Player is loading...
A-1181 Active extensor tendon rehabilitation for zones 3-7; short arc motion and relative motion – two different approaches
Gwendolyn van Strien, The Netherlands
Friday, June 15, 2018 · 2:05 p.m. · 27m 04s
Embed
Embed code is not allowed
This talk is part of a Private webcast, embeding is not permited.Transcriptions
Note: this content has been automatically generated.
00:00:00
turn in everybody uh i hope you saw my email address i do
00:00:04
not object if people have questions that you email me and
00:00:08
send your questions to me and i'm also prepare to maybe share a p. d. f. with my talk so you don't have
00:00:15
to put your phone up all the time because sometimes that gets a little weird when all those points go up
00:00:20
so you can get a p. d. f. if you write an email alright i'm
00:00:23
gonna talk about early active treatment of extensive tenants joe's three through seven
00:00:30
and um why we started doing early actives kind of interesting because the review done
00:00:36
in two thousand eight by tall smart showed that there was really no difference
00:00:40
in the beginning there was a whole different short term evidence at four weeks early
00:00:43
controlled was a little bit better than him always asian but twelve weeks
00:00:47
and we know this the results were equal so it was no problem there so why do early active it's so much more difficult
00:00:54
but in a later review by hammond in two thousand twelve
00:00:57
show that yes there were no long term differences but
00:01:01
fairly active had way less complications that immobile stationarity passive with the dynamic traction
00:01:07
you can see the numbers here i'm sorry uh four point one percent four point three percent and already active one point seven
00:01:14
but if you take notice of what the uh complications are the mobile station and dynamic
00:01:19
have tina licenses that need to be to be done and sometimes extends or like
00:01:23
to rupture sort of the same in all three of them but the problems that you see here art he jens
00:01:29
and they need secondary surgery so they're just as bad as a rupture because you have
00:01:33
to re operate so it's still a failed result even though it's not a rupture
00:01:37
so um because of that we went to uh try to the movie early with the extends attendance
00:01:45
making a mobile us you can do dynamic passive mobile station not my style i'm at today we're not
00:01:51
only gonna talk about two active protocols and not about the not active particles is not discussed today
00:01:58
but active mobile i say she can do two ways you can do a limited park motion kind of early motion and you
00:02:03
can do relative motion extension which was of of a written
00:02:07
up by doctor merit and julie how will the therapist
00:02:11
uh so the first one the short arc motion to limit our motion it's it's uh um i
00:02:17
spent that was actually a very simple the forty five degrees extension of terrorist groups and
00:02:26
thirty to fifty if a decrease faction of the n. p. joins the original article says fifty degrees but i tend to go to thirty
00:02:32
uh i do this all night i cried my surgeon all i decide to do
00:02:37
this meant all the tendons are injured because my preferences with relative motion
00:02:41
but if you do this you have to exercise is a very simple protocol active extension from
00:02:46
this point with straight fingers and the other exercises p. i. p. d. r. p. flexion
00:02:51
my you scratch with your fingertips on the splint and you pull them into flexion you
00:02:56
do that very slowly don't go straight into flexion because then you get ruptures
00:03:01
and you have to rule for you do this for four weeks with for exercise of
00:03:04
four repetitions per day and four repetitions per exercises for for for a very easy
00:03:10
then gradually you increase the flexion you scratch the surface of the spongy get into flexion and after four
00:03:16
to six weeks you get out of the splint depending on how much extension like you have
00:03:21
and sometimes you have to stay to spend for another two weeks if you still have
00:03:24
a lack and otherwise you can just go increase flexion and then things are just
00:03:28
great because it's a very easy and it works protocol it works really well
00:03:32
but sometimes you have this stubborn tendency from right from the beginning it you can't get it up
00:03:36
and then it might be an idea to put this little v. shapes plant
00:03:40
in there is an insert and it keeps the digit at in extension
00:03:44
so at night you'll have a couple of hours of extension and rest
00:03:49
so that's a good idea to do so that was one protocol
00:03:52
um the research bible strode show that if you compare
00:03:56
this one with dynamic a passive and immobile association with the i. p. in the pipe the l. p. free
00:04:03
that again the total actor range of motion was less it for weeks but at
00:04:07
twelve weeks results were sort of the same the grip strike was decreased
00:04:12
compared to the other side at twelve weeks and that was significant but also they tested if there was
00:04:18
any functional problem and the patients had no functional problem so there was decrease of grip strength
00:04:23
but still there was good function but what is not in this research is relative motion and we know from the research from
00:04:30
her if that about of motion is significantly better than him organisation so it should be better than all three of these
00:04:37
so but of motion extension it's my treatment of choice it
00:04:41
was a founded by doctor married in richmond virginia
00:04:45
and he said if you uh put the route of motion extension split on that were remote access to repair
00:04:52
regardless of where your fingers or as long as one the injured finger is higher than the other fingers
00:04:58
at the end p. joint and he did that with a cadaver you pulled on d. v. d. c. and he
00:05:03
made a little cut in the accent attended and you saw getting if there was no relative motions plant
00:05:09
and if you put the finger up in extension any pulled the same way on the
00:05:13
c. d. c. so there was no capping so apparently you can do this
00:05:17
and he started doing isn't it for many years and after many years because you start
00:05:21
in nineteen seventy seven two thousand five he came out with his uh results
00:05:27
and his protocol was basically based on one rule you
00:05:30
need one tending to be intact that's important
00:05:35
