Diagnostic and Interventional Imaging (2014) 95, 1035—1044

ICONOGRAPHIC REVIEW / Musculoskeletal imaging

Non-traumatic calcifications/ossifications of

the bone surface and soft tissues of the

wrist, hand and fingers: A diagnostic approach

a,∗ a,b a a

S. Touraine , M. Wybier , E. Sibileau , I. Genah ,

a,c a a

D. Petrover , C. Parlier-Cuau , V. Bousson , a

J.-D. Laredo

a

Radiologie ostéo-articulaire, hôpital Lariboisière, AP—HP, 2, rue Ambroise-Paré, 75475 Paris

cedex 10, France

b

Imagerie médicale Léonard-de-Vinci, 43, rue Cortambert, 75016 Paris, France

c

Centre d’imagerie Bachaumont, 6, rue Bachaumont, 75002 Paris, France

KEYWORDS Abstract In the absence of obvious trauma, the calcifications/ossifications of the bone sur-

Calcification; face and soft tissues of the wrist, hand and fingers can be challenging and may not be noticed or

Ossification; lead to unnecessary examinations and monitoring. Although these are usually benign conditions

Wrist; and despite a favorable spontaneous outcome, surgical resection may be required and recur-

Hand; rence may occur. In practice, only paraneoplastic syndromes such as secondary hypertrophic

Finger osteoarthropathy (Pierre Marie-Bamberger syndrome) may reveal a malignant tumor, most often

pulmonary. We suggest a diagnostic approach based on the initial clinical presentation (acute

pain, chronic pain, growth ± pain) and the radiological features.

© 2014 Éditions franc¸aises de radiologie. Published by Elsevier Masson SAS. All rights reserved.

Calcifications and ossifications that develop on the surface of bone and in the soft

tissue of the wrist, hand and fingers are usually benign. In practice, only paraneoplastic

syndromes such as Pierre-Marie-Bamberger syndrome may reveal a malignant tumor that is

usually pulmonary and cyanotic. Primary malignant tumors in the soft or paraosteal tissues

are rare in the wrist, hand and fingers. Acral metastases are rare and usually develop in

advanced, previously diagnosed tumoral diseases.

∗

Corresponding author.

E-mail address: [email protected] (S. Touraine).

http://dx.doi.org/10.1016/j.diii.2014.07.004

2211-5684/© 2014 Éditions franc¸aises de radiologie. Published by Elsevier Masson SAS. All rights reserved.

1036 S. Touraine et al.

The morphological features of these calcifications are

Table 1 Diagnostic table of calcifications of the soft tis-

less discriminant than the underlying anatomical structure

sues and the surface of the bones of the wrist, hand and

where they are located, an anatomical structure that is

fingers in relation to the initial clinical presentation.

not specific for the causative agent. The clinical features

(slow growing, swelling, acute or chronic pain) are essential Acute non-traumatic pain

diagnostic criteria (Table 1) to help determine the location Hydroxyapatite deposit

and morphology of these calcifications or ossifications. In Florid periostitis - Nora’s lesion - Turret exostosis

the absence of any obvious trauma, and because of the Myositis ossificans circumscripta

many different possible benign conditions, it is important

Chronic pain

to help the clinician define those that may require surgical

Tendinosis — Mechanical enthesopathy

management (osteochondromatosis, Nora’s lesion, vascular

Psoriatic arthritis

malformation, calcifying aponeurotic fibroma), those that Osteochondromatosis

may reveal a metabolic disorder or a systemic disease (cal-

Calcium pyrophosphate dihydrate crystal deposition

cium pyrophosphate dehydrate crystal deposition disease,

disease (CPPD)

gout, kidney failure, connective tissue disease, psoriatic Gout

arthritis) and those that can be treated symptomatically

Connectivitis (Scleroderma/CREST - Dermatomyositis)

(hydroxypatite crystal deposits, tendinosis).

Chronic renal failure

Pierre Marie-Bamberger syndrome

Swelling ± pain

Context of non-traumatic acute pain

Chondroma

Hydroxyapatite crystal deposits Vascular malformation

Calcifying aponeurotic fibroma

Hydroxyapatite is one of the most stable forms of basic cal-

cium phosphates (Fig. 1). It is naturally present in bone,

enamel and dentin, where it is the main mineral component.

