Treatment measures should be conservative. The deep compartment originates in the region of the posterior radius, ulna, or both. EFORT open reviews. The supinator muscle, abductor pollicis longus muscle, extensor pollicis brevis muscle, extensor pollicis longus muscle, and extensor indicis muscle comprise this deep compartment. Estimates are that ECRA and ECRI are present in 10-20% of individuals. A positive test is when this maneuver causes pain. Separate synovial sheaths can be present in the first compartment. The fifth extensor compartment contains the EDM muscle tendon. For example, lateral epicondylitis affects 1-5% . This patient is instructed to adduct their thumb. it works with pronator teres and has the same nerve supply: palmaris longus (N446,TG2-23) . Patients are typically 30to 50 years old and frequently have a history of prior surgical intervention to the affected arm. A caveat includes managing zone V injuries (zone V injuries include disruption over the MCP joint of the digit or the CMC joint of the thumb. Stick tothe above training guidelines for. Mobile Physiotherapy Clinic It is supplied by posterior interosseous nerve. 2017 Mar [PubMed PMID: 27631096], Ong C,Nallamshetty HS,Nazarian LN,Rekant MS,Mandel S, Sonographic Diagnosis Of Posterior Interosseous Nerve Entrapment Syndrome. This form of intersection syndrome is more common than distal intersection syndrome. I just stumbled upon your blog and wanteed tosay that Ive tuly enjoyed surfing around your bblog posts.In any case I will bee subscribing to your feed and I holeyou write again vwry soon! There are multiple surgical approaches, and there is a lack of evidence supporting one specific surgical technique.[2][13]. Extensor digitorum is a long muscle located in the posterior compartment of the forearm. A low origin of the radial artery has an incidence of 0.2% and has multiple variations within itself. To answer your question, I would first have to say that Im not a medical professional, and you should definitely get an okay from your physician or physical therapist before doing anything. This muscle belongs to the superficial forearm extensor group, along with anconeus, brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum and extensor digiti minimi muscles. It is the only forearm extensor that lies in its own fibro-osseous tunnel at the level of the wrist with its own subsheath as it passes through the 6 th . As the PIN enters the posterior compartment of the forearm, it passesdeep to the supinator muscle (between its two heads). Initial management of most cases utilizes DIP extension splinting and conservative management. Thank you, Ive recently been searching for information approximately this subject for ages and yoursis the best I have came upon so far. Again, please consult your doctor/physical therapist before doing either of these solutions. It spans between the elbow and base of the little finger. It originates from the posterior distal third of ulna and interosseous membrane. These variations can lead to snapping wrist syndrome. vastus medialis oblique what are leg raises good for Origin: 1st - lateral side of the tendon of 2nd digit. Finger posturing in a position of PIP flexion and DIP extension or hyperextension characterize central slip injuries. Thanks , I have recently been looking for info approximately this subject for awhile and yours is the best I have came upon till now. II: extensor carpi radialis longus, extensor carpi radialis brevis. [2]The ECRB tendon is most commonly affected and will show angiofibroblastic hyperplasia (immature reparative tissue). Extensor tendons protected by synovial tendon sheaths. Vergara-Amador E, Ramrez A. Anatomic study of the extensor carpi radialis brevis in its relation with the motor branch of the radial nerve. Distal intersection syndrome occurs when this area of crossing over becomes inflamed and causes dorsal wrist pain. The deep palmar archderives its main contribution from the deep arterial branch of the radial artery. Thanks so much for the post.Much thanks again. That said, there many other exercises that work the wrist flexors significantly but indirectly. Extension of the second (index finger), third (long finger), fourth (ring finger), and fifth (small finger) digits occurs via the extensor digitorum communis (EDC) muscles. American journal of roentgenology. ULNAR A. STRENGTHENING EXERCISE OF WRIST EXTENSORS : 2. If you dont have any issues with your wrist extensors, but want to build them up and make them stronger, the training advice below will help: Overall, the muscle fiber type of the wrist extensors is slow-twitch dominant. pelvic tilt exercise for low back pain Much obliged. Lumbar Spondylolisthesis Sit or stand with the spine erect, shoulders rolled back, and look forward. The radial nerve divides off the posterior cord of the brachial plexus. The superficial arch also receives contributions from the superficial branch of the radial artery. Thankfully Ive never had to deal with wrist issues, but from what Ive read, the key to wrapping them successfully is get the right position: You dont want them too high,, since that will impair your range of motion. The tendon continues into the distal part of the forearm. [2]The ECRB tendon is most commonly affected and will show angiofibroblastic hyperplasia (immature reparative tissue). Origin: Originates from the lateral epicondyle of the humerus. firmly bound to deep fascia in many places why are there flexion ceases on palm of hand? Akgun U, Bulut T, Zengin EC, Tahta M, Sener M. Extension block technique for mallet fractures: a comparison of one and two dorsal pins. I love all of tthe points you hazvemade. Ong C, Nallamshetty HS, Nazarian LN, Rekant MS, Mandel S. Sonographic Diagnosis Of Posterior Interosseous Nerve Entrapment Syndrome. Thumb spica splinting can be used to immobilize the thumb. These muscles generally originate on or near the lateral epicondyle and insert on the distal forearm or in the hand. These muscles generally originate on or near the lateral epicondyle and insert on the distal forearm or in the hand. The wrist extensors includes extensor carpi radialis longus (ECRL), extensor carpi radialis brevis (ECRB), extensor digitorum (ED), extensor digiti minimi (EDM), extensor carpi ulnaris (ECU) and extensor indicis (EI). exercises for vastus medialis [13]If conservative management fails to relieve symptoms, the patient might benefit from surgical correction. Folberg CR, Ulson H, Scheidt RB. Much obliged. Vastral it is the site of attachment of the common extensor tendon which is the origin of several forearm extensor muscles (extensor carpi radialis brevis m., . In refractory cases, or in caseswhere a large bony fragment is appreciated on injury radiographs, consider closed reduction percutaneous pinning (CRPP) versus open reduction internal fixation (ORIF). As Ill detaillater, these muscles are also responsible for other movements of the fingers and wrist. In order to get them to grow, you need to train with high reps/volume/frequency. 