then the first couple of days and i have to say that this a protocol is actually an
00:05:40
updated protocol uh uh from what it was the beginning uh i spoke to julie how
00:05:46
and she uh told me how she changed it in two thousand seventeen last year and this is the
00:05:51
updated protocol so the couple of numbers will be different from what you see in the literature
00:05:55
so the first ten days you start with the relative motion extensions point it'll be in fifteen degrees of
00:06:02
extension compared to the other fingers and you have a wrist splint uh in twenty
00:06:06
five degrees extension but neil is that a lot of a therapist now
00:06:11
don't use the wrist splint for zones four and five so you'll see
00:06:15
that happening more and more the exercise you do is focused
00:06:18
and full thirst and full extension where you gradually introduce it don't do it on the first day right way full range motion
00:06:25
and if you do not use to respond then of course you're not allowed to
00:06:28
do with faction and act and make a fist that's not a lot
00:06:34
so this is the protocol for the first week or ten days and not using to respond has been
00:06:40
done for about the and i would say i think it's couple years like five years now
00:06:46
and there's about four hundred patients globally it have been safely treated without to respond so it can be done
00:06:52
safely okay so it's done more and more letters on six and seven you still need to respond
00:06:59
so after those first seven to ten days you start gradually
00:07:02
doing more exercise as you add respond to x. exercises
00:07:06
where you have to take off to respond all obviously and again no waste faced with the was function together
00:07:12
a full thing or extension should be full it should be full now so by two weeks you
00:07:17
should have full extension in this point and they can use their hands as the splints allow
00:07:22
just like activities the crucial extra information that the the writers of the protocol would like to give is that
00:07:29
you have to tell the patient to we are displayed at all times and if you do not we're
00:07:33
to respond you should put it on at night at least for user difference played as you can see here
00:07:39
where you have the the the relative motion split off and have a full splint for at night
00:07:45
and you do your exercises five to ten times every waking hour i don't really necessary believing that if people
00:07:51
do really well i don't do every hour and i don't do five to ten times i'll do less
00:07:56
if it works well light eight yell if possible and spent like duties if it's possible displayed
00:08:01
then the next two weeks uh this owns four and five you can stop the response so you only
00:08:07
have to butts motion but zero six and seven you'll continue between the exercise too weird to respect
00:08:13
and you can use your hand more and more as it allows a more tension on the tandem
00:08:18
and the next two weeks four to six weeks also owns have
00:08:22
only the relative motion spent there's no response anymore you can
00:08:25
go from like two medium to heavy use with your hands people go to work with the splint on no problem
00:08:31
and at six weeks basically all the relative motion spence should and should stop except when you
00:08:37
do have the labour work you can try to one word a little bit longer
00:08:42
it's satan proven since nineteen seventy seven i like i said doctor merit he
00:08:46
did a lot of these in a period since nineteen seventy seven
00:08:50
and at six weeks early measured early six weeks he had
00:08:54
two ways of measuring the a range of motion the
00:08:57
mean compared to normal and it took total active motion and they were both very high ninety eight point five
00:09:03
grip strength was eighty five percent compared to the other side and mind you it's at six weeks not twelve weeks
00:09:09
so you already have a strong hand and this is really important they only
00:09:13
saw them an average of eight times during the whole session and
00:09:16
mostly they were discharged seven weeks so that's when they were done and could go back to work and go on living
00:09:22
their lives with a normal hand no ruptures no dystrophy no infections
00:09:27
and so to return to work is really the big selling point on this one and the mean
00:09:31
return to work was eighteen days so with spends on they can go back to work
00:09:37
alright so retrospective there was an article done by herself and she actually get
00:09:43
not used to respond and she traded a whole bunch of patience and she measured
00:09:49
this combination the relative motion and at night the static spent and she compared that to four weeks casting the
00:09:54
two weeks weeding out of the cast so immobile station no ruptures no extension like that were installed
00:10:00
so here are the results and early results at six weeks you can see that a lot of motion is doing
00:10:05
really really well did an excellent and a couple of fear now the mobile station is not doing so great
00:10:11
and if you look at twelve weeks then you see still twelve weeks almost all of them are
00:10:16
excellent and the okay the mobile station came back and there's a whole bunch and they're
00:10:20
good a couple of excellent but it takes so long it takes such a long time to
00:10:25
get to that result in with the route of motion you get it really early on
00:10:29
and the other thing is if you had your hand her to you want a good or next that result we all want excellent
00:10:34
results and you get a lot more chances are excellent results we do about this motion if you look at these graphs
00:10:41
and that's the work thing again because this is the big selling point of course
00:10:45
it's a financially better for for for a health care system for working patient because as you can see
00:10:51
forty two days earlier at work if you do relative motion almost
00:10:55
have was back to work at six weeks and before six
00:10:59
weeks and manual workers or people with heavy duty work there were five out of eleven that we're back to work
00:11:06
with their spends on so you can go back to work if you have your own business it's no problem
00:11:11
here's some results this is eight weeks for therapy visits settle band digit uh third digit
00:11:17
and the result is just excellent and to say excellent i mean we're talking excellent results here
00:11:23
this is an excellent results delayed repair two weeks was missed in the e. r.