An acute and solitary periarticular, peritendinous or intraar-

ticular hydroxyapatite deposit may occur, possibly due to

Figure 1. Acute deposits of hydroxyapatite crystals in the soft tissues of three different patients: on conventional radiography at the base

of P1 of the 2nd ray (arrow) (A), on axial CT scan at the distal insertion of the extensor carpi radialis longus muscle on the 2nd metacarpal

base (arrow) (B), on conventional radiography (arrows) (C), ultrasound (D) and Doppler ultrasound near the triquetral bone and the distal

insertion of the extensor carpi ulnaris (E). Note on ultrasound the echogenic mass with the calcium spots and no posterior shadow cone

(D-star) and the Doppler hyperhemia consistant with the local inflammation (E).

Non-traumatic calcifications/ossifications 1037

local hypoxia leading to crystalline precipitate. Recent, or

fairly recent traumas are found in certain cases when the

patient is questioned.

Theoretically this acute deposit may develop anywhere,

but certain zones are more common (‘‘disease with cal-

cium phosphate crystals in multiple tendons’’), such as the

apophyseal insertion of the greater or lesser tuberosity of

the humerus, the deltoid V-shaped tendinous confluence and

insertion on the deltoid tuberosity of the humerus, the inser-

tion of the gluteus maximus on the linea aspera as well as

the cervical spine (periodontoid soft tissue and transverse

ligament of the atlas, insertion of the long muscle of neck).

The calcification may be located in the tendon, its sheath

or in the adjacent serous bursa. The sudden inflammatory

reaction associated with partial or total resorption of this

calcium deposit is the cause of the violent clinical reaction

as well as the biological inflammatory syndrome. These cal-

cium crystal deposits may also be found in the wrist, the

hand or the fingers, although this is less frequent, where

they may mimic arthritis or tenosynovitis [1]. The insertion

Figure 2. X-ray of a florid periostitis of the 5th finger at 3 month

of the flexor carpi ulnaris on the pisiform bone is frequently

intervals. A. Periosteal growth begins on the radial aspect of

involved in the wrist [2]. Whatever the location is, these

P1(arrow). B. Large long bone growth (arrows) along the axis of the

deposits are often solitary or fragmented, fairly round or

phalangeal diaphysis causes bone enlargement (courtesy of Dr Anne

oval shaped, of irregular density, milky and without trabe- Miquel, Hôpital Saint-Antoine, Paris).

cular or cortical bone, differentiating them from a process of

ossification. Cortical erosions may be found in contact with

painful mass that mainly affects the hand (55%), the long

the deposits. Intramedullary penetration with an cancellous

bones (27%) or the feet (15%). The ossified mass may

bone edema may be observed especially on the femoral or

have a pedunculated or sessile attachment to the under-

humeral diaphyses. The outcome is usually favorable within

lying periosteum, with no periosteal reaction or medullary

several days. In the hand or fingers, persistent deposits may

continuity. The histological analysis shows fibrous tissue,

require surgical resection because of discomfort, swelling,

cartilage, areas of enchondral ossification and a clear cap

or impingement of adjacent anatomical structures.

of cartilage in certain cases. There is a high degree of cellu-

larity with no atypia. Surgical resection is usually performed

but there is a risk of recurrence.

Proliferative periostitis, Forid reactive

Turret exostosis (Fig. 4) is a bone growth that develops

periostitis, Nora’s Lesion, Turret exostosis

on the surface of the bone, usually on the dorsal aspect

of the proximal or middle phalanx. It is a result of a minor

These entities may be expressions of the same disease. They

trauma of the deep aspect of the extensor tendon of the fin-

may be diverse presentations of so-called reactive periosteal

ger resulting in a subperiosteal hematoma, which ossifies as

lesions that are observed on radiographic imaging at differ-

it progresses. [5]. Turret exostosis is attached to the perios-

ent times [3]. A traumatic or microtraumatic origin of these

teum with a sessile base and has a cartilage peripheral cap

entities is a subject of debate, because trauma is not always

[6] which, for some authors, suggests a lack of ossification

reported. These different lesions are usually found in the

because of the distance from the periosteal vascularization

extremities and in particular the proximal phalanges of the [3].

fingers.

