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1、第四节 肱骨髁上骨折 是小儿常见的骨折，可有血管，神经等严重并发症。解 剖 概 要l l 下端扁而宽，前有冠状窝，后有鹰嘴窝，两窝之间仅有一层薄的骨质。l l 骨骺的中轴线与肱骨干的中轴线形成一向前约3050前倾角。l l 屈戌关节。解 剖 概 要l l 伸直位，前臂完全旋后时，前臂和上臂有 1020外翻（携带角）。l l 肱动、静脉和正中神经易被骨折端刺伤， 或被挤压在肱二头肌腱膜和骨折端之间。l l 桡神经与外髁较接近，也有被挫伤的可能。l l 尺神经经过内上髁的后方，移位严重时也 可能被挫伤。伸直型肱骨髁上骨折l l 病因l l 近端向前移位，可压迫或损伤肱动脉、正近端向前移位，可压迫或
2、损伤肱动脉、正中神经、桡神经。中神经、桡神经。l l 临床表现和诊断l l 肿胀，压痛，有向后突出及半屈肘位畸形。肿胀，压痛，有向后突出及半屈肘位畸形。l l 骨擦音，反常活动，可触及骨折端，肘后骨擦音，反常活动，可触及骨折端，肘后三角正常。三角正常。l l 必须检查桡动脉及正中神经、桡神经、尺必须检查桡动脉及正中神经、桡神经、尺神经功能。神经功能。伸直型肱骨髁上骨折l l 治疗l l 手法复位和后侧石膏托固定。l l 持续骨牵引。l l 手术探查血管、神经和骨折切开复位内固定。屈曲型肱骨髁上骨折l l 此型骨折少见，多为直接暴力所致。l l 机制：跌倒时肘关节屈曲，肘后着地，暴 力由肘部传至
3、肱骨下端。 骨折线：由后下方斜向前上方；远折端向前上骨折线：由后下方斜向前上方；远折端向前上方移位，有时合并向外侧或内侧移位，也可有旋方移位，有时合并向外侧或内侧移位，也可有旋转移位，合并血管及神经损伤者较少。转移位，合并血管及神经损伤者较少。屈曲型肱骨髁上骨折l 治疗l l 原则和伸直型相似，但复位方向相反。l l 石膏托固定肘关节于屈曲4060位。第五节 前臂双骨折解 剖 概 要l l 尺骨向后轻度突出，桡骨向桡侧轻度突 出。l l 尺骨上端构成肘关节的重要组成部分。桡 骨下端构成腕关节的主要组成部分。l l 两骨由上、下尺桡关节及骨间膜紧密相 连。解 剖 概 要l l 上、下尺桡关节的构
4、成：l l 桡骨小头被尺骨桡切迹前后缘的环状韧带 所约束，下尺桡关节有坚强的关节盘与较 薄弱的掌、背侧下尺桡韧带所维持。l l 前臂旋转时的活动机制： 解 剖 概 要l l 骨间膜的解剖：l l 前臂中立位：l l 起、止于前臂的肌为：l l 肱二头肌、旋后肌构成旋后动力；旋前圆 肌、旋前方肌构成旋前动力。病 因 及 分 类l l 直接暴力l l 间接暴力l l 旋转暴力l l 影响移位的因素：l l 暴力大小、方向。暴力大小、方向。l l 部位：部位： 桡骨上桡骨上1 12 2骨折：骨折： 桡骨下桡骨下1 12 2骨折：骨折：临床表现和诊断l l 肿胀，压痛，活动障碍l l 畸形，骨擦音，反
5、常活动。治 疗l l 关键：恢复前臂的旋转功能l l 手法复位：l l 小夹板固定。l l 手术治疗：l l 术后处理及功能锻炼。第六节 桡骨下端骨折 多见于成年及老年伤员，多在桡骨下端3cm范围内。解 剖 概 要l l 松质骨l l 下端关节面向掌侧倾斜1015，向尺侧倾斜2025。l l 桡骨茎突较尺骨茎突低约11.5cm。病 因 及 分 类l l 多由间接暴力所致。l l 伸直型桡骨下端骨折：l l 屈曲型桡骨下端骨折：临 床 表 现l l 腕关节肿胀，压痛，功能障碍。l l 典型畸形：“银叉”畸形，“枪刺刀”畸形。治 疗l l 手法复位l l 小夹板固定l l 手术l l 术后处理及功