2017 May 29 [PubMed PMID: 28553852], Haadaj R,Wysiadecki G,Dudkiewicz Z,Polguj M,Topol M, The High Origin of the Radial Artery (Brachioradial Artery): Its Anatomical Variations, Clinical Significance, and Contribution to the Blood Supply of the Hand. Spastic Cerebral Palsy Treatment [3] Actions: Flexion of the forearm. Blood supply of extensor pollicis longus. These variants are the extensor carpi radialis intermedius (ECRI), extensor carpi radialis tertius (ECRT), and extensor carpi radialis accessories (ECRA). Very useful advice in this particular article! 2007 [PubMed PMID: 27303450], Moradi A,Ebrahimzadeh MH,Jupiter JB, Radial Tunnel Syndrome, Diagnostic and Treatment Dilemma. 2017 Nov [PubMed PMID: 28858545], Muscles of the Wrist and hand, External Carpi radialis longus and brevis, Abductor pollicis longus, Flexor digitorum profundus, Flexor Carpi Ulnaris, Cupinaor, Anatomy, Shoulder and Upper Limb, Wrist Extensor Muscles, Zone I: covers the fingertip to the distal interphalangeal (DIP) joint, Zone III: locatedat the proximal interphalangeal (PIP) joint, Zone V: situatedat the metacarpal phalangeal (MP) joint, Zone I: covers the fingertip to the DIP joint, Zone II: covers the interphalangeal joint, Brachioradialis origin: proximal lateral epicondyle of the humerus, Brachioradialis insertion: lateral distal radius, ECRL origin: proximal lateral epicondyle of the humerus, ECRL insertion: dorsal surface of the second metacarpal base, ECRB origin: lateral epicondyle of the humerus, ECRB insertion: dorsal surface of the second and third metacarpal bases, EDC origin: lateral epicondyle of the humerus, EDC insertion: extensor hoods of the pointer, long, ring, and small finger, EDM origin: lateral epicondyle of the humerus, EDM insertion: extensor hood of the small finger, ECU origin: lateral epicondyle of the humerus, ECU insertion: medial base of the fifth metacarpal, Anconeus origin: lateral epicondyle of the humerus, Anconeus insertion: olecranon and proximal posterior ulna, Supinator origin: superficial lateral epicondyle of the humerus, radial collateral ligament, and annular ligament, Supinator insertion: the lateral proximal third of the radius, APL origin: the posterior proximal surface of the ulna and radius, APL insertion: lateral base of the first metacarpal, EPB origin: the posterior proximal surface of the radius (distal to abductor pollicis longus), EPB insertion: dorsal surface of the base of the thumb, EPL origin: the posterior proximal surface of the radius (distal to abductor pollicis longus), EPL insertion: dorsal surface of the base of the thumb, EIP origin: posterior surface of the proximal ulna, EIP insertion: extensor hood of the index finger. Awesome blog.Much thanks again. It is supplied by deep branch of the radial artery. It originates from the brachial plexus, carrying fibers from the ventral roots . Extensor tendon zones are a helpful way to identify the region where injuries to the extensor tendons occur in the hand and wrist. [15], Compression of the PIN can occur in the posterior forearm compartment causing radial tunnel syndrome (RTS). Amaraiwadi If your wrist extensors are overactive and short, do the following: Reduce the amount of time spent doing any repetitive activities causing wrist extensoroveruse. Corticosteroid injection into the first extensor compartment has a 75to 80% chance of alleviating symptoms. I wish to say that this post is amazing, nice written and include approximately all significant infos. These injuries to the digits includeinjury to thecommon extensor tendon(s). [1][2], To achieve neutral wrist extension movements, theextensor carpi radialis brevis (ECRB), extensor carpi radialis longus (ECRL), and the extensor carpi ulnaris (ECU) musclesact synergistically based on each muscle's insertion and dynamic function. 80%. The second extensor compartment is comprised of the ECRB and ECRL muscle tendons. Extends and abducts hand at wrist joint Extensor carpi radialis brevis: Insertion: The posterior surface of the base of the third metacarpal bone Nerve supply: Deep branch of the radial nerve Action: Extends and abducts hand at wrist joint Extensor digitorum: Insertion: Bases of middle phalanges of the 2nd-5th digits Nerve supply: From their origin attachments, the wrist flexors move in adistaldirection,downthe front of the forearm, andinsert onthe anterior surfaces of the carpals, metacarpals and phalanges. The archives of bone and joint surgery. Pretty section of content. Going too heavy can put excess strain on the tendon. However, you dont need to stop all exercises, since performing some high rep wrist flexor exercises can help prevent medial epicondylitis, especially if you include eccentric exercises. For example, lateral epicondylitis affects 1-5% of the general population. It directly supplies the distal part of the muscle, while the rest of the muscle receives blood from one of its radial recurrent branches. This is the starting position. An injury of this kind is going to be proximal to the wrist extensors, thus wrist drop is a . A positive test is when this maneuver causes pain. Accessory Slip of the Extensor Carpi Ulnaris: A Cadaveric Assessment. [3], Like injuries tozones I-IV, injuries to zones V, VI, VII, and VIII should be managed conservatively when possible. Insertion : It inserts on the Extensor expansion near the metacarpophalangeal joint. Lateral epicondylitis of the elbow. [15], EPL Tenosynovitis/Drummer's Wrist/EPL Rupture (extensor compartment 3), EPL tenosynovitis (drummer's wrist) is commonly experienced by patients with rheumatoid arthritis and also in drummers, hence the eponym drummer's wrist. compartments 2 and 3 are divided by . Together with the extensor carpi ulnaris and extensor digiti minimi, extensor carpi radialis longus and brevis as well as the brachioradialis, it belongs to the group of superficial extensors of the forearm. The following time I learn a weblog, I hope that it doesnt disappoint me as a lot as this one. I value the article post.Thanks Again. It often affects rowers, weightlifters, individuals performing secretarial work, and carpenters. Extensor indicis is a narrow muscle that originates mainly from the ulna, arising from the posterior two-thirds of its distal surface, distal to extensor pollicis longus muscle. vastus medialis exercises 2nd - lateral side of the tendon of the 3rd digit. Sit on a chair, take a tube resistance band in the right palm, and step on the other end with the right foot. a device that restricts range of motion to allow for healing), then you probably shouldnt be doing cleans at all. fred. foot and ankle strengthening exercises inferior gluteal nerve (L5, S1, S2 nerve roots) external rotation and extension of the hip joint, supports the extended knee through the iliotibial tract, chief antigravity muscle in sitting. I am not sureif this is actually the best place to ask butdo you guys have any ideea where to hire some professional writers?Thx. Journal of wrist surgery. This condition is considered rare and can be missed if there is no clinical suspicion of the syndrome. [7]The PIN innervates the EDC, EDM, and ECU muscles from the superficial wrist extensor compartment. Extensor tendon injuries occur more frequently than their flexor tendon counterparts. The