Trigger Finger - (Locked Thumb)

[Hannums]

Since I have developed a problem with a Trigger Thumb for the past several months, I've been doing my homework on the issue and wanted to share this website with those of you who may have an issue with it, or know clients, etc. that need information on this chronic condition. It's worth your time to review the various segments of the site & watch the surgical repair for it as well. I'm still hoping to resolve it without having to resort to surgery - but we'll see. In the meantime I've been advised by a certified hand therapist I met online through one of our member's sites on Face book - (Walt Fritz) MyofascialReleaseForum@groups.facebook.com While this is a closed group, people can become members by requesting to join. Major kudos & thanks to Walt for starting the group & making it available to so many others!

I'm sharing this info because this is not an uncommon issue for bodyworkers & the hope is that others will find some useful information on this post.

Her explanation & suggestions for me: Edgar Cayce's Castor oil wrap to the thumb/wrist daily for 1 hr. will help to decrease the inflammation to the flexor tendon sheath.. Also Epsom salt soaks... You might consider wearing a night extension splint to the thumb/wrist and when all else fails an injection with cortisone+marcaine to the joint/tendon area by a skilled Hand Surgeon. If that fails then a simple surgical opening of the flexor tendon sheath and nodule removal.. Trigger thumbs can be very limiting and painful...of course MFR unwinding techniques to try to alleviate the fluid build up causing the tendon excursion limitations and snagging. pad your car steering wheel with a sheepskin cover..and think of padding all hard surfaces to protect volar surface of the thumb.

Trigger thumb is not a primary,neurological issue nor cause...The median nerve is not affected unless it is one of the 3 branches to the thenar eminence affected secondary d/t edema or trauma. It is indeed a mechanical problem stemming from the pulley system at the volar MP joint and affecting the tendon sheath of the FPL. It is often caused as a result of blunt trauma and/or repetitive use..could also be a secondary cause from diabetes, and other autoimmune diseases. I DO agree that MFR to the ENTIRE upper extremity is ALWAYS indicated..

She's also recommending xrays & a good evaluation by a Prolotherapy Doc (they specialize in hands) My causes are most likely from overuse & repetitive strain as a bodyworker of 21 years - plus all the other misc. things I do on a regular basis around the home, etc. especially picking up pieces of firewood throughout the winter to fuel our woodstove. I have a distinct memory of feeling the ouch from working the woodpile last year - sometime around the holidays, so this has gone on for some time now.

Prolotherapy ("Proliferative Injection Therapy") involves injecting an otherwise non-pharmacological and non-active irritant solution into the body, generally in the region of tendons or ligaments for the purpose of strengthening weakened connective tissue and alleviating musculoskeletal pain. Of course this injection is most often done with Cortisone/Steriod type solutions, which I don't like the idea of using as Cortisone just deadens the tissues, it doesn't resolve the issue, and is known to destroy the joints - which is why most docs will only give up to 3 of these injections (often without explaining the "minor" side effect just mentioned).

While I'm not big on injections myself, it is one of the treatments for this condition that apparently can have good results.

Hope that those who've taken time to read this have found it to be useful & informative!

http://www.assh.org/Public/HandConditions/Pages/TriggerFinger.aspx

I also found this reference book that others may want to check out as well: Splinting the hand and upper extremity: principles and process By MaryLynn A. Jacobs, Noelle M. Austin
http://books.google.com/books?id=cnCCIqO7AuIC&pg=RA1-PA6&lpg=RA1-PA6&dq=volar+MP+joint&source=bl&ots=rGRdM33BSK&sig=A31XBeoKJ4zkQnLmXknzIhZF0yI&hl=en&ei=Oas9TvbJJM-1tweXuuWVAw&sa=X&oi=book_result&ct=result&resnum=10&ved=0CFwQ6AEwCQ#v=onepage&q=volar%20MP%20joint&f=false




What is trigger finger or stenosing tenosynovitis?

Stenosing tenosynovitis, commonly known as “trigger finger” or “trigger thumb”, involves the pulleys and tendons in the hand that bend the fingers. The tendons work like long ropes connecting the muscles of the forearm with the bones of the fingers and thumb. In the finger, the pulleys are a series of rings that form a tunnel through which the tendons must glide, much like the guides on a fishing rod through which the line (or tendon) must pass. These pulleys hold the tendons close against the bone. The tendons and the tunnel have a slick lining that allows easy gliding of the tendon through the pulleys (see Figure 1).