Florid periostitis (Fig. 2) begins with painful swelling of

Myositis ossificans circumscripta

the soft tissues (dactylitis) associated with a periosteal reac-

The term myositis ossificans circumscripta (MOC) corre-

tion that progresses along the phalangeal diaphysis within

sponds to a sudden process of heterotopic ossification that

several weeks. It may be circumferential and mimic an infec-

is preceded in certain cases by often minor injury. In fact,

tious (osteomyelitis) or tumoral (osteosarcoma) process in

the term is not accurate because this ‘‘osteogenic storm’’

the bone [4]. The periosteal lesion is often compact and

can occur outside the muscle, in contact with the fas-

irregular with a crenelated appearance that may result in

cias, the tendons or the adipose tissue. MOC usually occurs

fusiform enlargement of the phalanx. Cortical erosion has

in the deep tissue in contact with the large muscles of

occasionally been described in contact with the periosteal

the extremities. Moreover, this process does not initially

lesion. Unlike exostosis, the lesion progresses and produces

involve inflammatory cells [7]. The pathological examination

more mature bone with no visible continuity with the

shows that MOC is organized into zones with proliferation

medullary canal of the underlying bone. Histologically, dif-

of fusiform pseudosarcomatous cells during the first week

ferent quantities of fibrous tissue, cartilage and an osteoid

followed by the development of annular ossification which

matrix are visible associated with a proliferation of fibrob-

progresses centripitally. The development of MOC is rare in

last/myofibroblast cells.

the hand, although a few cases have been reported in the

Clinically, bizarre parosteal osteochondromatous prolif-

literature [8—11].

eration or Nora’s lesion (Fig. 3) presents as a moderately

1038 S. Touraine et al.

Figure 3. Nora’s lesion of the 4th finger. A. and B. CT scan (A) and CT volume rendering (B) show periosteal growth on the radial aspect

of P2. C. Coronal MR T2 STIR-weighted image shows the lesion with a hyperintense cartilaginous matrix (arrow). D. Axial CT scan shows a

partially ossified lesion attached to the periosteum of the phalanx. E. and F. Axial MR scan shows the lesion with a cartilaginous component

in intermediate intensity on T1-weighted image (E) and hyperintensity on T2-weighted image (F) (courtesy of Dr Anne Miquel, Hôpital

Saint-Antoine, Paris).

Context of chronic pain

Tendinosis and mechanical enthesopathy

Although it is not a separate pathological entity, mechanical

enthesopathy may be associated with calcifications and/or

periostosis. It is rare in the hands or fingers. It usually

involves the insertion of the extensor and flexor carpi radi-

alis on the dorsal and ventral 2nd and 3rd metacarpal bases,

respectively. In the wrist, it involves the flexor carpi ulnaris,

which is the only extrinsic muscle of the wrist that inserts

on the carpus (pisiform). Injury to the radial extensors is

favored by the presence of a carpal boss, which develops

due to the presence of an accessory ossicle (os styloideum)

or the presence of osteophytes due to osteoarthritis of the

2nd or 3rd metacarpal bases in contact with the trapezoid

and the capitatum [12]. Distal enthesopathy of the flexor

carpi radialis is usually associated with trapezio-metacarpal

or scapho-trapezio-trapezoidal osteoarthritis.

Psoriatic arthritis

Psoriatic arthritis is an asymmetric mono- oligo- or pol-

Figure 4. Turret exostosis of the 2nd finger. A. Conventional radio-

yarthritis that affects the small joints, in particular the

graphy shows bone growths (arrow) developed on the ulnar aspect

interphalangeal joints of the hands and feet (Fig. 5). In 25%

of P1 with a sessile attachment to the periosteum. B. Coronal MR T1-

of cases, it affects one or several fingers, involving different

weighted image shows a lesion with an ossified base in hypointensity

and a cartilaginous cap with intermediate intensity. C. Coronal MR joints (MCP, IPP, IPD) of a same digital ray. Clinically there

T2 STIR-weighted shows the peripheral cartilaginous cap in high is dactylitis. Psoriasis of the skin, scalp or nails is an impor-

hyperintensity (arrow) (courtesy of Dr Samir Benadjaoud, Hôpital tant diagnostic feature. Nevertheless, arthritis may precede

Saint-Joseph, Paris).