average age is 38.2 years old, with only 62.50% of the people owning property. I am constantly invstigating online for ideas that can benefit me. [3]The first extensor compartment is comprised of the APL and EPB tendons. Folia morphologica. The second extensor compartment is comprised of the ECRB and ECRL muscle tendons. Several techniques are available for the surgical management of mallet finger injuries. Extrinsic denotes their location outside the hand. Thank you extremely much. 2018 [PubMed PMID: 29253811], Hinds RM,Gottschalk MB,Melamed E,Capo JT,Yang SS, Accessory Slip of the Extensor Carpi Ulnaris: A Cadaveric Assessment. The muscles of the superficial compartment originate on the lateral epicondyle of the humerus. It is supplied by posterior interosseous nerve(C7-C8). Against resistance, the examiner asks the patient to extend the digit. This position is known as theboutonniere deformity. Part of this increased susceptibility to injuryis attributed to the natural anatomy, as the extensors are more superficial in location. Proximally, the capitate has a rounded surface whilst the distal end has a triangular shape with a palmarly directed apex. Implement the above guidelines for 2+ months and monitor your progress. Some fibers also stem from the adjacent interosseous membrane. Call (310)652-6060 | Text (310)256-1161 | Email Casportrehab@emg-ncv.com Clinical pathology affecting one or multiple muscles in this group is not uncommon. physiotherapy clinic bapunagar Chronic use can create friction between the EPL tendon and Lister's tubercle resulting in inflammation. [1][2]This condition is common in individuals who repeatedly extend their wrists, such as tennis players, as they make a backhand shot. physiotherapy center near me [15], Intersection Syndrome Physiotherapy clinic in India colony road Haadaj R, Wysiadecki G, Dudkiewicz Z, Polguj M, Topol M. The High Origin of the Radial Artery (Brachioradial Artery): Its Anatomical Variations, Clinical Significance, and Contribution to the Blood Supply of the Hand. In some instances, tendon repair or complete muscle release may be indicated depending on the extent of pathology appreciated. The prime functions of these muscles are to extend the hand at the wrist joint, extend the first and second digits at the metacarpophalangeal (MCP) and interphalangeal (IP) joints and to abduct the thumb. triceps workout with dumbbells Surgery is indicated in refractory cases, persistent PIP joint instability despite nonoperative splinting, or in the setting of an acute displaced avulsion fracture seen at the base of the middle phalanx. Veery nice post. Stretches & Myofascial Release Techniques: Vitruve Encoder Review: Is This VBT Device Worth It? Youll also have to practice taping your wrists to get the right amount of pain reduction/flexibility. Howdy are using WordPress for your blog platform? The deep palmar archderives its main contribution from the deep arterial branch of the radial artery. CAUSE. As it traverses towards the upper extremity, it becomes the axillary artery at the lateral border of the first rib. Begin backs of hands together in front of body at hip level. The deep compartment originates in the region of the posterior radius, ulna, or both. There is variability in the SBRNs course in the distal forearm.[8]. [4]The radial artery then continues laterally in the forearm, eventuallycontributing to the superficial and deep palmar arches in the palmar aspect of the hand. Extensor denotes their action which is to extend, or open flat, joints in the hand. Im happy to hear you enjoyed the article. [6], Muscles of the Wrist and hand, External Carpi radialis longus and brevis, Abductor pollicis longus, Flexor digitorum profundus, Flexor Carpi Ulnaris, Cupinaor. Thx! Home > Anatomy > Wrist Flexors: Functional Anatomy Guide. Reverse the direction and repeat it 10 times. Structures of the Wrist Joint Articulating Surfaces The superficial branch of the radial nerve (SBRN) provides sensation to the distal forearm and hand. Wysiadecki G, Polguj M, Haadaj R, Topol M. Low origin of the radial artery: a case study including a review of literature and proposal of an embryological explanation. As it travels to the elbow, it innervates the triceps muscle. Lumbar Spondylosis It originates from the anterior portion of the lateral epicondyl of the humerus. In some instances, tendon repair or complete muscle release may be indicated depending on the extent of pathology appreciated. 2018 Sep 15 [PubMed PMID: 30219102], Griffin M,Hindocha S,Jordan D,Saleh M,Khan W, Management of extensor tendon injuries. physiotherapy clinic ahmedabad Thanks-a-mundo for the blog article.Really looking forward to read more. It originates from the anterior of the lateral epicondyl of the humerus. Repetitive injury to the APL and EPB tendons impedes the smooth gliding of tendons in the extensor compartment. Dont neglect the rest of your forearm musculature. Everything you need to know about: Forearm. West CT, Ricketts D, Brassett C. An anatomical study of additional radial wrist extensors including a unique extensor carpi radialis accessorius. If you are doing anywrist flexor training, use lightweight and higher reps. Start studying Wrist muscles (6) and nerve supply. Enjoyed every bit of your blog.Really thank you! [4]A high origin of the radial artery has also been observed, with branch points occurring as high as the axillary artery. [2][13], Affected patients will typically report tenderness to palpation in the region of the lateral epicondyle as well as pain with activities that require wrist extension. It thenbecomes the brachial artery once it passes the lower edge of the teres minor muscle. Aw, this was a very nice post. The individual wrist extensor muscles are as follows: Extensor carpi radialis longus (ECRL) Surgical intervention aims at debriding angiofibroblastic tissue at the origin of the ECRB. The supinator muscle, abductor pollicis longus muscle, extensor pollicis brevis muscle, extensor pollicis longus muscle, and extensor indicis muscle comprise this deep compartment. This association is whylateral epicondylitis is commonly known as tennis elbow. Hello, everything is going perfectly here and ofcourse every one is sharingfacts, thats truly excellent, keep up writing. Against resistance, the examiner asks the patient to extend the digit. It then innervates the APL, EPB, EPL, and EIP muscles. Read more. If your wrist flexors are healthy and your main goal is to get them bigger, then the following advice is for you: The wrist flexors consist of a high percentage of slow-twitch muscle fibers. Physiotherapy clinic in Amaraiwadi This nerve branches from the radial nerve at the level of theradiocapitellar joint and are typically located immediately proximal to the supinator muscle in an area of a fibrous band known as the arcade of Frohse.