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PubMed1987

Colles' fracture as an indicator of increased risk of hip fracture. An epidemiological study.

The relative value of previous Colles' fracture and previous fractures of any other type as an indicator of likelihood of sustaining a subsequent hip fracture was investigated. The frequency of hip fractures was no higher in a group of 242 women and 20 men who had a past history of radius shaft or Colles' fracture than it was in 412 women and 112 men with a history of previous fractures of other types. Only in women, and only up to the age of 62, was the prevalence of previous Colles' fracture higher among hip fracture patients than in the general population. The prevalence of previous fractures of other types among hip fracture patients, however, was higher in women until the age of 70 and in men until the age of 80 than in the general population.

Adult↗
PubMed1978

Functional fracture-bracing of long-bone fractures of the lower extremity in children.

Fifty-six tibial fractures in fifty-five children, sixteen years old or younger, and seventeen femoral fractures in seventeen children in the same age group, seven of them with associated tibial fractures, were treated by fracture-bracing. The tibial fractures healed in an average of 13.2 weeks with no complications that could be attributed to failure of the method. The femoral fractures healed in an average of seventeen weeks. There was an angular femoral deformity of more than 5 degrees in seven of seventeen patients, all but one in fractures of the middle third of the femoral shaft. Of nine distal fractures, only one had angulation of more than 5 degrees. Therefore, the method should be restricted to fractures in the distal third of the femoral shaft. Fracture-bracing gave more freedom to the child and was eminently satisfactory to the parents.

Adolescent↗
PubMed1981

A comparison of the effect of open intramedullary nailing and compression-plate fixation on fracture-site blood flow and fracture union.

UNLABELLED: We compared the effects of compression-plating and open intramedullary nailing after reaming on the vascular supply to a standard fracture site, on the rate of fracture union, and on the biomechanical quality of bone after union, and on the biomechanical quality of bone after union in dogs. The proper location of a compression plate in relation to the periosteum also was investigated. Bone blood flow reached higher levels and remained elevated longer in fractures that were fixed with a rod than in those fixed with a plate. Rod-fixed fractures healed by periosteal callus, whereas plate-fixed fractures healed by endosteal callus. The fracture gained mechanical strength more slowly in the rod-fixed group than in the plate-fixed group. Subperiosteal or extraperiosteal placement of a plate revealed similar effects on bone-healing. CLINICAL RELEVANCE: Decisions to use intramedullary rods or compression plates for internal fixation of fractures should be based on knowledge of the biological effects of these procedures on blood flow at the fracture site and on the mechanical strength of the healing fracture. This study defines in quantitative terms the advantages and disadvantages of intramedullary rods compared with compression plates in the internal fixation of fractures.

Animals↗
PubMed2003

[The prosthesis nail -- a new stable fixation device for periprosthetic fractures and critical fractures of the proximal femur].

Increasing numbers of total hip arthroplasties in combination with increasing age and growing daily activities of the elderly lead to increasing numbers of periprosthetic fractures and revision arthroplasties in osteoporotic bone. The prosthesis nail is a hybrid of a hip prosthesis and an intramedullary nail allowing immediate full weight bearing and early rehabilitation. The prosthesis nail consists of three self-locking components: a distally locked intramedullary nail, different lengthening modules, and a hip prosthesis module. From 1992 to 1999, 28 prosthesis nails were implanted in 26 patients (40-88 years, mean age: 71 years). The indications were 21 peri- and subprosthetic fractures caused by trauma, 2 fractures of the proximal femur in combination with a fracture of the femoral head or severe degenerative arthritis, and 4 revision arthroplasties associated with poor bone quality. A combination of the prosthesis nail and bone cement was used in one patient suffering from a pathological fracture of the distal femur. Patients were additionally treated with wire cerclage (six patients) and autogenous bone grafting (ten patients). All patients-except those who received a reconstruction of the acetabulum in the same session (four patients)-were mobilized with full weight bearing on the operated side as soon as wound pain diminished. Bone healing was observed in all periprosthetic fractures. In three patients the prosthesis nail had to be revised: one patient suffered from recurrent dislocations and in one patient weighing 350 pounds limb shortening occurred after the distal locking screw broke. Intramedullary infection was observed once after treatment of a periprosthetic fracture. When bone union was achieved the prosthesis nail was removed and the patient was mobilized with a girdlestone situation. The idea of the prosthesis nail is based on the logical consequence of treating femur fractures with the most efficient procedure, which is intramedullary nailing. The prosthesis nail can be applied according to the requirements of the fracture as a reamed or unreamed nail and immediate full weight bearing is possible. Considering the high average age of the patients, low morbidity, short rehabilitation time, and low costs are the major advantages of this new device. Taking into account the unfavorable preoperative conditions associated with elderly and multimorbid patients, the rate of complications is relatively low.