the skin condition in 10% of cases. The rheumatoid factor is

Non-traumatic calcifications/ossifications 1039

Figure 5. Psoriatic arthritis. A. X-ray of the fingers shows reactive hyperostosis involving the diaphyses and the phalangeal apical tufts

(arrows) associated with bone erosions (arrowhead). B. Periosteal calcifications involving the distal radioulnar articulation (arrows).

always negative. Radiography shows bone resorptions and

hyperostosis. Extended periostosis appears as bone wispy

and dense outgrowths (whiskering and spurs respectively)

associated with marginal articular erosions and enthesitis

[13] that may even be visible at a distance from the joint,

for example on the radial styloid process [14]. These bony

outgrowths should not be confused with the short bone spurs

that may be visible on the tendon insertions on the lateral

sides of the proximal phalanges, which are normal variants

[15] and have no clinical significance.

Osteochondromatosis

Synovial osteochondromatosis is a primary or secondary

osteocartilaginous metaplasia of the synovial tissue (Fig. 6).

It may involve the joint or the synovial membrane of a ten-

don or bursa. In the hand and wrist, osteochondromatosis

mainly involves the joints of fingers or the flexor tendon

sheaths [16,17].

Intraarticular osteochondromatosis is rarer in the wrist or

hand than in the knee, hip, elbow, shoulder or ankle. How-

ever, because of an extensive synovial territory, the tendon

sheaths of the hand are frequently involved [18]. Conven-

tional radiography identifies the soft tissue swelling and the

presence of more or less calcified loose bodies. Erosion of

the cortical bone (‘‘scalloping’’) in contact with the loose

bodies may be found. Treatment includes a synovectomy and

excision of the loose bodies. Postoperative recurrence is fre-

quent and may occur at a distance from the initial location

along the tenosynovial sheath. [19].

Calcium pyrophosphate dihydrate crystal

deposition disease (CPPD)

Diverse clinico-radiographic presentations are observed

from solitary articular and para-articular calcifications to

Figure 6. Articular and tenosynovial osteochondromatosis in

arthropathy with articular degeneration. Chondrocalcinosis

two different patients. A. CT scan of the thumb shows numer-

is defined by the presence of hyalin cartilage and fibro-

ous interphalangeal articular loose bodies (arrows). B. Sagittal MR

cartilage whatever the type of crystal is, although it

T2-weighted image of the thumb shows interphalangeal articular

usually involves CPPD crystals. Most diseases involving CPPD effusion (arrow). C. and D. Sagittal and axial CT scan show several

deposits are sporadic forms and usually involve women over ossified loose bodies involving the superficial flexor tendon sheath

the age of 50, usually after the age of 70. In younger (arrows).

1040 S. Touraine et al.

patients, a family form of the disease should be looked for is more frequent than that of metacarpo-phalangeal joints.

which usually develops between 20 and 40 years old (with a Involvement is asymmetric associating erosions and bone

predominance in France in Alsatian families) or a secondary spurs (enthesophytosis and osteophytosis) [22].

form (revealing hyperparathyroidism, hemochromatosis or The association of gout and para-articular CPPD deposits

hypomagnesemia in particular) [20]. is possible in particular in the fingers. In this case, the cal-

The disease may be asymptomatic (10—20% of cases) and cifications are related to CPPD crystals, and not the result

discovered by chance on X-ray. CPPD can also mimic a degen- of gout tophus calcifications.

erative arthropathy (pseudo-arthritic appearance on X-ray

in 35—60% of cases) with bilateral symmetric polyarticular Connectivitis

involvement. More rarely, a rapidly degenerative arthropa-

thy may also be observed. In 10—20% of cases, the clinical

Calcinosis of the soft tissues (calcinosis cutis) is frequently

features include pseudo-gout, acute arthritis, occasional

associated with connectivitis and more particularly with sys-

fever, and significant local inflammation.

temic scleroderma and dermatomyositis [23] (Fig. 8).