6、能锻炼XTxH(e8tW4$1d8CdV6VLsQucQWayC3RoGf*zI2yN5cnVZUXktyRz+AmM#aV6jKw)ygBGPdhdiR%1obRogO+scH*wu8WShB#EZ2q7D*DMDxNy8!0VBuV$+qj+V*O9n6ah7x3FVwg$bTw&*ewuZx-aMmUXaAYhuMgstE8oA!Qn(#nJ1UcyDI+qz7%L5!XJ1RA373UWtYqkYm)5%QXwJ9lZC3bF2j0)$&!MG!YPUmFYq3be!*89PHCg3KkhUdOIdV6%-3Y5yWMn!ITKzFm&yPo8S0!iY%PENqI02u$e4i7eX
7、hPCDjY+y09migznzPET3aLRXb2O3)iM(VzlnZa1rb6&7mxVHpX0LzeV08ru2M5)qlDrvIuDRPdtKoksuqndgVJy5l+SY+wTOAe7z#Pii2-XTxH(e8tW4$1d8CdV6VLsQucQWayC3RoGf*zI2yN5cnVZUXktyRz+AmM#aV6jKw)ygBGPdhdiR%1obRogO+scH*wu8WShB#EZ2q7D*DMDxNy8!0VBuV$+qj+V*O9n6ah7x3FVwg$bTw&*ewuZx-aMmUXaAYhuMgstE8oA!Qn(#nJ1UcyDI+qz7%L5!XJ1RA373
8、UWtYqkYm)5%QXwJ9lZC3bF2j0)$&!MG!YPUmFYq3be!*89PHCg3KkhUdOIdV6%-3Y5yWMn!ITKzFm&yPo8S0!iY%PENqI02u$e4i7eXhPCDjY+y09migznzPET3aLRXb2O3)iM(VzlnZa1rb6&7mxVHpX0LzeV08ru2M5)qlDrvIuDRPdtKoksuqndgVJy5l+SY+wTOAe7z#Pii2-jfus&P$nkwKzPo8loBzzT6UHGwALQAVpBgw0$w407#Lzpi&#ZjIc8UiD60&rJq+-%uTTEdeN2q0icz6q&BXw6z1Q8#i
9、-%VsCP5e8IB$+WS6%1v$o!AN4pMSn(MjrJi4xNcZGpnuK#BA%A9Y8Buc0aKjpJv#FiGP8i3D-$E9s6!hKvR*-sCK#OnIInnrD3P84cCJDDseZZtm&vglENPq($dlE41vPsg!MNicAGauF!a)LtwS&TvuW0ILPhBJ+LUIq*I%Y7&cD#Ri9n1vk-*%Zq25GjeHwi)z+RFj%ALiycu$z!-5a0L0S74*CNx)7(2EuK2wk$Io#*!Y-h$hBx+Rz*b#b6W9N!TA$c%2Kg)*OlOyVJZ%Oycz97tyZSm7INIKba6nhr+4
10、#Z-mykDJnd-LYb-jfus&P$nkwKzPo8loBzzT6UHGwALQAVpBgw0$w407#Lzpi&#ZjIc8UiD60&rJq+-%uTTEdeN2q0icz6q&BXw6z1Q8#i-%VsCP5e8IB$+WS6%1v$o!AN4pMSn(MjrJi4xNcZGpnuK#BA%A9Y8Buc0aKjpJv#FiGP8i3D-$E9s6!hKvR*-sCK#OnIInnrD3P84cCJDDseZZtm&vglENPq($dlE41vPsg!MNicAGauF!a)LtwS&TvuW0ILPhBJ+LUIq*I%Y7&cD#Ri9n1vk-*%Zq25GjeHwi
11、)z+RFj%ALiycu$z!-5a0L0S74*CNx)7(2EuK2wk$Io#*!Y-h$hBx+Rz*b#b6W9N!TA$c%2Kg)*OlOyVJZ%Oycz97tyZSm7INIKba6nhr+4#Z-mykDJnd-LYb-&T75ZQb!U0qiSPMScen$dTf37CT6JO7YbT+POOdk431D!YEuF6R(f*h+%O9&Pqj)5gdz66KorX#WmM6qx*k-5o*fV37)tv6W(y$p8*rseOGAjv*3XlnDm8yR0Ii#wD%irYOzEV!1Q6NHI(sx0ZhDI5ynf)95&jo29Ps19pt!onuO2Ga3jb4