Trigger finger/thumb occurs when the pulley at the base of the finger becomes too thick and constricting around the tendon, making it hard for the tendon to move freely through the pulley. Sometimes the tendon develops a nodule (knot) or swelling of its lining. Because of the increased resistance to the gliding of the tendon through the pulley, one may feel pain, popping, or a catching feeling in the finger or thumb (see Figure 2). The catching or triggering action is distinctive, as seen in this brief video clip of a ring trigger finger. When the tendon catches, it produces inflammation and more swelling. This causes a vicious cycle of triggering, inflammation, and swelling. Sometimes the finger becomes stuck or locked, and is hard to straighten or bend.
What causes trigger finger / stenosing tenosynovitis?

Causes for this condition are not always clear. Some trigger fingers are associated with medical conditions such as rheumatoid arthritis, gout, and diabetes. Local trauma to the palm/base of the finger may be a factor on occasion, but in most cases there is not a clear cause.

Signs and symptoms of trigger finger / stenosing tenosynovitis

Trigger finger/thumb may start with discomfort felt at the base of the finger or thumb, where they join the palm. This area is often tender to local pressure. A nodule may sometimes be found in this area. When the finger begins to trigger or lock, the patient may think the problem is at the middle knuckle of the finger or the tip knuckle of the thumb, since the tendon that is sticking is the one that moves these joints.

Treatment of trigger finger / stenosing tenosynovitis

The goal of treatment in trigger finger/thumb is to eliminate the catching or locking and allow full movement of the finger or thumb without discomfort. Swelling around the flexor tendon and tendon sheath must be reduced to allow smooth gliding of the tendon. The wearing of a splint or taking an oral anti-inflammatory medication may sometimes help. Treatment may also include changing activities to reduce swelling. An injection of steroid into the area around the tendon and pulley is often effective in relieving the trigger finger/thumb.

If non-surgical forms of treatment do not relieve the symptoms, surgery may be recommended. This surgery is performed as an outpatient, usually with simple local anesthesia. The goal of surgery is to open the pulley at the base of the finger so that the tendon can glide more freely. Active motion of the finger generally begins immediately after surgery. Normal use of the hand can usually be resumed once comfort permits. Some patients may feel tenderness, discomfort, and swelling about the area of their surgery longer than others. Occasionally, hand therapy is required after surgery to regain better use.

 

[Anastasia Marie]

FWIW,

My mother had a trigger finger (not the thumb). We couldn't correct the problem with MFR or massage related techniques, but kept it minimally annoying for a number of years, this way.

Eventually she needed more. I referred her to an orthopedic I work with and he gave her the steroid injection, which helped for about 8 months. His comment that was- if, after a year it hadn't come back after the steroid injection, that she most likely didn't need the surgery. However, if it came back in less than the year, surgery was the next step. Hers came back and she opted to have the surgery (day surgery). It went excellently and she has not had a problem with that finger since.

My only suggestion when locating a surgeon for this, is that you fully trust him/her and that they are known for being conservative in their actions.

Best of luck!


Here are some links for cross-reference to this thread topic:

• trigger finger
  
  
• From: Re: My least favorite diagnosis (sigh)

  I have a recent case involving trigger finger in both hands. There is extensive medical documentation from the year+ of hand therapy she went through, plus she saw a massage therapist for other things. She is now symptom-free, with her dexterity and hand strength improving rapidly. If I remember to write the case review, it should make for interesting reading. :grin:

• An NMT class on Trigger Finger (past post):
  

  This is in Jacksonville, FL
  Medical Massage/Neuromuscular Seminars Offered at Alpha School of Massage
  
  
  April 8 & 9, 2006 Medical Massage/NMT for the elbow, wrist & hand: Learn
  to
  treat wrist drop; tennis elbow; golfer’s elbow; carpal tunnel syndrome;
  trigger finger; pronator teres syndrome; & more.
  
  
  
  Call Michael Garcia R.N., L.M.T. at (904) 389-9117 or e-mail at
  progarcia@earthlink.net to register or for more information. Courses are
  approved for 16 hrs. ceu’s. $150.00 if registered 30 or more days in
  advance.