Calcifications of the periarticular soft tissues involve the

Scleroderma is a disease of the connective tissue, arte-

synovial membrane, the capsule, the tendons and the lig-

rioles and microvessels resulting in fibrosis and vascular

aments. They are thin and linear. Synovial calcifications

obliteration. It is characterized by the presence of anticen-

are located throughout the joint space and form ill-defined

tromere or antitopoisomerase I antibodies. There is a diffuse

blurry opaque calcifications of low density. The metacarpo-

and progressive form and a form that is more limited to

phalangeal joints are frequently involved in the hand. In the

the cutaneous tissues named CREST syndrome (abbreviation

wrist, synovial calcifications are mainly radiocarpal at the

for Calcinosis, Raynaud’s syndrome, Esophageal dysmotility,

carpal triangular fibrocartilaginous complex and the distal

Sclerodactylia and Telangiectasia). Both forms can present

radioulnar joint. Tendinous calcifications are found along the

with calcinosis of the soft tissues, which is frequent in the

main axis of the tendon, and may have a stratified appear-

hand, and which corresponds to aggregates of sometimes

ance. Real calcified masses may be visible in the soft tissues

large, pseudotumoral hydroxyapatite crystals. The phys-

and can mimic gout [21] (Fig. 7).

iopathogenisis of these deposits is a subject of debate. They

are painless, may become ulcerated and in this case have a

Gout chalky appearance. Osteoarticular involvement is possible

and includes erosive and degenerative arthritis with epi-

physeal erosions, joint space narrowing and acro-osteolysis

Osteoarticular involvement in gout corresponds to the

[24].

presence of intra- or para-articular monosodium urate crys-

Dermatomyositis is a diffuse inflammatory myopathy that

tals. This is the sign of chronic hyperuricemia, above the

is found in children in 50% of cases and adults around

monosodium urate saturation point, which causes the slow

40 years old, especially men. There is a bilateral symmet-

formation of crystals. Except for secondary forms and enzy-

ric and proximal motor deficit of the limbs associated with

mopathies, primary gout is usually found in men over the age

cutaneous symptoms including subcutaneous calcinosis. This

of 40. Tophi usually develop several years after the onset of

calcinosis is especially frequent in the pediatric form of

symptoms and are tissue deposits of urea whose volume is

the disease. Calcifications are linear and curved, mainly

correlated to the level of hyperuricemia and the duration of

observed in the knee, elbow and fingers, sometimes asso-

disease without treatment. Calcifications occur later with

ciated with a milky liquid discharge and resorption of the

variable densities. Subcutaneous tissues, tendons, paraar-

tips of the distal phalanx. Muscle calcifications are mainly

ticular soft tissues, and osteoarticular tissues are involved

observed in the proximal limbs and intermuscular fascias

while the joint is preserved for a long time. In the hand,

[25].

involvement of interphalangeal joints (proximal and distal)

Figure 7. ‘‘Pseudo-tophus’’ of calcium pyrophosphate dihydrate (CPPD) crystals. Coronal (A) and axial (B) CT scans of the calcified mass

(arrows) that has eroded the metacarpal cortex and penetrated the medullary canal.

Non-traumatic calcifications/ossifications 1041

Figure 8. Numerous calcifications (arrows) of the soft tissues of the fingers in scleroderma (CREST syndrome) (A) and dermatomyositis

(B).

Chronic Renal failure sheaths involving the phalanges, the metacarpal and carpal

bones and the diaphysis of the long bones.

Hydroxyapatite deposits are found in the soft tissues of

patients with chronic renal failure (Fig. 9). The frequency

seems to increase with the duration of the renal fail-

More or less painful swelling

ure and dialysis of patients. They are due to secondary

hyperparathyroidism, the increase in phosphocalcium and Chondromas

alkalosis. These deposits form round or oval radio-opaque

aggregates, usually located in the para-articular areas of Bone chondromas (enchondromas, subperiosteal chondro-

the shoulder and wrist and the interphalangeal joints of the mas) frequently involve the fingers (Fig. 11). They may be

fingers, hips and ankles [26]. They are usually asymptomatic solitary or multiple in enchondromatosis (Ollier’s disease).

but may be associated with joint pain and osteodystrophy. They may be asymptomatic or revealed by a stress fracture.

