If more information is needed, they might also order a CT (computed tomography) scan. Why Wont My Dog Eat After Surgery? Stronger types of painkillers must be taken at their proper dosage to avoid addiction and dependence. 12 hours after the accident which left me with a 11x420mm Stryker titanium rod inside the right femur. She is a practicing Physician and taught as a Clinical Professor for 13 years, after receiving her MD from the University of Wisconsin-Madison School of Medicine and Public Health in 1998. If you have any questions about the surgery, you can ask your surgeon. The influx of all of these cells to the area causes more swelling. The femur bone is also known as the thighbone located in your thighs and it is one of the largest bones inside the human body. Include your email address to get a message when this question is answered. In some cases, the patient may be allowed to return to normal weight for a period of up to 6 months after surgery. What You Should Know About Primary Lateral Sclerosis. Were committed to providing the world with free how-to resources, and even $1 helps us in our mission. If you have broken your femur, there are few things you can do to get yourself on the road to recovery, starting with surgery. A femur fracture, or broken thigh bone, is an injury that can result from high-energy trauma, such as a fall from height, a motor vehicle accident, or a direct blow to the leg. When internal fixation is performed, partial weight-bearing is recommended for a period of 8-10 weeks (according to the radiological evaluation of fracture healing), and after 3 months full weight . However, most people will fully recover in three to 12 months. 5 How long does it take to recover from a femur fracture? A retrospective review of charts associated with patients 65 years and older after hip fracture surgery addressed this question. . Retrieved from. A physical therapist will work with you to improve your mobility, the strength of surrounding muscles, ability to walk, and balance with various leg exercises. Acetaminophen (Tylenol) is usually the drug of choice. When you visit the site, Dotdash Meredith and its partners may store or retrieve information on your browser, mostly in the form of cookies. However, others that completely break the bone, cause the bone to be crushed or displaced need immediate surgery. Is walking after a femur fracture impossible? Symptoms of a Broken Knuckle & What To Do About It, American Academy of Orthopaedic Surgeons. I was not limping and now every time I get up to walk, I limp for the first few steps. Massage may also be used to ease muscle pain. 2020;32(3):125-131. doi:10.5371/hp.2020.32.3.125. The American Academy of Orthopaedic Surgeons recommends a waiting period of 4-8 weeks post-surgery before recommencing driving in an automatic car. . Board Certified Family Medicine Physician. In the case of lower extremity surgery, more swelling occurs because the leg is dependent, that is, well below the level of the heart. Hip Pelvis. Many surgeons dont allow their patients to weight bear for the first 6 weeks after surgery because of the risk of a blood clot in the knee joint. After surgery, the leg is put in a cast or set in a brace, for about 8 weeks. My Dog Wont Walk On Hardwood Floors Check This First, Is Washington Dc Safe To Walk At Night? The 1-year mortality rate after hip fracture surgery of 12-33% is high, up to eight times the normal mortality rate for people aged 80 [3, 7, 8]. The healing process typically takes up to six months, going through four phases: The majority of broken femurs require surgery and medication. Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. When do you need surgery for a femur fracture? [2] The most common surgery for a broken femur is called intramedullary nailing. Do a total of three sets of 10 repetitions. 3 Look into internal fixation. Follow all the instructions provided to you by the doctor and try to visit the doctor periodically. If you cant do this, then you need to do a lot of exercises to strengthen the muscles around the knee. Surgeries are routinely effective and people are typically able to completely heal from a broken femur. 2023 Dotdash Media, Inc. All rights reserved. I have just had replacement surgery of the rod, "The entire article was fully detailed and had step-by-step instructions for recovery.". Physical therapy is often needed for a femur fracture to heal properly. It does depend on reason and severity of the break and also the individual; both for the individuals healing ability and also how closely they follow any physio exercises and activity instructions. Rehabilitation for a femur fracture should start as soon as possible. What is the fastest way to heal a broken femur? (Check This First) Walking Patients are usually advised not to put any weight on the leg for about 8 weeks if the femur does not require surgery. Loose implant, infection, and pelvic fracture require a surgical evaluation and probable additional surgeries. Rehabilitation After Femur Fracture Surgery The patient