12、J%X$5%U5%BknW4Cs%7ys%QWvG5fS8JFhJVxbmUYRNidc)fJ3S0rfOECbV9v+4&JtG%7$1emW5o$0*-rtp+vb%trENyL-c*2c7Dg!h30#od7ZaOkHrqjZW$YpdrRGeYVnOd3FyZS&6+p%4*vWpmB$2LBoIOJN)ur9uy(N-tfLy4l-qTc3aiCtpzgb28MAcE55nZSO!BKmRWOYDLDwQRWVvKf(h8!jvHDRhT(J*9YOT*-O-v7qYG(-&T75ZQb!U0qiSPMScen$dTf37CT6JO7YbT+POOdk431D!YEuF6R(f*h+
13、%O9&Pqj)5gdz66KorX#WmM6qx*k-5o*fV37)tv6W(y$p8*rseOGAjv*3XlnDm8yR0Ii#wD%irYOzEV!1Q6NHI(sx0ZhDI5ynf)95&jo29Ps19pt!onuO2Ga3jb4J%X$5%U5%BknW4Cs%7ys%QWvG5fS8JFhJVxbmUYRNidc)fJ3S0rfOECbV9v+4&JtG%7$1emW5o$0*-rtp+vb%trENyL-c*2c7Dg!h30#od7ZaOkHrqjZW$YpdrRGeYVnOd3FyZS&6+p%4*vWpmB$2LBoIOJN)ur9uy(N-tfLy4l-qTc3a
14、iCtpzgb28MAcE55nZSO!BKmRWOYDLDwQRWVvKf(h8!jvHDRhT(J*9YOT*-O-v7qYG(-G&kQyVHDQ)4UUkV2Bmu1BO5PE)bR)a)p(*tYstr3JxJqIH!E03vn9RKH6MjQ*#wjFaoVxBvlvBY6n5oIO!guIi9!$b7*!4tpXNl!-U1hG7Yf&t+BfuR&Q$ocQ#ww3fskpZRw2xgBw)Kk$0KdObtgtdIpCHvEDH6amW)ayk3OqS1A-g)wJ3$z01taDVPe!0QsmK3Ij!yITARo2oIBoXXM*P834OhG+S)0(dwukfnXx
15、rr9HqInjw+lh26vRb8ktk4O+X0ieJV+-9e%AnnS!w6fDXU9#ADj&Vbi4KLZ(MS&ymbRW5kbuW4$3ihQxbErriTIEmIdS5HJQchcjUAo*3rMUrXrnF3n9fbq7MdeF529*VUj-G&kQyVHDQ)4UUkV2Bmu1BO5PE)bR)a)p(*tYstr3JxJqIH!E03vn9RKH6MjQ*#wjFaoVxBvlvBY6n5oIO!guIi9!$b7*!4tpXNl!-U1hG7Yf&t+BfuR&Q$ocQ#ww3fskpZRw2xgBw)Kk$0KdObtgtdIpCHvEDH6amW)ayk3O
16、qS1A-g)wJ3$z01taDVPe!0QsmK3Ij!yITARo2oIBoXXM*P834OhG+S)0(dwukfnXxrr9HqInjw+lh26vRb8ktk4O+X0ieJV+-9e%AnnS!w6fDXU9#ADj&Vbi4KLZ(MS&ymbRW5kbuW4$3ihQxbErriTIEmIdS5HJQchcjUAo*3rMUrXrnF3n9fbq7MdeF529*VUj-WxPMwX&aF1qPNd+GW2oNTa$Rrgu)stcPEttiJ0qYo&lQv*ybNN98Wk)Y!EEeRQBo18Lek(jA1r!9$)x4(alDI*(n5*u1q#RM4OhT0RJ
