correct localization of the proximal end of the torn tendon in our study.

As a consequence of their relatively superficial location in the wrist, peripheral nerves may be damaged by trauma.[7] The nerve most commonly injured in the upper extremity is the radial nerve, followed by the ulnar and median nerves,[7],[8] however in the region of hand and wrist the most common nerve to be injured is median nerve, then ulnar nerve, and finally, the radial nerve.[9] Because of the superficial course of the peripheral nerves in the wrist, high-frequency USG seems to be an optimal imaging method. Although high-resolution USG of the peripheral nerves may be considered a new topic in medicine, USG has been used as a diagnostic tool for three decades. Solbiati et al.[21] studied the USG appearance of the recurrent laryngeal nerve in 1985, and in 1988, Fornage used USG to evaluate peripheral nerves in healthy controls and in 11 patients with a mass that developed from a peripheral nerve.[22] The USG findings for injured nerves included disruption or total loss of the normal fascicular pattern of the nerve, local swelling or thickening and decreased echogenicity of the nerve, loss of integrity of the nerve bundle, and neuroma formation at the transected nerve end.[10],[11] Thus, high-resolution USG can be used to facilitate the preoperative diagnosis and planning of the optimal treatment strategy. All 50 patients with signs and symptoms of clinically proven nerve injuries were subjected to high-frequency high-resolution USG examination and a detailed and focused ultrasound examination of the injured part was done. The injured nerves as reported on high resolution USG were per operatively explored, and findings were correlated, here too care was taken to identify missing injuries which high-resolution USG failed to detect. The total of 48 nerves which were examined in the whole duration of the study was 48, out of which the number of nerves which were reported as injured on high-resolution USG was 19 and the number of nerves which were reported as intact were 29. There were 2 false positive (2 of ulnar nerve) and 3 false negative (1 of Median nerve and 2 of ulnar nerve) results of USG findings as compared to intraoperative findings. Out of the 20 injured nerves as detected during surgery, 4 were detected as complete tears, 5 were detected as partial tears, 1 was detected as complete tear with neuroma formation and 10 were detected as partial tears with neuroma formation. Hence, the crux is that, out of 20 nerve injuries found at surgery, high-resolution USG was able to detect only 17 of them and radiologists wrongly reported 2 nerve injuries on high-resolution USG, which were not found intra-operatively. So with 2 false positive and 3 false negative high-resolution USG findings, the sensitivity, specificity, positive predictive value, and negative predictive value of high-resolution USG in detecting nerve injuries intraoperatively with surgical exploration as reference standard, came out to be 85%, 92.85%, 89.47% and 89.65%, respectively. Regarding retraction and localization of the proximal end of the torn nerves, in the study high-resolution USG was able to correctly locate the proximal end in only 4 of the 5 complete tears (80%). These findings were in accordance with a similar study entitled “high-frequency ultrasound evaluation of traumatic peripheral nerve injuries (2012)” by Hollister et al.[23] where they used new high-frequency ultrasound to evaluate 24 patients with 29 traumatic nerve injuries. There were a variety of causes including gunshot wounds, blunt injuries, burns, stabbings, and motor vehicle accidents. The patients were then either treated surgically with nerve status directly observed or followed clinically for recovery of nerve function. The ultrasound findings corresponded with the clinical outcome of 28 of the 29 nerves. Lee et al. performed a retrospective analysis of 13 patients with USG evaluation and surgical treatment of nerve lesions and the results suggested high-resolution USG was an effective imaging investigation that augmented electrophysiological and other neuroimaging studies.[24] Our results were however moderately different from the results obtained by Soubeyrand et al.[20] in their study entitled “penetrating volar injuries of the hand: Diagnostic accuracy of USG in depicting soft-tissue lesions” where USG missed 4 of 16 nerve injuries detected in 81 examined nerves in addition to 6 false positive results. In that study the sensitivity, specificity, positive predictive value, and negative predictive value of high resolution USG in detecting nerve injuries preoperatively with surgical exploration as reference standard, came out to be 75%, 90.8%, 66.7%, and 93.7%, respectively, as against 85%, 92.85%, 89.47% and 89.65%, respectively, in our study. This disparity in the results could be attributed to many factors including smaller sample size of this study, location of the lesions, i.e., in our study a large proportion of the lesions were in the arm, forearm, and wrist region where nerves can be assessed more easily as compared to the hand as in the above-mentioned study. And finally time of presentation, in their study all cases presented in emergency within a few hours of injury when there was excessive inflammation and high resolution USG examination was thus difficult at that time, however in our study most of the patients presented late from weeks to months, until then inflammation subsided and USG examination was relatively easy; moreover, in chronic cases, there were more chances of neuroma formation which are obviously easier to detect thus leading to higher sensitivity, specificity, positive predictive value, and negative predictive value in our study.

The technologic advances achieved over the past few years, the role of high-resolution USG as the first-line imaging modality in the assessment of penetrating tendon and nerve injuries has been further strengthened and has gained full acceptance. Recent technologic advances include higher frequency (10–15 MHz) broad bandwidth probes, with better near field beam focusing and grayscale processing, giving very high resolution near field imaging. (ultrasound has better than twice the resolution of magnetic resonance imaging (MRI).[25] In contrast to the MRI which is also a very accurate imaging modality for this purpose, high-resolution USG is significantly cheaper as well as it has its own benefit of being a dynamic study. At the same time, USG is a rapid, nonionizing, portable mode of investigation. In this study, high-resolution USG has proved to be highly effective in preoperative detection of tendon and nerve lesions in penetrating trauma as validated by previous similar studies.


  Conclusion Top


It is concluded that high-resolution USG is significantly cheaper and dynamic diagnostic modality which can be used to provide additional information for diagnosing tendon and nerve tears and their location and types in cases of penetrating wounds of hand and wrist.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

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