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Drugs & Diseases > Orthopedic Surgery

TRIGGER FINGER

Updated: Jan 17, 2023
* Author: Satishchandra Kale, MD, MBBS, MBA, MCh(Orth), FRCS(Edin),
FRCS(Tr&Orth); Chief Editor: Harris Gellman, MD more...

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Sections
Trigger Finger

* Sections Trigger Finger
* Overview

* Practice Essentials
* Background
* Anatomy
* Pathophysiology
* Etiology
* Epidemiology
* Prognosis
* Patient Education
* Show All
* Presentation

* History
* Physical Examination
* Show All
* DDx
* Workup

* Approach Considerations
* Radiography
* Histologic Findings
* Staging
* Show All
* Treatment

* Approach Considerations
* Corticosteroid Injection Into Tendon Sheath
* Splinting
* Surgical Release
* Kapandji Enlargement-Plasty of A1 Pulley
* Physical Therapy
* Occupational Therapy
* Complications
* Show All
* Medication

* Medication Summary
* Nonsteroidal Anti-inflammatory Drugs
* Corticosteroids
* Show All
* Questions & Answers
* Media Gallery
* References

Overview

PRACTICE ESSENTIALS

Trigger finger (TF; also referred to as stenosing tenosynovitis), one of the
most common causes of hand pain and disability, is a condition that causes pain,
stiffness, and a sensation of locking or catching when the digit is flexed and
extended. (See the image below.) The patient may present with a digit locked in
a particular position, most often flexion (bent position), which may require
gentle, passive manipulation into full extension. [1] TF most commonly affects
the ring finger and the thumb (trigger thumb) but can also occur in the other
fingers.

Trigger finger often results in difficulty flexing or (in this case) extending
metacarpophalangeal joint of involved digit.
View Media Gallery

TF results from thickening of the flexor tendon within the distal aspect of the
palm. [2, 3] This thickening causes abnormal gliding and locking of the tendon
within the tendon sheath. Specifically, the affected tendon is caught at the
edge of the first anular (A1) pulley.

SIGNS AND SYMPTOMS OF TRIGGER FINGER

Signs and symptoms of TF are as follows:

* Locking or catching during active flexion-extension activity (passive
manipulation may be needed to extend the digit in the later stages)

* Stiff digit, especially in long-standing or neglected cases

* Pain over the distal palm

* Pain radiating along the digit

* Triggering on active or passive extension by the patient

* Palpable snapping sensation or crepitus over the A1 pulley

* Tenderness over the A1 pulley

* Palpable nodule in the line of the flexor digitorum superficialis (FDS), just
distal to the metacarpophalangeal (MCP) joint in the palm

* Fixed-flexion deformity in late presentations, especially in the proximal
interphalangeal (PIP) joint

* Evidence of associated conditions (eg, rheumatoid arthritis [RA], gout)

* Early signs of triggering in other digits (may be bilateral)

Children with trigger thumb rarely complain of pain. They usually are brought in
for evaluation when aged 1-4 years, when the parent first notices a flexed
posture of the thumb’s interphalangeal (IP) joint. These children often
demonstrate bilateral fixed flexion contractures of the thumb by the time they
present to the physician. [4] By the time the child presents to the clinic,
surgical treatment is already indicated in most instances.

See Clinical Presentation for more detail.

DIAGNOSIS OF TRIGGER FINGER

As a rule, no lab tests are needed in the diagnosis of TF. If there is a concern
regarding an associated, undiagnosed condition, such as diabetes mellitus (DM),
RA, or another connective tissue disease, tests such as those assessing
glycosylated hemoglobin (HgbA1c), fasting blood sugar, or rheumatoid factor
should be ordered.

Radiography rarely is indicated in TF. [5] Hand radiographs are performed only
if abnormal pathology (eg, abnormal sesamoids, loose bodies in the MCP joint,
osteoarthritic spurs on the metacarpal head, avulsion injuries of collateral
ligaments) is suspected.

See Workup for more detail.

MANAGEMENT OF TRIGGER FINGER

Conservative treatment

Corticosteroid injection in the area of tendon sheath thickening is considered
to be the first-line treatment of choice for TF.