[/quote]



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Topic review - Trigger Finger - (Locked Thumb)






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pueppi






 
Post subject: 
Re: Trigger Finger - (Locked Thumb)
 













FWIW, My mother had a trigger finger (not the thumb). We couldn't correct the problem with MFR or massage related techniques, but kept it minimally annoying for a number of years, this way.Eventually she needed more. I referred her to an orthopedic I work with and he gave her the steroid injection, which helped for about 8 months. His comment that was- if, after a year it hadn't come back after the steroid injection, that she most likely didn't need the surgery. However, if it came back in less than the year, surgery was the next step. Hers came back and she opted to have the surgery (day surgery). It went excellently and she has not had a problem with that finger since.My only suggestion when locating a surgeon for this, is that you fully trust him/her and that they are known for being conservative in their actions.Best of luck!Here are some links for cross-reference to this thread topic: trigger finger From: Re: My least favorite diagnosis (sigh)JasonE wrote:I have a recent case involving trigger finger in both hands. There is extensive medical documentation from the year+ of hand therapy she went through, plus she saw a massage therapist for other things. She is now symptom-free, with her dexterity and hand strength improving rapidly. If I remember to write the case review, it should make for interesting reading. An NMT class on Trigger Finger (past post):JaxGal wrote:This is in Jacksonville, FLMedical Massage/Neuromuscular Seminars Offered at Alpha School of MassageApril 8 & 9, 2006 Medical Massage/NMT for the elbow, wrist & hand: Learntotreat wrist drop; tennis elbow; golfer’s elbow; carpal tunnel syndrome;trigger finger; pronator teres syndrome; & more. Call Michael Garcia R.N., L.M.T. at (904) 389-9117 or e-mail atprogarcia@earthlink.net to register or for more information. Courses areapproved for 16 hrs. ceu’s. $150.00 if registered 30 or more days inadvance.

FWIW, My mother had a trigger finger ([i]not the thumb[/i]). We couldn't correct the problem with MFR or massage related techniques, but kept it minimally annoying for a number of years, this way.Eventually she needed more. I referred her to an orthopedic I work with and he gave her the steroid injection, which helped for about 8 months. His comment that was- if, after a year it hadn't come back after the steroid injection, that she most likely didn't need the surgery. However, if it came back in less than the year, surgery was the next step. Hers came back and she opted to have the surgery ([i]day surgery[/i]). It went excellently and she has not had a problem with that finger since.My only suggestion when locating a surgeon for this, is that you fully trust him/her and that they are known for being conservative in their actions.Best of luck![i]Here are some links for cross-reference to this thread topic:[/i][list][*] [url=http://www.massageplanet.com/forum/viewtopic.php?f=24&t=18883&start=0&hilit=trigger+finger][b]trigger finger[/b][/url][*] From: [i][url=http://www.massageplanet.com/forum/viewtopic.php?f=24&t=21487&p=153539&hilit=+trigger+finger#p153539][b]Re: My least favorite diagnosis (sigh)[/b][/url][/i][quote="JasonE"]I have a recent case involving trigger finger in both hands. There is extensive medical documentation from the year+ of hand therapy she went through, plus she saw a massage therapist for other things. She is now symptom-free, with her dexterity and hand strength improving rapidly. If I remember to write the case review, it should make for interesting reading. :grin:[/quote][*] An NMT class on Trigger Finger (past post):[quote="JaxGal"]This is in Jacksonville, FLMedical Massage/Neuromuscular Seminars Offered at Alpha School of MassageApril 8 & 9, 2006 Medical Massage/NMT for the elbow, wrist & hand: Learntotreat wrist drop; tennis elbow; golfer’s elbow; carpal tunnel syndrome;trigger finger; pronator teres syndrome; & more. Call Michael Garcia R.N., L.M.T. at (904) 389-9117 or e-mail atprogarcia@earthlink.net to register or for more information. Courses areapproved for 16 hrs. ceu’s. $150.00 if registered 30 or more days inadvance.[/list]











Posted: Sun Aug 07, 2011 5:48 am














riversinger






 
Post subject: 
Trigger Finger - (Locked Thumb)
 