Acetabulum↗
PubMed1999

Spontaneous subcapital femoral neck fracture complicating a healed intertrochanteric fracture.

A spontaneous subcapital femoral neck fracture is an uncommon complication of a healed intertrochanteric hip fracture. To determine the etiology of this complication, 274 patients who had been treated for intertrochanteric hip fractures were followed up over an 8-year period from June 1988 to June 1996. We found 7 fractures of the subcapital femoral neck without a history of a trauma. The remaining 267 patients were defined as the control group. All seven patients with fractures of the subcapital femoral neck were women, and their average age at the time of compression hip screw (CHS) fixation was 83 years (range 74-92 years). The subcapital fractures occurred between 4 and 36 months after CHS fixation. The difference in the Singh index between the patient and control groups was statistically significant (P < 0.01). However, with regard to the position of the screw, spinal score, age, ambulatory ability, height, weight, and intertrochanteric fracture type (Jensen type), the differences between the patient and control groups were not statistically significant. Based on our findings, we conclude that a high grade of osteoporosis is the most important predisposing factor in the spontaneous development of a subcapital femoral neck fracture after a healed intertrochanteric hip fracture.

Aged↗
PubMed2007

Incidence of fracture-healing complications after femoral neck fractures.

What is the relationship between the age or gender of the patient and the incidence of fracture-healing complications after internal fixation of intracapsular fractures? We aimed to determine the association between the age of the patient and fracture nonunion and also to establish if the gender of the patient had any influence on the occurrence of fracture nonunion. We prospectively studied 1133 patients with intracapsular fractures of the femoral neck treated by internal fixation. The overall incidence of nonunion was 19.3%. Fracture nonunion was less common for undisplaced fractures than for displaced fractures (48 of 565 [8.5%] versus 171 of 568 [30.1%]) and in men than in women (35 of 271 [12.9%] versus 184 of 862 [21.3%]). The incidence of nonunion progressively increased with age from one of 17 (5.9%) in patients younger than 40 years to 84 of 337 (24.9%) in patients in their 70s. For patients in their 80s, the incidence of nonunion began to decrease, but if patients who died within 1 year after injury were excluded, the incidence continued to increase. Our study showed an increased risk for intracapsular hip fractures developing nonunion with older age and in females.

Adolescent↗
PubMed1999

Deep infection and fracture healing in immediate and delayed locked intramedullary nailing for open femoral fractures.

Fifty-nine patients with 61 open femoral fractures were treated with immediate locked intramedullary (IM) nailing (group 1; n=15), delayed IM nailing following nonoperative treatment (group 2; n=42), and delayed IM nailing following external fixation (group 3; n=7). Sixteen fractures were Gustilo type I, 28 were type II, 7 were type IIIA, 6 were type IIIB, and 4 were type IIIC open fractures. Four (6.6%) deep infections occurred. Significant differences existed in the deep infection rate (DIR) between types I and II and all type III fractures (2.3% for types I and II versus 17.6% for type III). The deep infection rate did not differ significantly among the nailing groups (13.3%, 2.6%, and 15.3% for groups 1, 2, and 3, respectively), nor did the deep infection rate correlate with the degree of fracture comminution, the existence of polytrauma or polyskeletal trauma, or preexistence of superficial or pin-site infections. Seven (11.7%) of these fractures resulted in nonunion, excluding one secondary amputation; the nonunion rate correlated with fracture location. There were no significant differences in the mean fracture healing times between any of the nailing groups. These results suggest that IM nailing for the treatment of type III open femoral fractures should be considered carefully, regardless of whether it is performed immediately or delayed.

Adolescent↗
PubMedDate not supplied

The unilateral external fixator (Monofixator) in acute fracture treatment: experience in 50 fractures.