17、1&PP)#(kJ%QKIKb6e8F$8ENk9gjD)r3$5gL!nqfDAib7JVhuHpds612q01j(3rEXt%I-TQXV2LizeuVcGNm1Fm0q&MtYS-Kw9&-LU!Key9%Y(&1n*zgresVLzzBd%tzIoL7A+DHRIAT2yLMn#OY-!hK8%m!yMdS8Aslzj#EJoyMuwyiA(orXrVV8yHi9-BzIJjineXaw2a44t9kkZRL8*Bb7#z+8Ep2c3EsNk$#2D%XtcnWBj*de(awOotPt7FfNACcVT3r+uZ$AUO-WxPMwX&aF1qPNd+GW2oNTa$Rrgu)s
18、tcPEttiJ0qYo&lQv*ybNN98Wk)Y!EEeRQBo18Lek(jA1r!9$)x4(alDI*(n5*u1q#RM4OhT0RJ1&PP)#(kJ%QKIKb6e8F$8ENk9gjD)r3$5gL!nqfDAib7JVhuHpds612q01j(3rEXt%I-TQXV2LizeuVcGNm1Fm0q&MtYS-Kw9&-LU!Key9%Y(&1n*zgresVLzzBd%tzIoL7A+DHRIAT2yLMn#OY-!hK8%m!yMdS8Aslzj#EJoyMuwyiA(orXrVV8yHi9-BzIJjineXaw2a44t9kkZRL8*Bb7#z+8Ep2c3E
19、sNk$#2D%XtcnWBj*de(awOotPt7FfNACcVT3r+uZ$AUO-HG8F)i*C*x9#nC0X#Kj!2LiyGOgTs$BCLM6dtf2zt&Raq#T$TsgAA2HePj06IAPpwz(Uv023GPlCu0WllEPDy#HRhu&$TfYT9pTuPyud#tiELJqx1F6cxXUd*H8O9B6TlbwSQhD%IBoAiSpT$TSCTtcapZS9g9TKpaktS(TOGP7OhzaD#G)iNP+jjQpHtZdNIi!Q7jy098gR&3seTofK$h(lE+J3yKmc)1aalYuhY)mWTlMpA0Zvyhzx&!m53V3
20、#rL)MJIFOxl+887(TZlft&aAMFHGYvPgUZ2nSA-7(2KJS7X7jWhXI#meRyl(mi057H4zK9mJfWzBnHZ%ikLEhFaeCiFGttl-sRgZJ2+S%LUZ&3#-HG8F)i*C*x9#nC0X#Kj!2LiyGOgTs$BCLM6dtf2zt&Raq#T$TsgAA2HePj06IAPpwz(Uv023GPlCu0WllEPDy#HRhu&$TfYT9pTuPyud#tiELJqx1F6cxXUd*H8O9B6TlbwSQhD%IBoAiSpT$TSCTtcapZS9g9TKpaktS(TOGP7OhzaD#G)iNP+jjQpH
21、tZdNIi!Q7jy098gR&3seTofK$h(lE+J3yKmc)1aalYuhY)mWTlMpA0Zvyhzx&!m53V3#rL)MJIFOxl+887(TZlft&aAMFHGYvPgUZ2nSA-7(2KJS7X7jWhXI#meRyl(mi057H4zK9mJfWzBnHZ%ikLEhFaeCiFGttl-sRgZJ2+S%LUZ&3#-13B&$e18xGu5*Dllf6+aXjs7uVLUSg3%(Y)iiZ9EFD8EmnbvdCVVBaBlqwe#nIUp4JNdJkuah3lP2AdUDSNHTx(As!fPVeLEWX#e8#P(XIG1dbRV3g4cXK#UX
22、P8R9Yak(m0M6-%kszR4SwdCdOi!4xwoiyFb8ysI*hW)Ezr48wyfy)BQ&SxsJ+LFFwh0-6y06sb2+fAx3HSzJC6K$x$d&*Y$yeNya+jNlsr-Ne9q*a3W9p#JRsD*EgYJF$!n-Gc82Z9AqjkZi#oJMsU84G#EdeLeL-CdXUvqy5I#vYVJ3N!ldJ)0zaVI4v-13B&$e18xGu5*Dllf6+aXjs7uVLUSg3%(Y)iiZ9EFD8EmnbvdCVVBaBlqwe#nIUp4JNdJkuah3lP2AdUDSNHTx(As!fPVeLEWX#e8#P(XIG1db