Since I have developed a problem with a Trigger Thumb for the past several months, I've been doing my homework on the issue and wanted to share this website with those of you who may have an issue with it, or know clients, etc. that need information on this chronic condition. It's worth your time to review the various segments of the site & watch the surgical repair for it as well. I'm still hoping to resolve it without having to resort to surgery - but we'll see. In the meantime I've been advised by a certified hand therapist I met online through one of our member's sites on Face book - (Walt Fritz) MyofascialReleaseForum@groups.facebook.com While this is a closed group, people can become members by requesting to join. Major kudos & thanks to Walt for starting the group & making it available to so many others! I'm sharing this info because this is not an uncommon issue for bodyworkers & the hope is that others will find some useful information on this post.Her explanation & suggestions for me: Edgar Cayce's Castor oil wrap to the thumb/wrist daily for 1 hr. will help to decrease the inflammation to the flexor tendon sheath.. Also Epsom salt soaks... You might consider wearing a night extension splint to the thumb/wrist and when all else fails an injection with cortisone+marcaine to the joint/tendon area by a skilled Hand Surgeon. If that fails then a simple surgical opening of the flexor tendon sheath and nodule removal.. Trigger thumbs can be very limiting and painful...of course MFR unwinding techniques to try to alleviate the fluid build up causing the tendon excursion limitations and snagging. pad your car steering wheel with a sheepskin cover..and think of padding all hard surfaces to protect volar surface of the thumb.Trigger thumb is not a primary,neurological issue nor cause...The median nerve is not affected unless it is one of the 3 branches to the thenar eminence affected secondary d/t edema or trauma. It is indeed a mechanical problem stemming from the pulley system at the volar MP joint and affecting the tendon sheath of the FPL. It is often caused as a result of blunt trauma and/or repetitive use..could also be a secondary cause from diabetes, and other autoimmune diseases. I DO agree that MFR to the ENTIRE upper extremity is ALWAYS indicated.. She's also recommending xrays & a good evaluation by a Prolotherapy Doc (they specialize in hands) My causes are most likely from overuse & repetitive strain as a bodyworker of 21 years - plus all the other misc. things I do on a regular basis around the home, etc. especially picking up pieces of firewood throughout the winter to fuel our woodstove. I have a distinct memory of feeling the ouch from working the woodpile last year - sometime around the holidays, so this has gone on for some time now. Prolotherapy ("Proliferative Injection Therapy") involves injecting an otherwise non-pharmacological and non-active irritant solution into the body, generally in the region of tendons or ligaments for the purpose of strengthening weakened connective tissue and alleviating musculoskeletal pain. Of course this injection is most often done with Cortisone/Steriod type solutions, which I don't like the idea of using as Cortisone just deadens the tissues, it doesn't resolve the issue, and is known to destroy the joints - which is why most docs will only give up to 3 of these injections (often without explaining the "minor" side effect just mentioned).While I'm not big on injections myself, it is one of the treatments for this condition that apparently can have good results. Hope that those who've taken time to read this have found it to be useful & informative! http://www.assh.org/Public/HandConditio ... inger.aspxI also found this reference book that others may want to check out as well: Splinting the hand and upper extremity: principles and process By MaryLynn A. Jacobs, Noelle M. Austinhttp://books.google.com/books?id=cnCCIq ... nt&f=falseWhat is trigger finger or stenosing tenosynovitis?Stenosing tenosynovitis, commonly known as “trigger fingerâ€‌ or “trigger thumbâ€‌, involves the pulleys and tendons in the hand that bend the fingers. The tendons work like long ropes connecting the muscles of the forearm with the bones of the fingers and thumb. In the finger, the pulleys are a series of rings that form a tunnel through which the tendons must glide, much like the guides on a fishing rod through which the line (or tendon) must pass. These pulleys hold the tendons close against the bone. The tendons and the tunnel have a slick lining that allows easy gliding of the tendon through the pulleys (see Figure 1).Trigger finger/thumb occurs when the pulley at the base of the finger becomes too thick and constricting around the tendon, making it hard for the tendon to move freely through the pulley. Sometimes the tendon develops a nodule (knot) or swelling of its lining. Because of the increased resistance to the gliding of the tendon through the pulley, one may feel pain, popping, or a catching feeling in the finger or thumb (see Figure 2). The catching or triggering action is distinctive, as seen in this brief video clip of a ring trigger finger. When the tendon catches, it produces inflammation and more swelling. This causes a vicious cycle of triggering, inflammation, and swelling. Sometimes the finger becomes stuck or locked, and is hard to straighten or bend.What causes trigger finger / stenosing tenosynovitis? Causes for this condition are not always clear. Some trigger fingers are associated with medical conditions such as rheumatoid arthritis, gout, and diabetes. Local trauma to the palm/base of the finger may be a factor on occasion, but in most cases there is not a clear cause.Signs and symptoms of trigger finger / stenosing tenosynovitisTrigger finger/thumb may start with discomfort felt at the base of the finger or thumb, where they join the palm. This area is often tender to local pressure. A nodule may sometimes be found in this area. When the finger begins to trigger or lock, the patient may think the problem is at the middle knuckle of the finger or the tip knuckle of the thumb, since the tendon that is sticking is the one that moves these joints.Treatment of trigger finger / stenosing tenosynovitisThe goal of treatment in trigger finger/thumb is to eliminate the catching or locking and allow full movement of the finger or thumb without discomfort. Swelling around the flexor tendon and tendon sheath must be reduced to allow smooth gliding of the tendon. The wearing of a splint or taking an oral anti-inflammatory medication may sometimes help. Treatment may also include changing activities to reduce swelling. An injection of steroid into the area around the tendon and pulley is often effective in relieving the trigger finger/thumb.If non-surgical forms of treatment do not relieve the symptoms, surgery may be recommended. This surgery is performed as an outpatient, usually with simple local anesthesia. The goal of surgery is to open the pulley at the base of the finger so that the tendon can glide more freely. Active motion of the finger generally begins immediately after surgery. Normal use of the hand can usually be resumed once comfort permits. Some patients may feel tenderness, discomfort, and swelling about the area of their surgery longer than others. Occasionally, hand therapy is required after surgery to regain better use.