From 1988 to 1992, 50 fractures with associated soft tissue lesions were treated with an unilateral fixator (Monofixator). The location of the fracture was the tibia in 39 cases, the pelvis in 5 cases, the femur in 4 cases, the ankle and the humerus in one patient respectively. Twenty-two tibial fractures (56%) were open. Unproblematic healing with the monofixator was achieved in 71.8% of tibial fractures after a mean healing time of 18.2 weeks. Axial dynamic compression was performed in 18 tibial fractures. Planned reosteosynthesis was performed in 7 tibial fractures (18%). After secondary internal osteosynthesis, no late problems were seen. Complications with the monofixator in acute tibial fracture treatment consisted of refracture in 3 patients, pin track infection in 2 patients and hypertrophic pseudarthrosis in one patient. The monofixator provides a safe and stable fixation in tibial fractures with important associated soft tissue damage. In haemodynamically unstable patients with severe associated lesions, pelvic ring and femoral fractures can be reduced and stabilized satisfactorily with a monofixator, mostly until better condition permits definitive osteosynthesis.

Adolescent↗
PubMed2006

The effect of fiber insertion on fracture resistance of endodontically treated molars with MOD cavity and reattached fractured lingual cusps.

In this study, the effect of flowable composite reinforced with a leno wave ultra high modulus (LWUHM) polyethylene fiber (Ribbond) on fracture resistance of endodontically treated molars with MOD cavity and lingual cuspal fracture was evaluated. Sixty sound extracted human mandibular molars were randomly assigned to six groups (n = 10). Group 1 served as control. Teeth in groups 2-6 received root canal treatment and a MOD cavity preparation. Teeth in group 2 were kept unrestored. Lingual walls of specimens in groups 3-6 were fractured at the CEJ and reattached (C&B Super-Bond). Group 3 was kept unrestored, and group 4 was restored with a composite resin (CR) (AP-X). In group 5, a flowable resin (FR, Protect Liner F) and in group 6, a Ribbond in combination with FR were inserted inside the cavity before CR restoration. After finishing and polishing, the specimens were subjected to compressive loading perpendicular to the occlusal surface at a crosshead speed of 1 mm/min. The mean load necessary to fracture were recorded in Newton and the results were statistically analyzed. MOD cavity preparation reduced fracture resistance of endodontically treated teeth (p < 0.05). Fracture resistance of rebonded fractured specimens was found to be similar to that of the nonfractured samples (p > 0.05). Use of LWUHM polyethylene fiber Ribbond increased fracture strength of endodontically treated molar teeth with MOD cavity preparation and cuspal fracture (p < 0.05). As a result, it was concluded that the insertion of Ribbond inside the cavity has a positive effect on fracture strength of endodontically treated molar teeth with MOD cavity preparation and cuspal fracture.

Dental Materials↗
PubMed2000

Nutritional supplementation for hip fracture aftercare in the elderly.

BACKGROUND: Fractures of the hip are an important cause of later ill health and mortality in elderly people. People with hip fractures are often malnourished at the time of fracture, and have poor food intake in hospital. OBJECTIVES: This review assesses the effects of nutritional interventions in elderly people recovering from hip fracture. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group trials register, the Cochrane Controlled Trials Register, Medline, Nutrition Abstracts and Reviews, Embase, Biosis, Cinahl, Healthstar and reference lists. We contacted investigators, and hand searched Proceedings of the Nutrition Society, Clinical Nutrition and The Journal of Parenteral and Enteral Nutrition. Date of the most recent search: June 1999. SELECTION CRITERIA: Randomised and quasi-randomised trials of nutritional interventions of mainly older patients (aged over 65 years) with hip fracture. DATA COLLECTION AND ANALYSIS: Trial allocation to included, excluded and awaiting assessment categories, was by consensus. Both reviewers independently extracted data and assessed trial quality. Additional information was sought from all trialists. Pooling of data for primary outcomes and select exploratory analyses were undertaken. MAIN RESULTS: Fifteen randomised trials involving 943 participants were included. Overall the quality of trials was poor; specifically in terms of allocation concealment, assessor blinding and intention to treat analysis. This, and the limited availability of outcome data, mean that the following results must be interpreted with caution. Oral multinutrient feeds (providing non-protein energy, protein, some vitamins and minerals), evaluated by six trials, may reduce unfavourable outcome (death or complications) (14/66 versus 26/73; Peto odds ratio 0.28, 95% confidence interval 0.11 to 0.67), but did not demonstrate an effect on mortality (12/91 versus 14/97; Peto odds ratio 0.82, 95% confidence interval 0.34 to 1.96). Four trials, examining nasogastric multinutrient feeding, showed no evidence for an effect on mortality (Peto odds ratio 0.98, 95% confidence interval 0.44 to 2.17), but the studies were heterogeneous regarding case-mix. Insufficient information was provided to evaluate unfavourable outcome. The effect of protein in an oral feed, tested in two trials, showed no evidence for an effect on mortality (Peto odds ratio 0.93, 95% confidence interval 0.31 to 2.79), but may have reduced days spent in rehabilitation wards. Two trials, testing intravenous thiamin (vitamin B1) and other water soluble vitamins, or 1-alpha-hydroxycholecalciferol (an active form of vitamin D) respectively, produced no evidence of benefit for either vitamin supplement. REVIEWER'S CONCLUSIONS: The strongest evidence for the effectiveness of nutritional supplementation exists for oral protein and energy feeds, but the evidence is still very weak. Future trials are required which overcome the defects of the reviewed studies, particularly inadequate size, methodology and outcome assessment.