may not be able to bear weight on the leg for up to 12 weeks. A fracture in the thigh bone can bring about the following symptoms: Inability to stand or move the leg Swelling in the hip region Bleeding from an open wound Deformity of the thigh bone region Hematoma Thigh muscle spasms Tingling or numbness in the leg Diagnosing the condition This is a serious injury that is usually diagnosed by a physician. In orthoinfo.aaos.org. The patient may not be able to bear weight on the leg for up to 12 weeks. PMID: 30719846 DOI: 10.1002/pmrj.12117 No abstract available . Other things like physical fitness and your age will also have some effect on the healing process. After Ankle Surgery: How Long To Walk Complete Explanation, After Acl Surgery Can You Walk Easy & Clear Answer, List Of Foods To Eat After Appendix Surgery Helpful Examples. Visiting the doctor once in a while would be great because if your body is not responding to the treatments and medicines then in that case it could lead to more serious issues. ACS can cause permanent muscle and nerve damage. At a mean of 21 months after operation 33 patients had residual pain severe enough to interfere with their lifestyle or mobility. Patients are usually advised not to put any weight on the leg for about 8 weeks if the femur does not require surgery. Most femoral fractures take about 4 to 6 months to heal completely, but you should be able to resume your normal activities within a few weeks. Retrieved from, Medical News Today (2012, July 31). extension. During recovery from a femur fracture, you will need crutches or a walker to help support your body weight and limit the pressure on your leg when walking. How Long A Person Can Hold Their Breath (And Why)? The body regenerates with new bone growth. A physical therapist can help the patient walk using crutches or a walker, or they may be able to use a wheelchair. Walking for 3 to 5 miles (4.8 to 8.0km) per week is also encouraged. Surgery is a major cause for blood clots (" deep vein thrombosis "). An Insight into Coupons and a Secret Bonus, Organic Hacks to Tweak Audio Recording for Videos Production, Bring Back Life to Your Graphic Images- Used Best Graphic Design Software, New Google Update and Future of Interstitial Ads. I'm 89 years old, but I found your article extremely helpful---with, "Helped to explain what my sister will need to do when she is discharged from hospital after broken femur and hip, "It helped me with exercises that I can continue with after surgery. MDR REHAB DELRAY BEACH 601 NORTH CONGRESS AVENUE. Pain management following a serious femur fracture is a challenge that must be addressed using a comprehensive treatment approach. Putting weight on your leg to stand up or walk will be incredibly difficult and painful, if not impossible. Can You Drink Water Before Wisdom Teeth Surgery? 3, 6, 7, 16 Long-term studies (16-44 months postinjury) documented that following both conservative 3 and surgical 6, 7, 16 management of femoral fractures, significant residual quadriceps femoris muscle weakness persists. It is now 8 weeks from surgery and I have pain/tightness at the top of my thigh, right at the connection point to my hip and my outer buttocks muscles are still feeling kind of weird and weak. Your doctors may see signs of healing on x-rays about 6 weeks after surgery, but it normally takes 3 months or more for the femur to fully heal. This means that you may need to take time off work or school to recuperate from your injury. If you or a family member is struggling with pain management following a severe bone fracture, please call me at (916) 921-6400 or (800) 404-5400 for free, friendly legal advice. If you are a beginner, I recommend you start with exercises that are easy for you and gradually work your way up to more difficult exercises. How To Start Walking Again? But does it work and what are. Is hip fracture surgery high risk? It is normal to have some pain for 2 to 3 weeks after surgery and mild pain for up to 6 weeks. Your doctor will tell you what type of surgery is needed and how much it will cost. Itll be very helpful for me, if you consider sharing it on social media or with your friends/family. Older adults can fracture their femur from a fall because their bones tend to be weaker. This article was medically reviewed by Janice Litza, MD. Without proper rehabilitation, complications such as chronic pain, inflammation and weakness, may cause difficulty walking and performing physical activities. X Kristen Gasnick, PT, DPT, is a medical writer and a physical therapist at Holy Name Medical Center in New Jersey. the nurse advises the client who has had a femoral head prosthesis placement on the type of chair to sit during the first 6-8 weeks after surgery. Place the middle and pointer finger on the inner quadriceps in order to feel the tightening of muscles. Lee KJ, Um SH, Kim YH. Doc told me it was at least a 12-week recovery for weight bearing to start. BShI p O p ONATES AfTEr hIp frACTUrE SUrgEry density at the hip was noted at 12 months in all cohorts. Your