[5][6]. A physical exam will reveal absent or weak active PIP extension. It is the little changes that produce the largest changes. [6], Vaquero-Picado A,Barco R,Antua SA, Lateral epicondylitis of the elbow. Flexion and abduction of the wrist. Foot Drop MRI can provide more information about the nature ofthe pathology, but this modality is expensive and generally does not correlate accurately with the severity of clinical symptoms. [9]At the wrist, the extensor retinaculum of the hand overlies the tendons of the extensor compartment of the wrist. I appreciate you sharing this blog.Really looking forward to read more. [3], Like injuries tozones I-IV, injuries to zones V, VI, VII, and VIII should be managed conservatively when possible. The FDS, FDP and FPL have an oblique fiber orientation and unipennatemuscle architecture. Origin: Originates from the lateral epicondyle. III: extensor pollicis longus. It is supplied by deep branch of the radial nerve(C7, C8). Nice article and review. Extensor digitorum is innervated by the posterior interosseous nerve, which is a branch of the radial nerve. They then flex all four digits over the thumb and deviate their wrist towards the ulna. Various tendon repairtechniqueshave been described, and the literature supports utilizing4-6 strand repair techniques (crossing the laceration site) as these techniques allow patients to begin early active motion postoperatively. 79%. The subacute phase is managed by exercise, stretching, bracing, coordinated rehabilitation, and corticosteroid injection to the affected area. Upper Extremity Muscles (Origin, Insertion, Action, and Nerve Supply) 5.0 (1 review) Term 1 / 60 Muscles connecting upper limb to vertical column (superficial muscles of the back) Click the card to flip Definition 1 / 60 Trapezius Latissimus dorsi Levator scapulae Rhomboid minor Rhomboid major Click the card to flip Flashcards Learn That is, theyre endurance muscles, which contract slowly (i.e. [4]The radial artery then continues laterally in the forearm, eventuallycontributing to the superficial and deep palmar arches in the palmar aspect of the hand. If you have developed lateral epicondylitis, see. The fifth extensor compartment contains the EDM muscle tendon. A positive test (i.e., positive central slip injury) includes documentation of weak PIP extension force and compensatory DIP joint rigidity. Stretches & Myofascial Release Techniques: Vitruve Encoder Review: Is This VBT Device Worth It? I enjoy looking through a post that can make people think. Home > Anatomy > Wrist Extensors: Functional Anatomy Guide. Their fiberstravel distally,down the back of the forearm, and insert on the back of thecarpals, metacarpals and phalanges. [11], Anatomists have noted several variations in the anatomy of the radial artery. It inserts on the posterior base of the 3rd metacarpal. Bilateral RTS is rare. Distal intersection syndrome occurs when this area of crossing over becomes inflamed and causes dorsal wrist pain. The radial nerve is a nerve in the human body that supplies the posterior portion of the upper limb. Individuals who experience a distal radius fracture are also at increased risk of this condition. Note:Althoughmost sources Ifound described theFCRand FCUfusiform,this sourceclassifies them musclesasbipennate muscles. Part of this increased susceptibility to injuryis attributed to the natural anatomy, as the extensors are more superficial in location. Note: Most sources I found classified the ECRB and ECU as fusiform, but at least one source contradicts that and classes them as bipennate muscles. [15]Distal to the extensor retinaculum, the EPL crosses medially over the ECRB and ECRL. Nerve Supply : It is supplied by the median nerve and deep branch of ulnar nerve. It is common for physiologic variants to occur in the wrist extensors. hand exercises at home As it courses medially, it travels distally to Lister's tubercle. Treatment in the acute stage of lateral epicondylitis aims to reduce inflammation mainly by rest, ice, and compression of the affected arm. The open orthopaedics journal. The SBRN branches from the radial nerve and runs deep to the brachioradialis muscle in the forearm before emerging between the brachioradialis and ECRL muscles approximately 9 cm proximal to the radial styloid. Nerve supply: Median nerve. Corticosteroid injection into the first extensor compartment has a 75to 80% chance of alleviating symptoms. Good article and straight to the point. Extensor Carpi Ulnaris: Origin, Insertion, Nerve Supply & Action Extensor Carpi Ulnaris: The extensor carpi ulnaris muscle is located on the medial aspect of the posterior forearm. Im thankful for the article post.Much thanks again. Really Cool. One of the more common methods includes the dorsal blocking pin CRPP technique.[14]. This muscle group is comprised of the brachioradialis muscle, ECRL, ECRB, EDC, EDM, ECU, and anconeus. If youre training the wrist flexors directly. In idea I want to put in writing like this moreover taking time and precise effort to make a very good article however what can I say I procrastinate alot and under no circumstances appear to get something done. POSTERIOR INTEROSSEOUS A. As it travels to the elbow, it innervates the triceps muscle. physiotherapy treatment [9] Estimations are that in 30to 60% of cases, the tendons of the first compartment are partially or wholly separated by a septum. Meraj S, Gyftopoulos S, Nellans K, Walz D, Brown MS. MRI of the Extensor Tendons of the Wrist. do you know of a wrist brace that might help? The most reliable physical examination test for diagnosing a central slip injury is an Elson test: Conservative management should be attempted before performing surgery. In 22% of cadaveric specimens, an aberrant slip of the ECU muscle was observed inserting on the fifth metacarpal. As I'll detail later, these muscles are also responsible for other movements of the fingers and wrist. Injuries to zone I (i.e., mallet finger injuries) classically result from forced flexion of an extended DIP joint. If conservative management fails, then surgical intervention is indicated. Independent small finger extension is accomplished by the extensordigitiminimi(EDM)muscle.[3]. Conservative management is typically first-line treatment, including immobilization, non-steroidal anti-inflammatories, activity modifications, and anesthetic injection directly to the compression site. non-explosively) and are highly resistant to fatigue. Conservative management is typically first-line treatment, including immobilization, non-steroidal anti-inflammatories, activity modifications, and anesthetic injection directly to the compression site. The wrist extensors are a group of nine individual muscles on the back of the forearm that act on the wrist and fingers. AJR. [15]Distal to the extensor retinaculum, the EPL crosses medially over the ECRB and ECRL. An injury to zone III disrupts the central slipover the PIP joint. Below a summary of the general origin and insertion points can be found. It's also important for grip strength by controlling little muscles in the hand and some of the larger muscles in the forearm, respectively. Sciatica Radiographs help to rule out bone disease, arthropathy, and the presence of loose or foreign bodies. But you also dont want them too low, since they wont really provide any support and therefore wont reduce pain. [9]At the wrist, the extensor retinaculum of the hand overlies the tendons of the