Since I have developed a problem with a Trigger Thumb for the past several months, I've been doing my homework on the issue and wanted to share this website with those of you who may have an issue with it, or know clients, etc. that need information on this chronic condition. It's worth your time to review the various segments of the site & watch the surgical repair for it as well. I'm still hoping to resolve it without having to resort to surgery - but we'll see. In the meantime I've been advised by a certified hand therapist I met online through one of our member's sites on Face book - (Walt Fritz) MyofascialReleaseForum@groups.facebook.com While this is a closed group, people can become members by requesting to join. Major kudos & thanks to Walt for starting the group & making it available to so many others! I'm sharing this info because this is not an uncommon issue for bodyworkers & the hope is that others will find some useful information on this post.[u][b]Her explanation & suggestions for me[/b][/u]: Edgar Cayce's Castor oil wrap to the thumb/wrist daily for 1 hr. will help to decrease the inflammation to the flexor tendon sheath.. Also Epsom salt soaks... You might consider wearing a night extension splint to the thumb/wrist and when all else fails an injection with cortisone+marcaine to the joint/tendon area by a skilled Hand Surgeon. If that fails then a simple surgical opening of the flexor tendon sheath and nodule removal.. Trigger thumbs can be very limiting and painful...of course MFR unwinding techniques to try to alleviate the fluid build up causing the tendon excursion limitations and snagging. pad your car steering wheel with a sheepskin cover..and think of padding all hard surfaces to protect volar surface of the thumb.Trigger thumb is not a primary,neurological issue nor cause...The median nerve is not affected unless it is one of the 3 branches to the thenar eminence affected secondary d/t edema or trauma. It is indeed a mechanical problem stemming from the pulley system at the volar MP joint and affecting the tendon sheath of the FPL. It is often caused as a result of blunt trauma and/or repetitive use..could also be a secondary cause from diabetes, and other autoimmune diseases. I DO agree that MFR to the ENTIRE upper extremity is ALWAYS indicated.. She's also recommending xrays & a good evaluation by a Prolotherapy Doc (they specialize in hands) My causes are most likely from overuse & repetitive strain as a bodyworker of 21 years - plus all the other misc. things I do on a regular basis around the home, etc. especially picking up pieces of firewood throughout the winter to fuel our woodstove. I have a distinct memory of feeling the ouch from working the woodpile last year - sometime around the holidays, so this has gone on for some time now. [b]Prolotherapy ("Proliferative Injection Therapy")[/b] involves injecting an otherwise non-pharmacological and non-active irritant solution into the body, generally in the region of tendons or ligaments for the purpose of strengthening weakened connective tissue and alleviating musculoskeletal pain. Of course this injection is most often done with Cortisone/Steriod type solutions, which I don't like the idea of using as Cortisone just deadens the tissues, it doesn't resolve the issue, and is known to destroy the joints - which is why most docs will only give up to 3 of these injections (often without explaining the "minor" side effect just mentioned).While I'm not big on injections myself, it is one of the treatments for this condition that apparently can have good results. Hope that those who've taken time to read this have found it to be useful & informative! http://www.assh.org/Public/HandConditions/Pages/TriggerFinger.aspxI also found this reference book that others may want to check out as well: [b]Splinting the hand and upper extremity: principles and process By MaryLynn A. Jacobs, Noelle M. Austin[/b]http://books.google.com/books?id=cnCCIqO7AuIC&pg=RA1-PA6&lpg=RA1-PA6&dq=volar+MP+joint&source=bl&ots=rGRdM33BSK&sig=A31XBeoKJ4zkQnLmXknzIhZF0yI&hl=en&ei=Oas9TvbJJM-1tweXuuWVAw&sa=X&oi=book_result&ct=result&resnum=10&ved=0CFwQ6AEwCQ#v=onepage&q=volar%20MP%20joint&f=false[b]What is trigger finger or stenosing tenosynovitis?