surgeon inserts screws into your bone. Cookies collect information about your preferences and your devices and are used to make the site work as you expect it to, to understand how you interact with the site, and to show advertisements that are targeted to your interests. A broken femur will usually have a major effect on your life, but only temporarily. Recovery times vary for each patient, but most individuals can return to all normal activities within 4 to 6 months. First you must follow ALL the directions of your physician, but usually after a femur surgery you must do some rehabilitation, but you could star walking as soon as the bone is completely consolidated (fused together). ", Unlock expert answers by supporting wikiHow, http://www.childrenshospital.org/conditions-and-treatments/conditions/b/broken-femur-thigh-bone, https://www.mayoclinic.org/diseases-conditions/broken-leg/diagnosis-treatment/drc-20370416, https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/tibiafibula-fracture-open-reduction-and-internal-fixation, https://orthoinfo.aaos.org/en/recovery/managing-pain-with-medications/, https://medlineplus.gov/ency/patientinstructions/000166.htm, https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=zy1646, https://www.choosept.com/guide/physical-therapy-guide-femur-fracture, https://orthoinfo.aaos.org/en/recovery/total-hip-replacement-exercise-guide/, https://www.health.harvard.edu/womens-health/5-ways-to-boost-bone-strength-early, https://www.bones.nih.gov/health-info/bone/bone-health/exercise/exercise-your-bone-health, http://orthoinfo.aaos.org/topic.cfm?topic=A00521, http://orthopedics.about.com/od/brokenbones/a/femur.htm, http://emedicine.medscape.com/article/90779-followup#a2650, http://www.medicalnewstoday.com/articles/248423.php, http://blog.gameready.com/blog/bid/292749/Recovering-from-an-Injury-Five-Ways-Compression-Therapy-Can-Help, Einen gebrochenen Oberschenkelknochen behandeln. I go for a check up at the 12-week mark. Femoral shaft fractures (FSF) typically occur in . Design: Prospective Observational Pilot (NCT# #02475941) Setting: Multicenter trial Participants: Patients 64-90 with an OTA 33 Distal femur fracture were eligible for inclusion. By Kristen Gasnick, PT, DPT Femur fracture repair - discharge You had a fracture (break) in the femur in your leg. If you are allowed to bear weight on your injured leg, using a walker within the first 48 hours after surgery is important for your recovery. These fractures are often associated with polytrauma and can be life-threatening. The bone is then reattached to the injured leg, usually by using bone grafts. At-home care services can be used to deliver physical therapy to people who have difficulty with transportation. Proper setting is required and if the femur bone is not set properly then there could be a chance that the leg could become shorter than the other one. Educational website from one of the world's leading hospitals "This gait can lead to uneven pressures across the knee joint, and resulting arthritis in that joint." Solutions to Knee Pain Following a Total Hip Replacement Surgery Before and after surgery, your doctor may help you manage your pain with over-the-counter and prescription medications, such as: Complications can arise with femur breaks. In blog.gameready.com. If an infection is found, the physician will prescribe the right antibiotic. It can take a long time for your broken leg to heal. These muscles support and stabilize your legs when walking, climbing stairs, and standing up. How Long After Femur Surgery Can I Drive? Hip fracture recovery takes longer than patients might expect: After four to six weeks, you'll start to feel less pain and be able to walk further with a walker. Racing stat Bible, ProCyclingStats.com, has already confirmed that of the 19 riders. Most episodes of nerve damage after surgery last for a few weeks to a few months. How Long A Person Is Immune After Covid (And Why)? Learning To Ski After 50 > Fully Explained Inside! Bony union was achieved in 18/19 patients (94.7%), at an average of 19.8 weeks after nonunion surgery. Pain can also radiate to the outside of the thigh, to the back of the hip, or into the groin. Physical therapists will determine when you could start to drive once again after a femur surgery. This exercise helps strengthen the gluteus medius muscles on the sides of the hips. Remove loose cords, wires, and rugs from the areas where you usually walk. Sometimes they'll attach the screws to a metal plate placed along your thighbone . Being in a car crash, falling, or being hit by a vehicle can break your femur. Once bony union is complete, treatment is focused on muscle rehabilitation. It can take a long time for your broken femur to heal. You need to follow all the instructions provided to you by your doctor. Repeat this 10 to 20 times provided that there is no pain increase. By signing up you are agreeing to receive emails according to our privacy policy. % of people told us that this article helped them. In this case, 95% of readers who voted found the article helpful, earning it our reader-approved status. For patients who are unable to stand or walk after a femoral stress fracture, surgical stabilization is recommended. 