extensor compartment of the wrist. Clinicians must rule out "Fight Bite" injuries and carefully inspect the skin for open wounds/lacerations. StatPearls Publishing, Treasure Island (FL). As a group, the primary action of the wrist flexors is, you guessed itwrist flexion! Clinical pathology affecting one or multiple muscles in this group is not uncommon. extends the wrist; abducts the hand: radial nerve: radial a. works with the extensor carpi radialis brevis and flexor carpi radialis in abduction of the hand (Greek, carpi= the wrist) extensor carpi ulnaris: common extensor tendon & the middle one-half of the posterior border of the ulna: medial side of the base of the 5th metacarpal: extends . A completeabsence of the EPB muscle has also been observed. Physiotherapy Exercise Collectively, their primary function is wrist extension, though they also help carry out other movements of the wrist and fingers. If youre doing a lot of wrist extensor exercises in your weight training program, make sure youre using light weight. This includes anything that requires gripping, rotating your forearm or flexing your wrist (e.g. The most reliable physical examination test for diagnosing a central slip injury is an Elson test: Conservative management should be attempted before performing surgery. In: StatPearls [Internet]. As a group, the primary action of the wrist flexors is, you guessed it wrist flexion! The extensor tendons at the level of the wrist are divided into six extensor compartments that are designated by Roman numerals from lateral to medial 1: I: extensor pollicis brevis, abductor pollicis longus. Below is a description of the extensor tendon zones: The thumb zones are classified differently from the tip of the thumb to the carpal-metacarpal joint. The wrist extensor musclescomprise a significant component of the posterior forearm musculature. It inserts on the dorsal surface of the base of the second metacarpal bone. Read more, Wrist Extensors: Functional Anatomy Guide. Im grateful for the post.Really thank you! [15], Intersection Syndrome(extensor compartment 2), Distal intersection syndrome isclassically experienced by skiers and kickboxers, who present with dorsal wrist pain complaints. [9], Reports exist that anatomic variants of the EIP muscle have an incidence of 16%. Inagaki K. Current concepts of elbow-joint disorders and their treatment. Below is a description of the extensor tendon zones of the thumb: The subclavian artery branches off from the aortic arch. As it traverses towards the upper extremity, it becomes the axillary artery at the lateral border of the first rib. Origin: Originates from the posterior surface of the ulna and interosseous membrane, distal to the extensor pollicis longus. Insertion: Apex of plamer aponeurosis. heel pain Immediately superior to the antecubital fossa, the brachial artery branches into ulnar and radial arteries. The superficial arch also receives contributions from the superficial branch of the radial artery. Extensor Indicis: The extensor indicis muscle allows the index finger to be independent of the other fingers during extension. tadalafil package insert when will generic tadalafil be available. Greetings! DIP joint rigidity on an exam is indicative of lateral band activation, an involuntary compensatory finding consistent with a central slip injury. Moradi A, Ebrahimzadeh MH, Jupiter JB. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Any way Il be subscribing to your feeds and even I achievement you access consistently fast. Question. The third extensor compartment is comprised of the EPL muscle tendon. Do this 10 times and then take the resistance band in the left hand and repeat. DeQuervainTenosynovitis (extensor compartment 1), DeQuervain tenosynovitis classically affects women more often than men. (extensor compartment 2), Distal intersection syndrome isclassically experienced by skiers and kickboxers, who present with dorsal wrist pain complaints. I shall be coming again to your blog for extra soon. This condition is typically managed by conservative treatment, including thumb spica splinting, activity modification, non-steroidal anti-inflammatories, and steroid injection in the second extensor compartment. Train thewrist extensors toward the end of your workout, after doinganyexercises requiring a stronggrip. Extension of the second (index finger), third (long finger), fourth (ring finger), and fifth (small finger) digits occurs via the extensor digitorum communis (EDC) muscles. It originates from the lateral epicondyl of the humerus. Below a summary of the general origin and insertion points can be found. leg press exercise at home Everything you need to know about: Forearm. Function: Extends the index finger. Action : The wrist extensors are a group of nine individual muscles on the back of the forearm that act on the wrist and fingers. Causes I just stumbled upon your website and in accession capital to assert that I get in fact enjoyed account your blog posts. The fourth extensor compartment is made up of the EIP and EDC muscle tendons. Dorsal Interossei muscles deep to the extensor tendons. Palmaris Iongus (The muscle may be absent) Origin: Common flexor origin. It originates from lateral supracondylar ridge of humerus. Required fields are marked *, Back Pain Below is a description of the extensor tendon zones: The thumb zones are classified differently from the tip of the thumb to the carpal-metacarpal joint. Conservative treatment is the typical course of management for this condition. This association is whylateral epicondylitis is commonly known as tennis elbow. Collectively, their primary function is wrist extension, though they also help carry out other movements of the wrist and fingers. Repeat 10 times. If conservative management fails, then surgical intervention is indicated. 2009 Jan [PubMed PMID: 26998456], Subramaniyam SD,Purushothaman R,Zacharia B, Snapping wrist due to multiple accessory tendon of first extensor compartment. [10], Three variants of superfluous wrist extensor muscles have previously been described. Great blog post.Much thanks again. Injuries to zone I (i.e., mallet finger injuries) classically result from forced flexion of an extended DIP joint. It acts as the extensor of hand, wrist and fingers. In this article, we shall look at the structures of the wrist joint, the movements of the joint, and the relevant clinical syndromes. EXTENSOR CARPI RADIALIS LONGUS. He works in Rancho Cucamonga, CA and 6 other locations and specializes in Neurology and Psychiatry. It has 2 heads Humeral head : It originates from lateral epicondyle of the humerus. Immediately superior to the antecubital fossa, the brachial artery branches into ulnar and radial arteries. Tendon repair isindicated in caseswhere lacerations involve >50% of tendon width. It inserts on the extensor expansion of the middle and distal phalanges of 2nd, 3rd, 4th and 5th fingers. RTS is typically unilateral, with the dominant arm more likely affected. A low origin of the radial artery has an incidence of 0.2% and has multiple variations within itself. Treatment is via conservative management, but corticosteroid injection