Custom-made splinting of the MCP joint, albeit rarely used, is another
conservative treatment, used in patients who do not wish to undergo a steroid
injection or as an adjuvant to injection. Typically, a custom-made splint is
used to hold the MCP joint of the involved finger at 10-15° of flexion, leaving
the PIP and distal interphalangeal (DIP) joints free.

Surgery

Trigger digits that fail to respond to two injections usually require surgical
treatment, in the form of surgical release of the A1 pulley, under local
anesthesia. During trigger finger release, the proximal edge of the A1 pulley is
identified, and a scalpel blade is used to divide the entire A1 pulley in the
midline under vision. Dissection of the nodule in the tendon is rarely indicated
and may actually cause tendon weakening or rupture. With relief of triggering
and friction following the release of the A1 pulley, the nodule usually
regresses in size.

If a percutaneous approach is favored, a pair of blunt-tipped, fine scissors is
introduced through the incision, and the A1 pulley is transected.

The open technique is absolutely essential for the thumb or little finger or in
the presence of PIP contractures. Percutaneous release should be reserved for
the index, middle, and ring fingers. [6, 7, 8, 9]

Physical therapy

Physical therapy is generally not required for patients with TF. For cases of
chronic TF, however, treatment may include a trial of heating modalities
followed by sustained, nonballistic stretching of the flexor tendon, as well as
soft-tissue mobilization of the A1 pulley. After injection or surgery, a home
exercise (stretching) program may be one component of treatment.

See Treatment and Medication for more detail.

Next: Background

BACKGROUND

Trigger finger (TF) is one of the most common upper limb problems to be
encountered in orthopedic practice and is also one of the most common causes of
hand pain and disability. It results from thickening of the flexor tendon within
the distal aspect of the palm. [2, 3] This thickening causes abnormal gliding of
the tendon within the tendon sheath. Specifically, the affected tendon is caught
at the edge of the first anular (A1) pulley. (See Etiology and Pathophysiology.)

Patients can have difficulty flexing the affected digit if the tendon is caught
distal to the A1 pulley, or extending the digit if the tendon is caught proximal
to the pulley. The condition is very painful, especially when the locked digit
snaps (releases) beyond the restriction by the use of increased force.

The etiology of TF remains unknown or uncertain, although triggering seems to
occur more frequently in patients with rheumatoid arthritis (RA) or diabetes
mellitus (DM). (See Etiology and Pathophysiology.)

TF begins as discomfort in the palm during movements of the involved digit(s).
Gradually or, in some cases, acutely, the flexor tendon causes painful popping
or snapping as the patient flexes and extends the digit. The patient may present
with a digit locked in a particular position, most often flexion, which may
require gentle, passive manipulation into full extension. (See Presentation.)
[1]

TF has a predilection for the dominant hand, with the most commonly affected
digit being the thumb, followed by the ring, long, little, and index fingers.
(However, a retrospective study of 577 TFs by Schubert et al found no relation
to hand dominance. [10] ) The involvement of several fingers is not unusual.

Trigger finger occurs much less frequently in the pediatric population than in
adults and develops almost exclusively in the thumb. [11] Historically, the
condition in children has been referred to as congenital trigger thumb. [12]
Evidence indicates, however, that it usually presents sometime after infancy and
is thus more appropriately referred to as pediatric trigger thumb. (See
Epidemiology and Presentation.) [13] Yet, by the time medical opinion is sought,
surgery is usually indicated.

In the past, triggering of the digits was treated by splinting in extension,
which caused stiffness and, consequently, loss of MCP and IP flexion. Out of
dissatisfaction with this form of treatment, researchers used intrasheath
steroid injections instead, which resulted in a high proportion of good results.
(See Treatment and Medication.) [14, 10]

In an uncomplicated case of trigger digit, the first-line therapy is still
generally agreed to be injection into the tendon sheath, with surgical release
of the A1 pulley as second-line treatment.