Aged↗
PubMed1981

[Fractures and dislocation fractures of os calcis, tarsi, metatarsi, and hallux (author's transl)].

During a 25-year period, 24995 total patients were treated in the Unfallkrankenhaus in Meidling including: 3502 fractures of the os calcis, 919 dislocation fractures of the ossea tarsalea, 9675 fractures and dislocation fractures of the os metatarsalia, and 10899 fractures of the halux. For example, a walking cast was used for undislocated fractures; for unstable dislocated fractures, reduction and fixation with percutaneous wires were used. The same treatment was applied to fractures of the os calcis, with special consideration paid to circulation and age (limitation of 50 years). The treatment results are given for 197 fractures of the os calcis fixated by wire and for 32 Lisfranc dislocation fractures.

Adult↗
PubMed1995

Fracture line stability as a function of the internal fixation system: an in vitro comparison using a mandibular angle fracture model.

PURPOSE: This study was conducted to determine and compare the initial mechanical stability and functional capability of six contemporary internal fixation systems used to fix mandibular angle fractures. MATERIALS AND METHODS: An iterative analog of a mandibular angle fracture was developed to ensure replicability of material properties and fracture configuration across the test constructs. Each of six sets of mandible analog (1 set = 3 mandibles) was reduced according to prescribed technique by a variety of compressive and adaptive fixation systems. The compressive systems included the 1) eccentric dynamic compression plate, 2) Würzburg plate, 3) Luhr plate, and 4) solitary lag screw technique. The Champy miniplate and the Mennen clamp plate represented the adaptive fixation systems. The reduced analogs were placed in a straining frame, and simulated masticatory loads were applied to predetermined occlusal sites. Fracture line displacements were acquired and registered by displacement transducers attached to a computer-based data acquisition program. A coordinate transformation procedure was used to convert the generalized displacements at the fracture line into the individual rotations of the segments. An "instability factor" computed from the force-displacement data recorded at various loading conditions for each test construct was used to characterize a particular system's ability to restrain relative motion at the fracture surfaces. RESULTS: There were minimal variations in the stability profiles of the individual compressive fixation systems. However, the fixation stability provided by the compressive and adaptive systems differed significantly (P < or = .0001). A large initial setting and a susceptibility to variations in loading patterns characterized the functional stability provided by the adaptive systems. Even at low masticatory loads (2 DaN), the adaptive systems had an instability that was two to three times as much as that of the compressive systems. Post-hoc comparisons between pairs of devices showed that angle fractures fixed by compressive systems provided significantly greater stability (P < or = .05) than those fixed by the Champy and Mennen systems. Between the adaptive systems tested, fracture fixation with Mennen plates was more stable than reduction by Champy miniplates (P < or = .05) when averaged over loads. CONCLUSIONS: Compressive fixation systems are biomechanically superior to adaptive systems and provide good immediate functional stability to reduced mandibular angle fractures. The Champy and Mennen systems permit significantly higher motion at the fracture site, even at the attenuated masticatory forces encountered in the early postoperative period. Because the functional stability afforded by these adaptive systems is influenced by variations in the biting patterns, the risk of infection and complicated healing is correspondingly increased. Also, the low displacement resistance of the adaptive systems may not protect the alignment of the mandibular segments through the healing period and may manifest as occlusal discrepancies in the dentate patient. The biomechanical test system developed for this study allows an equitable comparison of fixation stability and appears to be a promising tool for investigating a variety of fixation systems and optimizing device design on a rational basis.