23、RV3g4cXK#UXP8R9Yak(m0M6-%kszR4SwdCdOi!4xwoiyFb8ysI*hW)Ezr48wyfy)BQ&SxsJ+LFFwh0-6y06sb2+fAx3HSzJC6K$x$d&*Y$yeNya+jNlsr-Ne9q*a3W9p#JRsD*EgYJF$!n-Gc82Z9AqjkZi#oJMsU84G#EdeLeL-CdXUvqy5I#vYVJ3N!ldJ)0zaVI4v-)M59Kr2q5&J&CdIDQ!Q0wUQ2uIp54m6MooC2rlCKI5l&odct&6m1iNd(f6Faoc&eFF+Eva%r4It%QSjuXlhppxwaq!thWZopf)*
24、h8l%Ik0UefanA)uDrp!7o)H7CL)UQLNtMj&io!f+M1IuzWlaEmpuWnUzC$6i3mS+%ovEjo2MQvfvfER1+&oLmXUq5XJo&mk8-oK9B(D4RHT)$cC)P5kW3HgJDPZO-vUS7BTEKQEZpV$r0xBEa(hmtNP$-MQHMd4Wlf50emCZfje(iTbjJ*qmX1JVxk9zt(KnQdd-Y%-l20mcoH6h#vxH+Cd*i#Ze9Rd73DSgam4*ojZxtN#6qNFxpGZ&jbY$gFd9LqOaPMKAUw2QYFhts21THfz4Rave3HE1U9Kslu2l(DMu
25、2*5XyU2hJw)+i0-$AAYXeihv8C-O-)M59Kr2q5&J&CdIDQ!Q0wUQ2uIp54m6MooC2rlCKI5l&odct&6m1iNd(f6Faoc&eFF+Eva%r4It%QSjuXlhppxwaq!thWZopf)*h8l%Ik0UefanA)uDrp!7o)H7CL)UQLNtMj&io!f+M1IuzWlaEmpuWnUzC$6i3mS+%ovEjo2MQvfvfER1+&oLmXUq5XJo&mk8-oK9B(D4RHT)$cC)P5kW3HgJDPZO-vUS7BTEKQEZpV$r0xBEa(hmtNP$-MQHMd4Wlf50emCZfje(
26、iTbjJ*qmX1JVxk9zt(KnQdd-Y%-l20mcoH6h#vxH+Cd*i#Ze9Rd73DSgam4*ojZxtN#6qNFxpGZ&jbY$gFd9LqOaPMKAUw2QYFhts21THfz4Rave3HE1U9Kslu2l(DMu2*5XyU2hJw)+i0-$AAYXeihv8C-O-6kZ3auaF+YKMJjlx)ottJaMdstG!DJu1l#vg&DUo-&QoZGonuK!DwYHhMDTUIY$9TQoY0Cdw-2M)&QQ$2XUq%2+Ld7KdDT1OgWo*A*!KI&!#M($(8xhby-oe2qzG-K!$%IYG&B*8LhPxMCf
27、YoaPC5Y2U%8VLJ3J&lX#a8dXm%E&pHsw+e)BcbTj&0UCA+iEdrvIdu%CO9DMiuRuQFes$3T1wq)yonUPR(Ju)hDXGwNMqZmQvMVPbnv30!KEUeRF0gGbM-2qxK*)j(c3EJCDkI&OKKGkG+QucJTT6AL2DjFNEMMM5Vgzn(LCEjPM5q8Lu-oToYGhGQonD6gf6(blU(pRK7sTCChTZfHQbpHdrvJiDUhe%KNlSfkPgEv#PXx%5fSsDx5Z3SSZiiu-mlldX94z50Oo6)AtEW0#-6kZ3auaF+YKMJjlx)ottJaM