Surgery, in the form of release of the A1 pulley, became popular when splinting
and/or injection therapy failed or in the presence of other pathology, such as
RA, in which injection treatment proved futile or there was a risk of tendon
rupture or infection.

Previous
Next: Background

ANATOMY

FINGERS

Tendon sheaths of the long flexors run from the level of the metacarpal heads
(distal palmar crease, superficial; volar plate, deep) to the distal phalanges.
They are attached to the underlying bones and volar plates, which prevent the
tendons from bowstringing. Predictable and efficient thickenings in the fibrous
flexor sheath act as pulleys, directing the sliding movements of the fingers.

The two types of pulleys are anular (A) and cruciate (C). Anular pulleys are
composed of single fibrous bands (ie, rings), whereas cruciate pulleys have two
crossing fibrous bands.

The order of the pulleys from proximal to distal is as follows:

* The A1 pulley overlies the MCP joints; it is released during surgery for TF
(see the image below)

* The A2 pulley overlies the proximal end of the proximal phalanx

* The C1 pulley overlies the middle of the proximal phalanx

* The A3 pulley lies over the PIP joint

* The C2 pulley lies over the proximal end of the middle phalanx

* The A4 pulley lies over the middle of the middle phalanx

* The C3 pulley lies over the distal end of the middle phalanx

* The A5 pulley lies over the proximal end of the distal phalanx

Flexor tendons pass within tendon sheath and beneath A1 pulley at approximately
metacarpal head, beyond which they travel into digit.
View Media Gallery

The A2 and A4 pulleys are vital in preventing bowstringing of the flexor tendons
and must be preserved or reconstructed after any damage to them.

THUMB

The flexor anatomy of the thumb differs from that of the fingers. The flexor
pollicis longus (FPL) tendon is a single tendon within the flexor sheath that
inserts onto the base of the distal phalanx. The fibro-osseous sheath is
composed of two anular pulleys (A1 and A2) that arise from the palmar plates of
the MCP and IP joints, respectively. The oblique pulley, which originates from
and inserts onto the proximal phalanx, is the most important pulley from a
biomechanical perspective. The oblique pulley is approximately 10 mm in length,
blending with a portion of the adductor pollicis insertion.

The digital nerves and arteries run parallel to the tendon sheath distally. At
the level of the MCP flexion crease, they lie just deep to the skin. Proximal to
the A1 pulley, the radial digital nerve of the thumb crosses obliquely over the
sheath.

Previous
Next: Background

PATHOPHYSIOLOGY

A mismatch between the flexor tendon and the proximal pulley mechanism occurs in
most cases of trigger finger. Normally, the tendons of the finger flexors glide
back and forth under a restraining pulley. [15, 16, 17] Thickening of the flexor
tendon sheath restricts the normal gliding mechanism. A nodule may develop on
the tendon, causing the tendon to get stuck at the proximal edge of the A1
pulley when the patient is attempting to extend the digit, thereby causing
difficulty. (See the image below.)

Inflamed nodule can restrict tendon from passing smoothly beneath A1 pulley. If
nodule is distal to A1 pulley (as shown in this sketch), then digit may get
stuck in extended position. Conversely, if nodule is proximal to A1 pulley, then
patient's digit is more likely to become stuck in flexed position.
View Media Gallery

When more forceful attempts are made to extend the digit, by using increased
force from the finger extensors or by applying an external force (for example,
by exerting force on the finger with the other hand), the digit classically
snaps open with significant pain at the distal palm and into the proximal aspect
of the affected digit. Less commonly, the nodule is restricted distal to the A1
pulley, resulting in difficulty flexing the digit.

Using sonoelastography, a newer technique for quantitative assessment of the
stiffness of soft tissues, the data from one study noted that the causes for
snapping in TF were increased stiffness and thickening of the A1 pulley. Three
weeks after corticosteroid injection, the pulley thickness and the ratio of
subcutaneous fat to the pulley both decreased; snapping disappeared in all
patients studied. [18]

Previous
Next: Background

ETIOLOGY

The etiology of trigger finger is unknown or uncertain. It is suspected that
nodule formation in the tendon, morphologic changes in the pulley, or both in
combination may effect triggering, though why these changes are actually
initiated remains unknown.