Analysis of Variance↗
PubMed2004

Volar Barton's fractures with concomitant dorsal fracture in older patients.

PURPOSE: To describe a variant of Barton's volar articular shearing fracture of the distal radial articular surface with a subtle concomitant fracture of the dorsal metaphyseal cortex. METHODS: This fracture pattern was observed in 6 women and 2 men with an average age of 67 years (range, 58-76 years). All 8 patients were treated with a volar plate and screws. The dorsal metaphyseal fracture was not recognized in 5 patients and a volar buttress plating technique using an intentionally undercontoured volar plate was used. In 3 patients the dorsal fracture line was identified before surgery and the plate was contoured to fit the volar surface of the distal radius. RESULTS: All 5 patients treated with an undercontoured plate had loss of the normal palmar tilt of the distal radius (average,-9.4 degrees; range, 0 degrees to-22 degrees ) and dorsal translation of the distal radial articular fragments. For the entire group the palmar tilt averaged-5.9 degrees (range, 0.0 degrees to-22.0 degrees ), the ulnar inclination 19 degrees (range, 10 degrees -23 degrees ), and the ulnar variance-0.9 mm (range, 0.0 to-3.0 mm). All patients attained forearm supination of 80 degrees and the average pronation was 75 degrees (range, 45 degrees -80 degrees ). According to Sarmiento's modification of the system of Gartland and Werley there were 1 excellent, 6 good, and 1 fair results. The average Patient-Rated Wrist Evaluation score was 16 (range, 0-35). CONCLUSIONS: Some fractures with an oblique volar marginal articular fracture of the distal radius and volar radiocarpal subluxation (known as Barton's fracture) may also have a fracture through the dorsal metaphyseal cortex. Failure to identify this fracture line can lead to dorsal translation and angulation of the distal radius articular surface, particularly when an undercontoured volar plate is used for internal fixation.

Aged↗
PubMed1998

Open reduction and internal fixation of unstable distal radius fractures with a low-profile plate: a multicenter study of 73 fractures.

A study of acute, dorsally displaced, unstable (high-energy) fractures of the distal radius was conducted to determine the safety and efficacy of a new low-profile plate for unstable distal radius fractures. Thirteen surgeons in 11 US cities participated in the study. A minimum follow-up period of 1 year was required to be included in the study. Seventy-three fractures in 71 patients met this criterion. Each fracture was treated according to a prospective protocol. An autogenous bone graft was used in 64 fractures. All procedures were completed using a radiolucent sterile traction table. No external fixators were used either during or after the operation. After bone grafting and while in traction, a fracture reduction clamp with a template preshaped to the normal contour of the dorsal radial metaphysis molded the fracture into reduction and then allowed precision drilling of the holes for the plate. Active wrist motion began at an average of 14 days. Satisfactory open reduction was obtained in 93% of the fractures and maintained in 88%. Ninety-five percent of the fractures demonstrated good or excellent outcomes using a standardized evaluation. Eighty-one percent of the outcomes were rated as excellent. This initial report demonstrates that the method is a safe and effective treatment for acute, unstable, dorsally displaced fractures of the distal radius.

Adolescent↗
PubMed1996

Femoral neck fracture following intertrochanteric fracture.

Four patients with femoral neck fracture following healed intertrochanteric fracture were evaluated retrospectively. This situation is a rare occurrence with a current literature review documenting only 15 cases. Patient charts and radiographs were retrospectively reviewed to evaluate the period from initial injury to definitive treatment for the femoral neck fracture. Emphasis was placed on associated risk factors and operative techniques. In case 1, the femoral neck fracture appeared to be clearly a traumatic fracture as it occurred 11 years after the intertrochanteric fracture. In cases 2, 3, and 4, multiple factors were believed to play a role in the generation of the femoral neck fractures, which occurred within 6 months of the original fracture. The etiology of such fractures remains speculative. All four patients were elderly, women with substantial medical comorbidities. Osteoporosis may be the most important single contributing factor to these fractures. Because management of this patient subgroup is notably more complex, surgeons need to be aware of the difficulties and prepared to deal with them.