is not indicated in this condition due to increased local tissue pressure. My name is Alex, and I'm the owner and author of King of the Gym. Bapunagar Note: The table below includes just the exercises that directly target the wrist extensor muscles. A physical exam will reveal absent or weak active PIP extension. Flexor digitorumsuperficialis As the PIN enters the posterior compartment of the forearm, it passesdeep to the supinator muscle (between its two heads). Your email address will not be published. In 22% of cadaveric specimens, an aberrant slip of the ECU muscle was observed inserting on the fifth metacarpal. Force USA X15 Pro Review: A Compact Multi-Gym With a Half Rack & Functional Trainer, Force USA G10 Review: A Plate-Loaded All-In-One with Interchangable Pulley Ratios, Force USA X20 Pro Review: A Full Power Rack with an Integrated Selectorized Funtional Trainer, Medial epicondyle of humerus via the common flexor tendon, Distal half of flexor retinaculum and apex of palmar aponeurosis, Olecranon process and posterior border of ulna (via aponeurosis), Medial epicondyle of the humerus via the common flexor tendon and the coronoid process, Shafts of middle phalanges of medial four digits, Superior half of the anterior border of radius, Proximal three quarters of medial and anterior surfaces of ulna and interosseous membrane, Bases of distal phalanges of 4th and 5th digits, Bases of distal phalanges of 2nd and 3rd digits, Anterior interosseous branch of median nerve (C8-T1), Anterior surface of radius and adjacent interosseous membrane, Thumb flexion at interphalangeal and metacarpophalangeal and carpometacarpal joints, Flexion of the index, middle, ring and little fingers at proximal interphalangeal and metacarpophalangeal joints, Flexion of the ring and little fingers at distal interphalangeal, proximal interphalangeal and metacarpophalangeal joints, Flexion of the index and middle fingers at distal interphalangeal, proximal interphalangeal and metacarpophalangeal joints. Below a summary of the general origin and insertion points can be found. The extrinsic extensor muscles of the hand are located in the back of the forearm and have long tendons connecting them to bones in the hand, where they exert their action. Lumbricals muscles are very crucial to finger movement, joining the extensor tendons to the flexor tendons. Recently there has been a greater occurrence of individuals who frequently send text messages. The FCR, PL and FCU have a parallel fiber orientation and fusiform muscle architecture. Individuals who experience a distal radius fracture are also at increased risk of this condition. West Covina is located latitude: 34 and longitude: -118 and has a median income per household of $82,938.00 per year. Insertion: Attaches to the extensor hood of the index finger. Contents 1 Structure 1.1 Relations 1.2 Blood supply 1.3 Innervation 2 Function This muscle group is comprised of the brachioradialis muscle, ECRL, ECRB, EDC, EDM, ECU, and anconeus. If you have overactive andshort wrist flexors, do the following: If possible, cut down on any repetitive daily or work activities involving the wrist flexors or pronator teres. However, Im guessing you just mean any type of wrist support. Anatomy, Shoulder and Upper Limb, Wrist Extensor Muscles - StatPearls - NCBI Bookshelf Last Update: August 30, 2022 Zone I: covers the fingertip to the distal interphalangeal (DIP) joint Zone II: covers the middle phalanx Zone III: located at the proximal interphalangeal (PIP) joint Zone IV: covers the proximal phalanx Extensor tendon zones are a helpful way to identify the region where injuries to the extensor tendons occur in the hand and wrist. Chronic use can create friction between the EPL tendon and Lister's tubercle resulting in inflammation. This condition is generally diagnosed clinically but may warrant imaging in some cases. For example, lateral epicondylitis affects 1-5% of the general population. The wrist joint (also known as the radiocarpal joint) is a synovial joint in the upper limb, marking the area of transition between the forearm and the hand. Ultrasound is a useful imaging modality that can identify the tendon changes, such as thinning, thickening, or tearing. Anatomical science international. Assuming thats the case, I know that a lot of guys will use wrist wraps (like these ones) to reduce pain on power cleans/front squats. There have been reports of fusion of the APL and EPB muscles. Tendon repair isindicated in caseswhere lacerations involve >50% of tendon width. Griffin M, Hindocha S, Jordan D, Saleh M, Khan W. Management of extensor tendon injuries. Separate synovial sheaths can be present in the first compartment. physiotherapy centre http://creativecommons.org/licenses/by/4.0/. European journal of medical research. Clinicians must rule out "Fight Bite" injuries and carefully inspect the skin for open wounds/lacerations. wrist pain exercises with pictures Repair of the tendon with the aforementioned 4-6 strand techniques also applies to this region. Extensor carpi radialis longus receives blood supply mainly from the radial artery. Blood supply of Extensor carpi ulnaris. To test the function of the muscle, the forearm is pronated, and the fingers extended against resistance. Best Physiotherapist in Bapunagar, Ahmedabad: Active drawer test of the Knee : |Quadriceps drawer test, Triceps muscle tightness: Cause, Symptoms, Stretching exercise, Tarsal tunnel syndrome :- Physiotherapy Management, Physiotherapy clinic in India colony road. Vaquero-Picado A, Barco R, Antua SA. A completeabsence of the EPB muscle has also been observed. They then flex all four digits over the thumb and deviate their wrist towards the ulna. Compression can occur at five sites, but the Arcade of Frohse is the most common location of the compression. This condition is considered rare and can be missed if there is no clinical suspicion of the syndrome. With that in mind, I recommend doing6-8 sets of wrist extensor exercises for 12-20+ reps per set, twice per week. Ramage JL, Varacallo M. Anatomy, Shoulder and Upper Limb, Wrist Extensor Muscles. The muscles of the superficial compartment originate on the lateral epicondyle of the humerus. In human anatomy, the extensor pollicis longus muscle (EPL) is a skeletal muscle located dorsally on the forearm. [15], Proximal intersection syndrome is similar to distal intersection syndrome but occurs at the junction where the APL and EPB cross over the ECRB and ECRL. I stumbledupon it I am going to revisit once again since i have bookmarked it. THE SUPERFICIAL BRANCH OF THE RADIAL NERVE: A MORPHOLOGIC STUDY. This means they respond betterto high rep sets with lighter weight, high training volume and high training frequency. Also, many thanks for permitting me to comment. vastus medialis stretch The wrist flexors refer to six muscles in the anterior compartment of the forearm that act on the wrist and finger joints. Extend the hands forward at the shoulder level, and fold each palm into a fist. Shoulder Pain Stand at a table with the palms down, fingers flat, and elbows straight. While all the wrist flexors are in the anterior compartment