Several studies have demonstrated a correlation between TF and activities that
require exertion of pressure in the palm while a powerful grip is used or that
involve repetitive, forceful digital flexion (eg, arc welding, use of heavy
shears). Proximal phalangeal flexion in power-grip activities causes high anular
loads at the distal edge of the A1 pulley. Hueston and Wilson have suggested
that bunching of the interwoven tendon fibers causes the reactive intratendinous
nodule observed at surgery. [19]

Thus, in conclusion, the exact etiology remains unknown, but certain conditions
such as DM or RA may predispose an individual to triggering of the digit.

Sampson et al concluded that the underlying pathobiologic mechanism for
triggering is fibrocartilaginous metaplasia of the pulleys due to trauma or
disease. [20] Several studies have failed to demonstrate the presence of acute
or chronic inflammatory cells within the tenosynovium. The suffix -itis in the
term stenosing tendovaginitis actually is a misnomer unless the condition is
associated with RA or inflammatory arthritis.

The exact etiology is still unknown, but it is thought that DM or autoimmune
conditions may contribute to morphologic changes in the pulley and/or the tendon
sheath to cause triggering. Systemic causes of TF are collagen-vascular
diseases, including the following [21] :

* RA

* DM

* Psoriatic arthritis

* Amyloidosis

* Hypothyroidism

* Sarcoidosis

* Pigmented villonodular synovitis

Septic causes of TF are secondary infections (eg, tuberculosis). A few case
reports have documented rare causes of TF, including tenosynovitis that itself
resulted from a Mycobacterium kansasii infection in an immunocompetent patient;
triggering following the development of calcific tendonitis has been reported in
a child. Such cases should invoke a high degree of suspicion.

The association of idiopathic TF with idiopathic carpal tunnel syndrome has long
been suggested. A study of 551 patients with no predisposing causes diagnosed
with either TF, carpal tunnel syndrome, or both based on clinical grounds
reported that 43% of patients with TF also had concomitant carpal tunnel
syndrome; this is significantly higher than the population prevalence of carpal
tunnel syndrome, which is about 4%. [22]

A retrospective study by Grandizio et al indicated that the risk of developing
TF following surgical carpal tunnel release is greater in patients with DM than
in those without DM. In the study, the investigators found that out of 1003
carpal tunnel releases in patients without DM, the incidence of TF at 6 and 12
months was 3% and 4%, respectively, whereas out of 214 carpal tunnel releases in
patients with DM, the incidence at 6 and 12 months was 8% and 10%, respectively.
The severity of the DM, however, was not found to be a significant factor in the
development of TF. [23]

TRIGGER THUMB

Trigger thumb (see the image below) usually occurs idiopathically, though it
develops more frequently in individuals with diabetes or osteoarthritis. Trigger
thumb is more likely to occur in an individual with any condition that causes
diffuse proliferation of the tenosynovium, such as inflammatory arthritis, gout,
or chronic infection (eg, fungus, atypical mycobacteria). This process can
extend distal to the MCP joint and, when severe, cause stiffness rather than
intermittent triggering.

Trigger thumb. A1 pulley exposed within surgical field (arrow). Digital
neurovascular bundles behind retractors.
View Media Gallery

Certain people appear more prone to tenosynovitic conditions; patients with
trigger thumb are more likely to develop carpal tunnel syndrome and de Quervain
disease. The roles of overuse and trauma in trigger thumb are controversial,
though the condition does have a predilection for the dominant hand.

Previous
Next: Background

EPIDEMIOLOGY

Trigger finger is a relatively common condition and occurs two to six times more
frequently in women than in men.

Several series found the peak incidence of trigger digit to be in individuals
aged 55-60 years. Age distribution has not changed significantly despite an
increase in computing activities and repetitive tasks. As previously mentioned,
TF in the pediatric population occurs much less frequently than in adults and
develops almost exclusively in the thumb. [11]

Previous
Next: Background

PROGNOSIS

INJECTION WITH OR WITHOUT SPLINTING

The prognosis in trigger finger is very good; most patients respond to
corticosteroid injection with or without associated splinting. Some cases of TF
may resolve spontaneously and then reoccur without obvious correlation with
treatment or exacerbating factors.