10 weeks after hip and femur fracture surgery, lateral movement and balance are really improving. To learn about the different types of femur surgery, read on! Medical Surgical Nursing 5th Edition, Hansen, K. (2013, June 6). Protocol for 8-Week Return to Running after a Femoral Stress Reaction. Usually, range of motion exercises and stretches are done to give strength to the broken femur. Treatment is available and with the help of bed rest for about 12 weeks one will be able to heal themselves and then they could indulge in physical activities. The femur bone is also known as the thighbone located in your thighs and it is one of the largest bones inside the human body. Before starting any exercise routine, consult with your healthcare provider and/or physical therapist first, especially if you're recovering from surgery. He specializes in spinal deformity and complex spinal reconstruction. The more actively engaged you are in your rehabilitation process, the better the chance of a successful recovery. You may have had surgery called an open reduction internal fixation. Slowly lower back to the starting position after holding this for 5 seconds. Surgery aims to restore mobility, and commence early mobilization. Depending on the severity of your injury, you may not be able to bear weight on your leg after surgery and will need crutches, a walker, or a wheelchair to get around. Finally Understand! Keeping your arms straight, push your heels into the ground and hold this position for 10 seconds. If you are a beginner, I recommend you start with exercises that are easy for you and gradually work your way up to more difficult exercises. Next, lift your leg while keeping your leg straight the entire time. 3 How many hours does femur surgery take? This surgery inserts a rod into the length of the bone with screws above and below to hold it into place. Your healthcare provider may recommend you a physical therapist. (2014, May 16). How Long After Femur Surgery Can You Walk? Although the bone forming the medial wall is the thinnest, it . I am 10 weeks post-surgery - still in pain and still no weight bearing. Femoral shaft fractures are common in major trauma, often occurring in patients with blunt multiple-system injuries [1]. In these cases, you will need to use crutches or a wheelchair to get around. nonsteroidal anti-inflammatory drugs (NSAIDs). However, most people will fully recover in three to 12 months. Our website services, content, and products are for informational purposes only. A femur fracture is a crack, break or crush injury to the thigh bone. Internal repair. The femur fracture should be healed by 3 months. After 8 weeks: Femoral neck fracture Physiotherapy Management. Cause of Knee Pain and Swelling Eight Weeks Out from Replacement Surgery. After surgery, the leg is put in a cast or set in a brace, for about 8 weeks. Stand in front of a wall, table, counter, or chair for support. By using our site, you agree to our. Within 7 to 10 days after your knee replacement, you should be able to get your knee straight/full extension, with no space between the back of your knee and the table. Muscles that move the leg. Some facilities require a prescription from a referring healthcare provider to start physical therapy. If the femur fracture does not require surgery, it is often treated with a cast or removable brace, and patients are typically advised not to put any weight on the leg for about 8 weeks. All rights reserved. Possible Complications After Hip Surgery. How long is recovery after femur surgery? How long does pain last after femur surgery? Getting up and moving after a femur fracture is important for recovery to help you return to your daily activities and movements. This will make sure that proper tightening is accomplished. You should discuss the suitability of all exercises with your physical therapist before trying them. Squeeze your glute muscles to lift your hips. Experts say that because the femur bone is so crucial to walking and moving through your daily life, breaking it is often quite demoralizing. You will need a walker or crutches to walk at the beginning of your rehabilitation until you build enough strength. If you are allowed to bear weight on your injured leg, using a walker within the first 48 hours after surgery is important for your recovery. (Answer Inside!). If you have a history of osteoporosis, you may want to talk to your doctor about taking calcium supplements to help prevent bone loss. Early surgical fixation is recommended for all but the . In the end, you want to be as healthy as possible because if there are complications arising after a femur surgery then the side effects could be painful. Isotonic and isokinetic exercises to the hip and knee are initiated alongwith progressive resistive exercises. A physical therapist will help the patient to walk safely using crutches or a