Calcium oxalate crystals may also be visible in cartilage, the They can grow within the bone and expand it presenting

synovial membrane, the joint capsule and the periarticular extraosseous growth that clinically appears as a deformed

and subcutaneous soft tissues [27]. These calcifications may finger. Chondromas with an epicenter in soft tissues are

be cloudy, reticulated, or punctuate depending on the tis- rare except for chondromas of the respiratory tract and

sue they are located in. Secondary oxalosis is favored by remnants of cervical cartilage of the brachial fissures. In

vitamin C supplements, for which oxalate is a catabolite. most cases, they occur in the extremities, the hands in

Finally, vascular calcifications are frequent in chronic renal 54—64% and the feet in 20—28% of cases. This benign tumor,

failure in relation to arteria media calcification, which may which is usually solitary, is a firm, mobile, slow growing

be seen on radiography and earlier on ultrasound [28]. mass that may be painful, and may adhere to the joint cap-

sule or the tendon sheath [30]. The MR scans show a lesion

with hyperintensity on T2-weighted images and a hypo- or

isointensity on T1-weighted images that is more or less het-

Hypertrophic pulmonary osteoarthropathy erogeneous depending on the extent of mineralization [31].

Post-contrast enhancement is usually peripheral and septal,

(Pierre Marie-Bamberger syndrome)

highlighting the lobulated architecture of the tumor [32].

Calcifications are visible in 33% - 77% of cases on radiogra-

This syndrome is generally associated with a cyan-

phy or CT scans and may suggest the mineralization pattern

otic pulmonary condition, which may or may not be

of a chondroid matrix [33]. These calcifications are usually

tumoral (Fig. 10). Non-tumoral causes include cyanotic car-

‘‘pop-corn’’ like with rings and arcs but may be punctiform

diopathies, chronic respiratory failure, and cystic fibrosis.

depending on the maturity of the tumor. They are central or

However, this syndrome is frequently paraneoplastic, asso-

peripheral defining the lobulated architecture of the lesion.

ciated with lung cancer, which it may reveal [29]. VEGF

The chondromas in fingers are less often calcified which may

(Vascular Endothelial Growth Factor) and PDGF (Platelet-

be due to an earlier clinical diagnosis.

Derived Growth Factor) are probably involved in the

pathogenesis of this disease. VEGF is secreted during chronic

hypoxia and by the tumor itself. Clinically, joint stiffness Vascular malformation

is frequent. Arthralgia and joint effusion associated with

hypertrophic wrists, hands and digital clubbing are also Vascular malformations may be found throughout the body

observed. Periostitis is visible on conventional radiogra- but are more often found in the pelvis, the limbs and the

phy with a periosteal proliferation forming peridiaphyseal skull (Fig. 12). Fifty to sixty-six percent of the lesions are

1042 S. Touraine et al.

Figure 9. Calcium deposits in a dialysis patient with chronic renal failure. Oval shaped, cloudy calcified masses (arrows) of the phalanges

of the toes (A) and fingers (B).

Figure 10. Hypertrophic pulmonary osteoarthropathy (Pierre Marie-Bamberger syndrome) associated with a bronchopulmonary carcinoma.

Periosteal proliferation with peridiaphyseal sheaths involving the radius and ulna (A) and the metacarpal bones (B).

Figure 11. Enchondromatosis (Ollier’s disease) involving the fingers (amputation of the right 5th and left 3rd fingers). A. On conventional

radiographs, the enchondromas appear as bone radiolucent and expanding lesions of the phalanges particularly visible on the 3rd and 4th

rays of the right hand and phalanges of the 2nd left finger. B. The extraosseous expansion of the chondromas of the 2nd left finger accounts

for the swelling and calcifications of the soft tissues (arrows).

Non-traumatic calcifications/ossifications 1043

Figure 12. Numerous phleboliths related to a large venous malformation involving the forearm and the palmar aspect of the hand, visible

on conventional radiographs in anterior-posterior view (A) and sagittal view (B) (courtesy of Dr Annouk Bisdorff, Hôpital Lariboisière, Paris).

venous malformations. In the hands and feet, only 10% of symptoms. The clinical presentation is essential to narrow

vascular malformations are arteriovenous [34]. down the diagnostic possibilities and must be considered in

Venous malformations or those with a main venous com- relation with the anatomical location and imaging features.

ponent (because they may be associated with lymphatic or

capillary vessels) are usually diagnosed in the upper limb

distal extremity because of their coloration that is more or

Disclosure of interest

less blue when it is superficial. These venous malformations

frequently show phleboliths (visible on X-ray or CT scans)

The authors declare that they have no conflicts of interest

that must not be confused, on MR images, with flow voids

concerning this article.

that are related to the rapid flow in arterial vessels [35].

Calcifying aponeurotic fibromas

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