Freiberg et al found a greater success rate for TF injection therapy when the
treatment was used in patients in whom an examiner could palpate a discrete,
rather than a diffuse, nodular consistency in the flexor sheath. [24] Digits
with a discrete, palpable nodule had a 93% success rate with a single injection
of triamcinolone at 3 months' follow-up, whereas digits with a diffuse pattern
had a 52% failure rate.

Marks and Gunther reported an 84% success rate in trigger digits and a 92%
success rate in trigger thumbs following a single injection of triamcinolone.
[14]

Using sonoelastography, a newer technique for quantitative assessment of the
stiffness of soft tissues, one group noted that the causes for snapping in TF
were increased stiffness and thickening of the A1 pulley. Three weeks after
corticosteroid injection, the pulley thickness and the ratio of subcutaneous fat
to the pulley both decreased; snapping disappeared in all patients studied. [18]

Griggs et al reported an overall success rate of 50% for steroid injection in
patients with DM. [25] Patients with insulin-dependent diabetes had a higher
incidence of multiple digit involvement and required surgical release more
frequently than did patients who were not insulin-dependent. [26, 27]

SURGERY

Patients who need surgical release generally have a very good outcome.
Percutaneous trigger finger release has been reported by several authors to be
safe and efficacious, with success rates of 74-94% and no complications having
been found at medium-term follow-up. The procedure is advised for individuals
with established primary TF who have symptoms lasting longer than 4 months or
for patients in whom injection therapy has failed to relieve symptoms. It is
considered a reasonable choice following one injection failure and actually may
confer cost benefits through permanent relief.

The prognosis is also very good for congenital trigger thumb that is treated
with resection of the tendon nodule.

A study suggests that perioperative characteristics and outcomes differ between
TF and trigger thumb and that the surgical outcome is poorer for TF than for
trigger thumb (partly due to flexion contracture of the PIP joint). [28]

PEDIATRIC

Triggering may resolve spontaneously in 23-63% of pediatric cases. If patients
are not treated by the time they have reached the age of 4 years, some may be
left with permanent flexion contractures. Surgical release of the A1 pulley
prior to this age leads to excellent results. [29, 30, 9]

Previous
Next: Background

PATIENT EDUCATION

As with patient education following any local injection, patients should be told
to watch for signs and symptoms of infection and bleeding. Any suggestion of
infection or excessive bleeding should be reported to the physician immediately.

Patients should understand that some increased tenderness may be noted at the
injection site for 2-4 days, until the corticosteroid begins to have a
significant therapeutic effect. If there is an inordinate amount of pain after
the procedure, patients should contact the physician who performed the
injection.

Patients should understand that a certain amount of numbness in the digit may
occur if some of the local anesthetic has come into contact with a digital
nerve; however, the numbness should resolve within a matter of hours after the
injection. Significant, persistent numbness should be reported to the physician
who performed the injection.

To minimize the risk of tendon rupture after corticosteroid injection, the
patient should be advised that for a few weeks after the injection, he or she
should avoid using the injected structures for excessively strenuous or forceful
activity.

Clinical Presentation

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Media Gallery

* Flexor tendons pass within tendon sheath and beneath A1 pulley at
approximately metacarpal head, beyond which they travel into digit.

* Inflamed nodule can restrict tendon from passing smoothly beneath A1 pulley.
If nodule is distal to A1 pulley (as shown in this sketch), then digit may
get stuck in extended position. Conversely, if nodule is proximal to A1
pulley, then patient's digit is more likely to become stuck in flexed
position.

* Trigger finger often results in difficulty flexing or (in this case)
extending metacarpophalangeal joint of involved digit.

* Introduction of needle into tendon sheath at 45° angle to palm for injection
treatment.

* Movement of needle with flexion of digit confirms correct positioning of
needle for injection treatment.

* Incision marked out in distal palmar crease for surgical division of A1
pulley.