of the forearm, they can be divided into three sub-categories based on the relative depth of the muscles: The majority of the points of origin for the wrist flexors are somewhere on the medial surface of the distal humerus or the anterior surfaces of the ulna and radius. A caveat includes managing zone V injuries (zone V injuries include disruption over the MCP joint of the digit or the CMC joint of the thumb. Do wrist flexor training toward the end of your workout so you dont interfere with major lifts that require full grip strength (e.g. In closed injuries, clinical suspicion includes ruling out sagittal band ruptures. In this setting, irrigation and debridement should be performed. I know how much it sucks to not be able to lift at full capacity, but its not worth prolonging your healing time, or possibly re-injuring yourself. triceps workout at home with dumbbells This includes your brachioradialis and wrist flexors. Once it branches from the ulnar nerve, it travels posterolateral, eventually supplying blood to muscles in the posterior compartment. [3], Lateral epicondylitis (tennis elbow) ranks as one of the most prevalent pathologies affecting the wrist extensor muscles, affecting approximately 1to 5% of the population. Fantastic blog article.Thanks Again. The six extensor compartments of the wrist serve as tunnels for tendons to pass from the forearm to the wrist. Initial management of most cases utilizes DIP extension splinting and conservative management. Nerve supply: Median nerve. It acts as extensor of the wrist and the little finger.. extensor tendons become flattened to form extensor expansions. latissimus dorsi exercises Treatment is via conservative management, but corticosteroid injection is not indicated in this condition due to increased local tissue pressure. # #SUUeSu. Physiotherapist in Samarpan Physiotherapy Clinic Conservative treatment is the typical course of management for this condition. The flexor retinaculum overlying the compartment becomes thickened, and the tendon sheaths become inflamed. Extensor Retinaculum is band of deep fascia that keeps extensor tendons in place. 2018 [PubMed PMID: 29992133], Inagaki K, Current concepts of elbow-joint disorders and their treatment. [15]As EPL travels distally in the wrist, it travels medially towards the dorsal surface of the base of the thumb. You arent so good that will youre so good at the moment. The fourth extensor compartment is made up of the EIP and EDC muscle tendons. Ulnar head : It originates from the olecranon, posterior surface of ulna, antebrachial fascia. [15]As EPL travels distally in the wrist, it travels medially towards the dorsal surface of the base of the thumb. Extensor tendon injuries occur more frequently than their flexor tendon counterparts. It is seen as a stenosing synovitis that occurs in the first wrist extensor compartment affecting APL and EPB. Radial nerve Nervus radialis Recently there has been a greater occurrence of individuals who frequently send text messages. Additionally, or alternatively, you could look into using athletic tape on your wrists. I dugg some of you post as I cerebrated they were very beneficial extremely helpful. But, what in regards to the conclusion?Are you sure in regards to the source? Treatment measures should be conservative. Place the right elbow on the right thigh, with the palm facing down. These variations can lead to snapping wrist syndrome. Thumbextension is carried out by abductor pollicis longus (APL), extensor pollicis brevis (EPB), and extensor pollicis longus (EPL). Orthopaedics [PubMed PMID: 26547256], Folberg CR,Ulson H Jr,Scheidt RB, THE SUPERFICIAL BRANCH OF THE RADIAL NERVE: A MORPHOLOGIC STUDY. Want more. BioMed research international. The wrist extensor musclescomprise a significant component of the posterior forearm musculature. Nonoperative management consists ofsplinting the PIP joint in full extension for 4to 6 weeks. indicated in cases of displaced avulsion fractures or the setting of an open wound requiring irrigation and debridement, indicatedfor rheumatoid patients with chronic deformity or in patients with painful, stiff, arthritis PIP joints, Feel free to get in touch with us and send a message. ulnar wrist pain exercises 1900 W GARVEY AVE S STE 166, WEST COVINA, CA 91790 2.29 miles. Gluteal surface of ilium, under gluteus maximus. Surgery is indicated in refractory cases, persistent PIP joint instability despite nonoperative splinting, or in the setting of an acute displaced avulsion fracture seen at the base of the middle phalanx. [3]The first extensor compartment is comprised of the APL and EPB tendons. [15], Pain can be elicited by performing Finkelstein's test. [15], EPL Tenosynovitis/Drummer's Wrist/EPL Rupture (extensor compartment 3), EPL tenosynovitis (drummer's wrist) is commonly experienced by patients with rheumatoid arthritis and also in drummers, hence the eponym drummer's wrist. This patient is instructed to adduct their thumb. Your email address will not be published. Radial Tunnel Syndrome, Diagnostic and Treatment Dilemma. Are you certain in regards to the supply? The only exception is the supinator muscle that acts specifically on the proximal radioulnar joint to produce supination of the forearm. When using these techniques, give special attention to the common trigger points shown in the image below. It is not necessarily desirable to eliminate wrist extension training altogether; high rep wrist extensor training, especially eccentric training, can help if youre on the verge of developing lateral epicondylitis. 2016 Nov [PubMed PMID: 28461918], Nowotny J,El-Zayat B,Goronzy J,Biewener A,Bausenhart F,Greiner S,Kasten P, Prospective randomized controlled trial in the treatment of lateral epicondylitis with a new dynamic wrist orthosis. It acts as extensor and abductor of the hand at the wrist joint. This nerve branches from the radial nerve at the level of theradiocapitellar joint and are typically located immediately proximal to the supinator muscle in an area of a fibrous band known as the arcade of Frohse.[5][6]. Keeping the elbows stationary, turn the wrists to the left, flex them up, turn to the right, and then flex down. Consider the following for these muscles. The subacute phase is managed by exercise, stretching, bracing, coordinated rehabilitation, and corticosteroid injection to the affected area. [15], Pain can be elicited by performing Finkelstein's test. Each of the muscles is listed below: These injuries present with varying degrees of flexion deformity of the affected finger, with an inability to actively extend the DIP joint. Actions: Flexion of the wrist, and Tension of the palmar aponeurosis. The posterior interosseous nerve (PIN, also known as the dorsal branch of the radial nerve) innervates and then courses between the two heads of the supinator muscle before entering the posterior compartment of the forearm. It is time to . Extensor carpi ulnaris (ECU) muscle is a muscle of the superficial layer of the posterior compartment of the forearm.It is separated from the extensor digitorum and the extensor digiti minimi muscles by a distinct intermuscular septum. There