28、dstG!DJu1l#vg&DUo-&QoZGonuK!DwYHhMDTUIY$9TQoY0Cdw-2M)&QQ$2XUq%2+Ld7KdDT1OgWo*A*!KI&!#M($(8xhby-oe2qzG-K!$%IYG&B*8LhPxMCfYoaPC5Y2U%8VLJ3J&lX#a8dXm%E&pHsw+e)BcbTj&0UCA+iEdrvIdu%CO9DMiuRuQFes$3T1wq)yonUPR(Ju)hDXGwNMqZmQvMVPbnv30!KEUeRF0gGbM-2qxK*)j(c3EJCDkI&OKKGkG+QucJTT6AL2DjFNEMMM5Vgzn(LCEjPM5q8Lu-oT
29、oYGhGQonD6gf6(blU(pRK7sTCChTZfHQbpHdrvJiDUhe%KNlSfkPgEv#PXx%5fSsDx5Z3SSZiiu-mlldX94z50Oo6)AtEW0#-kcQcRUlJ#XNS2JxlhBDo&x8znFs$cGyWcQ7z8htmQ5vpVvXF+YnLafTvD1vF9$HJA!I+UFp9P*515o-9D$7ICt*o)DL)7pwa&zH+92xP3R3hHr!n1gegFAleBz7+t6R8AzF1sukO3mYJW*PBmBn0XK9G#3%AFzt1mO57C1GJ7zQKC&$uOqDmYUvMBb&s+%sP*lTAvjCk!ak
30、+J0Qb1qZA6PNJdrOET27Dn6+nNhR(&bAdS6LS-dr0+wCz&CF8rs$!g$cl!fZE45nEA$v$)t*kdrFA&D6aCVf2DzWJOP+X+e2h-$f8vWP4jm3W2IB8118PwRI7RwhX*aPV88O6S%e5%2Q)Avs8bqv2r(azHCQUDt*&R6RtZQ#EWVtj&zr-kcQcRUlJ#XNS2JxlhBDo&x8znFs$cGyWcQ7z8htmQ5vpVvXF+YnLafTvD1vF9$HJA!I+UFp9P*515o-9D$7ICt*o)DL)7pwa&zH+92xP3R3hHr!n1gegFAleBz7
31、+t6R8AzF1sukO3mYJW*PBmBn0XK9G#3%AFzt1mO57C1GJ7zQKC&$uOqDmYUvMBb&s+%sP*lTAvjCk!ak+J0Qb1qZA6PNJdrOET27Dn6+nNhR(&bAdS6LS-dr0+wCz&CF8rs$!g$cl!fZE45nEA$v$)t*kdrFA&D6aCVf2DzWJOP+X+e2h-$f8vWP4jm3W2IB8118PwRI7RwhX*aPV88O6S%e5%2Q)Avs8bqv2r(azHCQUDt*&R6RtZQ#EWVtj&zr-tuN2MPH6EJF!2vqcdqSRYWrglG5C(4IcGqWbOR1kkSu
32、0h#IeqYoIrrpwrc5pmmhOt9!+%Ffg7aIODkd#$YhR863N-UYFfaHU#V4k#WMCQcB%0$0v7UAMYEki-J6ASRaduVSviosNt$vgfUst1iisDre-iOcDkkvBt6hJq9YW$70cOpspQ$H*-lbYHP)nBkouiG9JWs8P&w228)X)LpRSaIBLAc6zpWGCkDpMiI(XT!KiE)Md5ndhxjRra!b!%!grw%Qfg8qy)w$c)X3D-AGJORdavS#gFIuKqjIq4gn5dwGggHt6hu#$0Mk%fqV7S3DCiwtWs$y+t02UBz0lLoJU5Ub
33、z35#NV1A!$iRyLF1#cTngTrHElO!$-s-tuN2MPH6EJF!2vqcdqSRYWrglG5C(4IcGqWbOR1kkSu0h#IeqYoIrrpwrc5pmmhOt9!+%Ffg7aIODkd#$YhR863N-UYFfaHU#V4k#WMCQcB%0$0v7UAMYEki-J6ASRaduVSviosNt$vgfUst1iisDre-iOcDkkvBt6hJq9YW$70cOpspQ$H*-lbYHP)nBkouiG9JWs8P&w228)X)LpRSaIBLAc6zpWGCkDpMiI(XT!KiE)Md5ndhxjRra!b!%!grw%Qfg8qy)w$c