[/b]Stenosing tenosynovitis, commonly known as “trigger fingerâ€‌ or “trigger thumbâ€‌, involves the pulleys and tendons in the hand that bend the fingers. The tendons work like long ropes connecting the muscles of the forearm with the bones of the fingers and thumb. In the finger, the pulleys are a series of rings that form a tunnel through which the tendons must glide, much like the guides on a fishing rod through which the line (or tendon) must pass. These pulleys hold the tendons close against the bone. The tendons and the tunnel have a slick lining that allows easy gliding of the tendon through the pulleys (see Figure 1).Trigger finger/thumb occurs when the pulley at the base of the finger becomes too thick and constricting around the tendon, making it hard for the tendon to move freely through the pulley. Sometimes the tendon develops a nodule (knot) or swelling of its lining. Because of the increased resistance to the gliding of the tendon through the pulley, one may feel pain, popping, or a catching feeling in the finger or thumb (see Figure 2). The catching or triggering action is distinctive, as seen in this brief video clip of a ring trigger finger. When the tendon catches, it produces inflammation and more swelling. This causes a vicious cycle of triggering, inflammation, and swelling. Sometimes the finger becomes stuck or locked, and is hard to straighten or bend.What causes trigger finger / stenosing tenosynovitis? Causes for this condition are not always clear. Some trigger fingers are associated with medical conditions such as rheumatoid arthritis, gout, and diabetes. Local trauma to the palm/base of the finger may be a factor on occasion, but in most cases there is not a clear cause.[b]Signs and symptoms of trigger finger / stenosing tenosynovitis[/b]Trigger finger/thumb may start with discomfort felt at the base of the finger or thumb, where they join the palm. This area is often tender to local pressure. A nodule may sometimes be found in this area. When the finger begins to trigger or lock, the patient may think the problem is at the middle knuckle of the finger or the tip knuckle of the thumb, since the tendon that is sticking is the one that moves these joints.[b]Treatment of trigger finger / stenosing tenosynovitis[/b]The goal of treatment in trigger finger/thumb is to eliminate the catching or locking and allow full movement of the finger or thumb without discomfort. Swelling around the flexor tendon and tendon sheath must be reduced to allow smooth gliding of the tendon. The wearing of a splint or taking an oral anti-inflammatory medication may sometimes help. Treatment may also include changing activities to reduce swelling. An injection of steroid into the area around the tendon and pulley is often effective in relieving the trigger finger/thumb.If non-surgical forms of treatment do not relieve the symptoms, surgery may be recommended. This surgery is performed as an outpatient, usually with simple local anesthesia. The goal of surgery is to open the pulley at the base of the finger so that the tendon can glide more freely. Active motion of the finger generally begins immediately after surgery. Normal use of the hand can usually be resumed once comfort permits. Some patients may feel tenderness, discomfort, and swelling about the area of their surgery longer than others. Occasionally, hand therapy is required after surgery to regain better use.











Posted: Sun Aug 07, 2011 5:17 am


















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