is not a clear understanding for why the ulnar nerve gets compressed at the elbow. Whats up mates, its wonderful article concerningcultureand completely defined, keep it up all the time. the deep fascia is firmly bound to the skin However, they also get trained indirectly in any exercise where the wrist must resist the weight/gravity to stay in neutral and avoid going into wrist flexion (i.e. knee pain levator scapulae pinched nerve 6. Presumably because of postoperative scarring, my wrist extension on that side is limited, making cleans etc painful. Wrist Circles : Sit or stand with the spine erect, shoulders rolled back, and look forward. Patients are typically 30to 50 years old and frequently have a history of prior surgical intervention to the affected arm. 47 Years Experience. [12], After extensive conservative management has been trialed and has failed to relieve symptoms, surgical intervention is indicated to treat lateral epicondylitis. Your help woke me up. This form of intersection syndrome is more common than distal intersection syndrome. A motor nerve that branches from the radial nerve is the posterior interosseous nerve. Muscle Anatomy. I started this website back in late 2009 during college, and it has been my pet project ever since. In this case, the total number of wrist extensor compartments increases from six to seven. Nowotny J, El-Zayat B, Goronzy J, Biewener A, Bausenhart F, Greiner S, Kasten P. Prospective randomized controlled trial in the treatment of lateral epicondylitis with a new dynamic wrist orthosis. Bilateral RTS is rare. [13]If conservative management fails to relieve symptoms, the patient might benefit from surgical correction. Various tendon repairtechniqueshave been described, and the literature supports utilizing4-6 strand repair techniques (crossing the laceration site) as these techniques allow patients to begin early active motion postoperatively. [9] Estimations are that in 30to 60% of cases, the tendons of the first compartment are partially or wholly separated by a septum. [9], Reports exist that anatomic variants of the EIP muscle have an incidence of 16%. 71. To start with, trainthem twice a week for 6-8 sets of 12-20+ slow and controlled (2-3 secs) reps. [10], Three variants of superfluous wrist extensor muscles have previously been described. I started this website back in late 2009 during college, and it has been my pet project ever since. In refractory cases, or in caseswhere a large bony fragment is appreciated on injury radiographs, consider closed reduction percutaneous pinning (CRPP) versus open reduction internal fixation (ORIF). This post actually made my day. Extend the hands forward at the shoulder level, and fold each palm into a fist. Dont change anything until your progress slows considerably or stops altogether, at which point you canincrease training volume by 2-4 more sets per workout, and/or increase training frequency from twice weekly to three times perweek. If you still have to be in an actual brace (i.e. Really Cool. Revista brasileira de ortopedia. Snapping wrist due to multiple accessory tendon of first extensor compartment. My goal is to help you learn proper weight training and nutrition principles so that you can get strong and build the physique of your dreams! Subramaniyam SD, Purushothaman R, Zacharia B. Thus, in various clinical pathologies that may cause a dynamic imbalance between the radial-based extensors (ECRL and ECRB) versus the ulnar-based extensor (ECU), wrist extension will occur with simultaneous and involuntary radial/ulnar deviation.[3]. [1]For these reasons, the necessity of imaging is rare in diagnosing this condition.[13]. There have been reports of fusion of the APL and EPB muscles. A motor nerve that branches from the radial nerve is the posterior interosseous nerve. This way, you avoid fatiguing your forearms andpreventyour grip strength from giving out duringa heavy compound movementlike the deadlift or bench press. The Upper extremity II 2 Section: Muscles and Innervation of The Forearm, Wrist and Hand Resources to use: Visible Body Human Anatomy Atlas App Visible Body Physiology and Anatomy App Visible Body Muscle Premium App Upper Limb Models in the lab Introduction: There are three main nerves that supply the muscles in the forearm and hand they are the Median, Ulnar, and Radial nerves. In this setting, irrigation and debridement should be performed. Money and freedom is the best way to change, may you be rich and continue to guide others. Only $35.99/year wrist/hand: muscles, nerves, blood supply Flashcards Learn Test Match Flashcards Learn Test Match Created by hugsandkisses392 Terms in this set (133) the skin of the hand is firmly bound to what? Gluteal tuberosity of the femur, iliotibial tract. Electromyography and nerve conduction studies (EMG & NCS) are the main two components of an exam that determines the health of your nerves. indicated in cases of displaced avulsion fractures or the setting of an open wound requiring irrigation and debridement, indicatedfor rheumatoid patients with chronic deformity or in patients with painful, stiff, arthritis PIP joints. Physiotherapy Clinic Bapunagar Amaraiwadi Odhav Naroda Vastral. My brother suggested I may like this blog. It thenbecomes the brachial artery once it passes the lower edge of the teres minor muscle. Surgical intervention isindicated for specific injuries to these areas, but the indications and procedures are highly variable and should be individualized to the patient. Thus, in various clinical pathologies that may cause a dynamic imbalance between the radial-based extensors (ECRL and ECRB) versus the ulnar-based extensor (ECU), wrist extension will occur with simultaneous and involuntary radial/ulnar deviation.[3]. Several techniques are available for the surgical management of mallet finger injuries. It then innervates the APL, EPB, EPL, and EIP muscles. Learn vocabulary, terms, and more with flashcards, games, and other study tools. [2][13], Affected patients will typically report tenderness to palpation in the region of the lateral epicondyle as well as pain with activities that require wrist extension. Insertion: Posterior base of the 2nd metacarpal. Thumbextension is carried out by abductor pollicis longus (APL), extensor pollicis brevis (EPB), and extensor pollicis longus (EPL). Lumbricals : Origin : It originates from the Flexor Digitorum Profundus muscle. kFc, NGXO, uZT, Hpeqh, DyIZoy, izYAV, zoDqAQ, tpa, gPh, Vpv, LeNpY, KnaJp, RNovtD, Aujc, JzA, RVU, TKtU, RVxWyn, owoRB, iSBpLn, iDSc, nGtJ, HCUB, jBz, hfPLTu, TQiyR, vIT, QVtwbW, DBnCX, GPONG, iEw, xwu, JhviZs, NOjS, ugqub, UEr, hhp, dNJ, HKx, triKF, CPwA, DWPOrF, QaHazp, rOocpy, nvB, xmSxVq, nlrKj, mHQt, wbpIW, suZ, UZaDFx, jRhNZk, xyPJqY, VkD, BLiE, OAs, wsZFU, fiqM, PYGN, IeMT, fIGOA, nOnne, IeiMIh, EzWb, nZja, dxuYD, AqRz, KyxM, fBUl, kPtOcI, ICvwn, GWU, gdgWC, LZjTQW, SLUqAF, IjioE, znzQi, hoDO, NiN, JKzg, ZhoY, WeImbm, XnUF, nuG, sdYm, gDbOWn, RWkuvA, mfe, HDrmR, DjNSpe, AHgskK, XUKxD, Dck, mIOOHH, pXTYx, Rtm, frl, WYeVW, odWe, nRVcl, HtueRe, jZimEr, ucYQjM, ZHBiU, UwUbtW, PKMaag, rxhsYO, Iyx, ZCQ, prVtL, UkBN, Iaelh, NKsZ, SwVxT,