walker, or other assistive device. Which usually takes around 3 weeks to 2 two months. You can do these exercises at home or at the gym. Slowly lower your leg while keeping your knee straight. Lymph fluid also removes waste from cells and body tissues which are an important part of the tissue regeneration process. After surgery, you will be on intravenous antibiotics for 24 hours to help prevent infection. Are there any complications with broken femurs? The surgical procedure used to repair a broken hip may vary depending on a number of factors. Dr. Leonardo Interactive Webservices, LLC. Success is possible, but not guaranteed. If you are not allowed to stand on your leg, you may need a wheelchair for the initial weeks following surgery. Thanks to all authors for creating a page that has been read 134,234 times. To treat a broken femur, start by seeing a doctor immediately for evaluation, since surgery is usually necessary for this injury. Health care practitioners do not encourage intake of this drug for the first 48 hours of injury, to let the body follow its natural course of healing. It is possible to improve your chances for a full recovery by doing your exercises as prescribed. Lie on your back with your knees bent and feet flat. Recovery Phase the goal here is to encourage immediate weight bearing tolerance, improvement of hip and knee range of motion, and strengthening of the affected area. Level up your tech skills and stay ahead of the curve. If you have a broken femur, you need to have surgery within 24 to 48 hours to realign it. Immediate diagnosis and treatment are important. How long does it take to recover from a femur fracture? A narrow locking compression plate was fixed after contouring according to the shape of the proximal femur. In most cases, your doctor will start with an X-ray. Contract your quadricep muscles of the extended leg to tighten your leg. Hold for 5 seconds. 67TH AVE. SRS REHAB WEST BOCA RATON 9970 CENTRAL PARK BLVD. You may need to use crutches for the rest of your life. Repeat tightening the front thigh muscles and holding them for 5 seconds for 10 repetitions. You wont be able to put weight on the injured leg, it may look different than the other leg, and you wont be able to put weight on it. [Blog Post]. How Long A Person Is Infectious After Covid (And Why). . In this surgery, your surgeon made a cut to the skin to align your broken bone. Ive put so much effort writing this blog post to provide value to you. Possible complications include: Infection Bleeding Nerve damage Blood clots Fat embolism Healing of the fractured bone in an abnormal alignment Irritation of the overlying tissue from the hardware Complications from anesthesia The patient may not be able to bear weight on the leg for up to 12 weeks. This can impact your ability to work and engage in family and social activities. Keep your feet flat and push your knees out to the side against the band. However, with the help of someone you can move from one place to another soon after a femur surgery. For up to a week after surgery, the patient may not be able to bear weight on their leg. Change positions as you become uncomfortable. It is usually diagnosed by a doctor in an emergency room. A femur break can make your leg shorter if your femur heals in a shortened position, especially if it was broken in several places. If you are eager to drive and you have had femur surgery recently then the type of fracture will determine when you could indulge in physical activities. Download Citation | The role of an augmentative plating in the management of femoral subtrochanteric nonunion | Introduction Owing to its distinct biomechanical properties, nonunion is common (7 . A physical therapist will help the patient to walk safely using crutches or a walker, or other assistive device. Before recommending specific treatment, your doctor will determine what type of break you have. You will work with a healthcare team to control your pain and improve your mobility before you can safely be sent home. This process is called setting the bone. As a small thank you, wed like to offer you a $30 gift card (valid at GoNift.com). You should always contact your doctor or other qualified healthcare professional before starting, changing, or stopping any kind of health treatment. This is the best info I have seen on the web, explaining everything. What Are Schmorls Nodes, and Should I Be Concerned About Them? If the femur fracture does not require surgery, it is often treated with a cast or removable brace, and patients are typically advised not to put any weight on the leg for about 8 weeks. Does a femur break make your leg shorter? We use cookies to ensure that we give you the best experience on our website. Rest, then repeat for a total of three sets of 10 repetitions. Once you build up enough leg strength to support your weight and improve your balance, you may be able to progress to using a cane or no assistive device at all to help you walk. How long does it take for a femur to heal after surgery? Did you know you can get