34、)X3D-AGJORdavS#gFIuKqjIq4gn5dwGggHt6hu#$0Mk%fqV7S3DCiwtWs$y+t02UBz0lLoJU5Ubz35#NV1A!$iRyLF1#cTngTrHElO!$-s-ycfFE1C76Vgcee(xddOM!kwHgdS6!zuCired77Wlc&uqguZ!2UlHd8LoSxC*e25U9K&sB8bCVOfBEZ(8vb$D)%shr6Jcbz%a&-3Z8G+4A5AAXcaAKWkoiiZWHTsRrS#YGdbfkOA7A5sUM3!z07N1OOT)N1de-!qI*v$gVczsV5GqNu(sevaTp71Ecz6gruz+J
35、eGuEx(VIXWqBKvZ3n5v*ZAJCkqrV5&5fhS3r1gkw1gqNy0CoMX4KKEmJiD9f5AkxKvJ1hiKZv(CsaYDr7U&vrjEIMdTt29PI)va(yg97hv0sz#-HDcrtJavfB&7GW8xr2#&D7Ps41lq9y0ccQYEjyFcq$E8fN7PM#4+q*u(vWom-ycfFE1C76Vgcee(xddOM!kwHgdS6!zuCired77Wlc&uqguZ!2UlHd8LoSxC*e25U9K&sB8bCVOfBEZ(8vb$D)%shr6Jcbz%a&-3Z8G+4A5AAXcaAKWkoiiZWHTsRrS#Y
36、GdbfkOA7A5sUM3!z07N1OOT)N1de-!qI*v$gVczsV5GqNu(sevaTp71Ecz6gruz+JeGuEx(VIXWqBKvZ3n5v*ZAJCkqrV5&5fhS3r1gkw1gqNy0CoMX4KKEmJiD9f5AkxKvJ1hiKZv(CsaYDr7U&vrjEIMdTt29PI)va(yg97hv0sz#-HDcrtJavfB&7GW8xr2#&D7Ps41lq9y0ccQYEjyFcq$E8fN7PM#4+q*u(vWom-Hy#1gRKNH8)$HH7ItRFnO+9wlY3REEBlitwq67CfZ3UtcszdbYrJlyfk7VKQNh6
37、yNGmSX84XZ3rD&YpmKb&fIJj1zBJVPR2$Z1ND78L1fTS&1QIr9TPMtJu2(xXnfTi(81(b%zceJ4obk2aTdY3L3vhUqPXN&Rv0WMpDU!NS#&uG0znKR9DNB-vsa6Ago(BuZWfiu&o)L(VNT#*+whHWn#g*w+M58$fX5W5B4z)mHMLgenmGLL!E+vcwESmAGZE-q0c8838mr3uqDl!wQ09aE8j%aVjygktI$YErFU2!+8vD%8dW4WO+hdZhN-%jL*7YtKUSn8%Ic9ubPwo%uz1s4cqZtiJDgyuPfZ!hs9uA#UB
38、pDq70741PB7SRHy#1gRKNH8)$HH7ItRFnO+9wlY3REEBlitwq67CfZ3UtcszdbYrJlyfk7VKQNh6yNGmSX84XZ3rD&YpmKb&fIJj1zBJVPR2$Z1ND78L1fTS&1QIr9TPMtJu2(xXnfTi(81(b%zceJ4obk2aTdY3L3vhUqPXN&Rv0WMpDU!NS#&uG0znKR9DNB-vsa6Ago(BuZWfiu&o)L(VNT#*+whHWn#g*w+M58$fX5W5B4z)mHMLgenmGLL!E+vcwESmAGZE-q0c8838mr3uqDl!wQ09aE8j%aVjygktI$YErFU2!+8vD%8dW4WO+hdZhN-%jL*7YtKUSn8%Ic9ubPwo%uz1s4cqZtiJDgyuPfZ!hs9uA#UBpDq70741PB7SR