* A1 pulley is sectioned by using blunt-tipped, fine scissors, keeping strictly
in midline. Note digit being held in hyperextended position by assistant to
displace neurovascular bundles away from midline.

* Incision for trigger thumb release placed in metacarpophalangeal flexion
crease, centered over flexor tendon nodule.

* Trigger thumb. A1 pulley exposed within surgical field (arrow). Digital
neurovascular bundles behind retractors.

* Trigger thumb. A1 pulley has been released; flexor pollicis longus tendon is
now exposed. Retractors have been removed to demonstrate proximity of
neurovascular bundles (arrows) to tendon.

of 10

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CONTRIBUTOR INFORMATION AND DISCLOSURES

Author

Satishchandra Kale, MD, MBBS, MBA, MCh(Orth), FRCS(Edin), FRCS(Tr&Orth) Diploma
in Sports and Exercise Medicine(UK)

Satishchandra Kale, MD, MBBS, MBA, MCh(Orth), FRCS(Edin), FRCS(Tr&Orth) is a
member of the following medical societies: Bombay Orthopedic Society, British
Orthopaedic Association, Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical
Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic
Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine;
Clinical Professor of Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American
Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons,
American Orthopaedic Association, American Society for Surgery of the Hand,
Arkansas Medical Society, Florida Medical Association, Florida Orthopaedic
Society

Disclosure: Nothing to disclose.

Acknowledgements

Michael T Andary, MD, MS Professor, Residency Program Director, Department of
Physical Medicine and Rehabilitation, Michigan State University College of
Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies:
American Academy of Physical Medicine and Rehabilitation, American Association
of Neuromuscular and Electrodiagnostic Medicine, American Medical Association,
and Association of Academic Physiatrists

Disclosure: Allergan Honoraria Speaking and teaching

P atrick M Foye, MD Associate Professor of Physical Medicine and Rehabilitation,
Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic,
Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com),
University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Patrick M Foye, MD is a member of the following medical societies: American
Academy of Physical Medicine and Rehabilitation, American Association of
Neuromuscular and Electrodiagnostic Medicine, Association of Academic
Physiatrists, and International Spine Intervention Society

Disclosure: Nothing to disclose.

Joseph E Sheppard, MD Professor of Clinical Orthopedic Surgery, Chief of Hand
and Upper Extremity Service, Department of Orthopedic Surgery, University of
Arizona Health Sciences Center, University Physicians Healthcare

Joseph E Sheppard, MD is a member of the following medical societies: American
Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, and
Orthopaedics Overseas

Disclosure: Nothing to disclose.

David R Steinberg, MD Director of Hand Fellowship, Associate Professor,
Department of Orthopedic Surgery, University of Pennsylvania Health System

David R Steinberg, MD is a member of the following medical societies: American
Academy of Orthopaedic Surgeons and American Society for Surgery of the Hand

Disclosure: Johnson & Johnson nothing received, but have long-term ownership of
public equities none

Todd P Stitik, MD Professor, Department of Physical Medicine and Rehabilitation,
Director, Outpatient Occupational/Musculoskeletal Medicine, University of
Medicine and Dentistry of New Jersey-New Jersey Medical School

Todd P Stitik, MD is a member of the following medical societies: American
Academy of Physical Medicine and Rehabilitation, Association of Academic
Physiatrists, Phi Beta Kappa, and Physiatric Association of Spine, Sports and
Occupational Rehabilitation

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of
Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug
Reference

Disclosure: Medscape Salary Employment

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM President and Director, Georgia Pain
Physicians, PC; Clinical Associate Professor, Department of Physical Medicine
and Rehabilitation, Emory University School of Medicine

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM is a member of the following medical
societies: American Academy of Pain Medicine, American Academy of Physical
Medicine and Rehabilitation, American College of Sports Medicine, American
Medical Association, International Association for the Study of Pain, and Texas
Medical Association

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of Medscape Reference would like to thank medical
students Dena Abdelshahed and Leia Rispoli, plus Drs. Debra Ibrahim, Evish
Kamrava, Jason Lee, Cyrus Kao, and Dev Sinha, for their help in previous
revisions of a source article.

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