Aged↗
PubMed2004

[Talus fractures--fractures of the most important tarsal bone].

The talus is the key bone of the foot due to its location between the ankle and the subtalar joints. Through the flexion and extension of the ankle joint, the talus is the "propulsive bone" situated at the root of the first ray and the hallux. Through the subtalar and talo-navicular joints, the talus allows the foot to be "suspended" using a fancy spring mechanism involving ligaments and tendons. The talus thus transmits forces through two important joints without any direct muscular constraint. The talo-calcaneo-navicular joint may be called the "coxa pedis" due to the anatomical and functional similitudes with the coxofemoral joint ("coxa pelvis"). Fractures of the talus are rare. Talus fractures can be classified in "central" and "peripheral" fractures. Central fractures occur through a strong axial blow provided that the ankle and coxa pedis are locked by extrinsic muscular contraction. Peripheral fractures instead occur in an extreme position of the ankle or the coxa pedis, with a subluxation or complete dislocation of one or more of those joints. Central fractures produce a bony solution of continuity in between at least two of the ankle, subtalar and talo-navicular joints. Peripheral fractures mostly do implement joint surfaces which are sheared off. Aim of treating talus fractures is precise and stable reduction of the fragments because most often, the fractures cross the articular layers. The surgical approaches are critical, especially in displaced central fractures, because the reduction may require visual control all around the bone. There are three approaches which might be used as single approaches or combined simultaneously: the anteromedial approach along the subtalar joint from the navicular to the retro-malleolar region, the anterolateral approach centered on the sinus tarsi (Ollier) and the postero-lateral approach (Gallie). In many cases, a joint distraction device may help visualization of the different joint spaces as well as assist reduction of dislocations. Early joint mobilization, without weight bearing may be very profitable for good functional results. Aseptic necrosis (AVN) of the talus do not need special care if asymptomatic. On the long run, open operative arthrolysis might be added to the eventual removal of implants to considerably improve the results.

Adult↗
PubMed2002

Ulnar styloid fractures associated with distal radius fractures: incidence and implications for distal radioulnar joint instability.

Ulnar-sided injuries of the wrist have received more attention recently for their potential negative impact on the outcome of distal radius fractures. Radiographs and medical records were retrospectively reviewed for 166 distal radius fractures treated during a 1-year interval. Distal radius fractures were classified according to the AO system, and accompanying ulnar styloid fractures were evaluated for both size and displacement. Each distal radius fracture was also evaluated for radiographic and clinical evidence of distal radioulnar joint instability. The distribution of ulnar styloid fractures was not random; greater than one third involved the base. All distal radius fractures complicated by distal radioulnar joint instability were accompanied by an ulnar styloid fracture. A fracture at the ulnar styloid's base and significant displacement of an ulnar styloid fracture were found to increase the risk of distal radioulnar joint instability.

Adolescent↗
PubMed2005

Nonoperative treatment of displaced supracondylar fractures in children: Rigault type 2 fractures.

BACKGROUND: Current opinion in the medical literature concerning displaced supracondylar fractures of the distal humerus recommends pinning because with flexion braces there is a risk of both secondary displacement and Volkmann syndrome. PATIENTS AND METHODS: We analyzed 84 children with displaced supracondylar fractures. According to Rigault's classification, 30 children had grade 2 fractures, 21 had grade 3, 28 had grade 4 and 5 had multiple fragments, which were thus outside this classification. Fractures that could be reduced to a stable position under general anesthesia were treated with a posterior long arm splint with an average elbow flexion of 113 degrees (90-140). This technique was applied in 28 of the grade 2 fractures and in 4 of the grade 3 fractures, but in none of the grade 4 fractures. RESULTS: Of the 4 cases of Rigault grade 3 fractures treated nonoperatively, 3 had to be re-reduced and 1 needed an operation later on for varus correction. Of the 28 Rigault grade 2 fractures, 27 showed excellent results, and 1 had a good result. We advise nonoperative treatment in type 2 supracondylar fractures if stable reduction is achieved.

Child↗