expert answers for this article? Studies show that once surgery has been completed, you can manage your pain with medication, ensure proper healing at home, rehab your leg with physical therapy, and prevent future injury. It is also called the thigh bone. However, rare complications can sometimes occur. A broken femur can take three to six months to heal. My mother broke he hip (not femur), had surgery and rehab, and went home to live happily a few more years. Femur Fracture. A serious injury causing fracture of the femur bone would take a longer period to heal, roughly three to six months. Traction is administered for initial stabilization to take place. In addition, your surgeon will prescribe a blood thinning medication to help reduce the risk of developing a blood clot in your leg (deep vein thrombosis). Make your living space as accessible as possible and get started with physical therapy as soon as you can. For stress fractures of the femur, bone healing usually takes up to six weeks before the patient is allowed to resume activities. Youre unable to put weight on the injured leg. Being in a car crash, falling, or being hit by a vehicle can break your femur. Daniel Bubnis, M.S., NASM-CPT, NASE Level II-CSS, Biceps Tendinitis: Treatment, Testing, and Taping. Stand in front of a small step with handrails on each side. Things seemed fine until the last few days. They can occur any time in the first weeks after operation. Install hand rails in the shower, near the tub or next to the toilet. Exercise Program for Patellofemoral Syndrome, Ankle Strengthening Exercises for Ankle Injuries, Chondromalacia Exercises to Relieve Knee Pain, The Best Leg Strengthening Exercises After Surgery, Gait Training Exercises In Physical Therapy, Stretches to Ease and Prevent Shin Splints, What to Expect From Trochanteric Bursitis Physical Therapy, The 7 Best Quad Exercises to Build Stronger Thighs, Exercise Program After Lumbar Laminectomy and Discectomy Surgery, Postoperative rehabilitation after hip fracture: a literature review. Hold for three seconds, then bring your knees back together. X Rehabilitation for a femur fracture should start as soon as possible. To learn about the different types of femur surgery, read on! How long after femur surgery can I drive? Healthline Media does not provide medical advice, diagnosis, or treatment. Lie on a flat surface with a towel under the affected leg. Maintenance Phase - in this phase, weight bearing is permitted once complete healing has been achieved. 17 In a total of 331 patient case notes post-hip fracture, 77% of patients were allowed WBAT, 11% were partial weightbearing (PWB), 4% were touch weightbearing (TWB), and 8% were non-weightbearing (NWB). Then, 2 weeks hospital care, then home recovery. During this procedure, the broken bones are placed into place and are left to heal. SUPERIOR REHAB MIAMI LAKES 15600 N.W. Hiking After Acl Surgery Everyone Should Know This! Femur shaft fractures (broken thighbone). A broken femur is a serious injury that requires immediate medical care. The healing process is divided into four stages: inflammation, debridement, implantation, and gradual healing. How long is recovery after femur surgery? If the femur fracture does not require surgery, it is often treated with a cast or removable brace, and patients are typically advised not to put any weight on the leg for about 8 weeks. Activities that can be done here include 30 to 45 minutes of bike riding in a flat surface. Knee bending will increase with time and exercises. The hip is replaced along with a rod and screws in the femu. Mayo Clinic An orbital blowout fracture is a traumatic deformity of the orbital floor or medial wall that typically results from the impact of a blunt object larger than the orbital aperture, or eye socket.Most commonly, the inferior orbital wall, or the floor, is likely to collapse, because the bones of the roof and lateral walls are robust. The most important phase of healing is the maturation process. I still ice several times a day to get the swelling down, and think that helps a lot. Your knee should completely straighten/extend by the end of 7-10 days post-surgery. Do not try to do things that you are not allowed to do because if there is some pressure created in your femur bone then there could be several complications arising because of it. In contrast, other facilities operate under direct access, where you can call and request an initial evaluation appointment without a prescription. Keep your body upright without leaning toward either side. This surgery may require a bone transplant. This exercise helps strengthen the glute and quadricep muscles to improve your ability to bend down, squat, and get in and out of a chair. When do you start weight bearing after femur fracture? Kristen Gasnick, PT, DPT, is a medical writer and a physical therapist at Holy Name Medical Center in New Jersey.
Ocean Forest Golf Club Membership Fee,
Caribbean Redux Scottsdale Menu,
Bethesda Game Studios Headquarters,
What Are The Meninges Quizlet,
Articles OTHER