00:11:28
a patient a little scared she wore the responded about emotional longer then supposed to be for
00:11:33
the protocol but this is her range of motion at twelve weeks in she had
00:11:37
a full recovery of record strength to so this is not just a good
00:11:41
result this is an excellent result there's no difference with other fingers
00:11:46
the last article that came out on relative motions in two thousand seventeen by wong
00:11:50
and he the systematic review over a long period of time uh nineteen sixty c. already started
00:11:56
uh and you can see there's a slight better result forty buttons motion and he says it's
00:12:02
only slightly better but it's still the best choice because of the low cost fast return
00:12:06
to work less time in therapy and the normal use of the hand while there or
00:12:10
in the split you don't sit and spent for six weeks not using your hand
00:12:15
so um expenses three four again we're not gonna talk about the not active
00:12:19
are gonna go to is relative motion faction and short arc motion
00:12:24
the shorter commotion was done by evans sheep started this whole
00:12:27
protocol it's been around since the nineteen early nineteen eighties
00:12:31
uh in this political you have standard p. l. p. extensions split post operative you have this little splint
00:12:38
and then during the day you going to an exercise point where you do act oops active extension
00:12:43
uh from the template split that you get and you put displayed on and then you do
00:12:48
your extension your faction just very much liked an arch that i just showed you
00:12:52
and you go to thirty degrees of uh the sponge limit then you also if
00:12:57
the lateral bands or not a cut you can do this exercise splint
00:13:02
they get a little template where you hold the p. i. p. straight and the u. d. r. p. exercise reflection of the d. i. p.
00:13:09
but only if that lateral bands are not injured that way you can exercise to
00:13:13
d. i. p. without having to flex the p. i. p. this is what
00:13:17
you do and then over time you increase the amount of flexion of the template
00:13:21
splinter of some types point hey where you go into flexion more more
00:13:25
but only progress if there's no extension like it's a very simple protocol it works really well
00:13:31
but if you have a conservative uh injury you have not looked inside actually not really sure
00:13:37
what that settles that is doing if it's actually gonna heal in the right place cell
00:13:43
in this protocol the way she describes it uh the first two weeks you will do
00:13:47
full time normalisation sometimes combined in therapy with the therapist doing
00:13:52
a little bit of short arc motion and after two
00:13:54
weeks then should go to the normal short arc motion protocol and that sort of continues like i said before
00:13:59
she has some numbers and she did get an extension like about six six degrees but
00:14:04
she got pretty much good results all around so that's a pretty good protocol
00:14:09
now doctor married looked at relative motion flexion because he found this when he was working
00:14:15
on a cadaver you put the uh splint on about as much inflections plant
00:14:19
and it was holding the digit in a little bit of flexion any made essential slip injury
00:14:24
and then you started pulling on b. e. d. c. and you see it happening here
00:14:28
it's a very old video but you can still see what's happening is pulling on the d. c. and you can see that
00:14:33
the index finger is just extending find there's nothing wrong with it even though there is a sense of the injury
00:14:40
a certain point he will take off the splint there goes and now is gonna let go is gonna pull on the t. v. c. n.
00:14:45
b. c. in two or three poles that the hyper extension of the m. p.s obvious and the p. l. p. goes into flexion
00:14:52
and there you got you put near so if you leave the extension i'm checked and allow that
00:14:56
m. p. hyper extension to happen then things will fall apart at the p. l. p. joint
00:15:01
now we think it works like this that if you block the hyper extension then the extension for
00:15:08
space shuttle feel the connections to the lateral bands and so p. i. p. extensions possible
00:15:14
but only if you have passive p. i. p. extension of course if you have a stiff p. l. p.s not gonna go up obviously but if you have
00:15:21
the acute injury then this will be no problem and so through the connections the dorsal pull on the level bands will be
00:15:27
helping the extension through whatever remains of the extends or mechanism right
00:15:33
so doctor merit i talk i'm just this last week to make sure that i had the latest news
00:15:38
and he is reading a chapter for the rehabilitation of they handed up extremity it's in press
00:15:43
and he says you know you really should talk about bin slows rumbles and a
00:15:46
lot of people don't know what that is well is that shape right there
00:15:50
and winslow describe it and basically says if you look at extends or mechanism you have to central slip
00:15:56
you have the medial slip and the lateral slip and they join together with the can joint level bands to the and the
00:16:01
terminal slip that is the wrong bus right there and he
00:16:05
works with this to explain how relative motion flexion works
00:16:09
he says if you look at the p. i. clean directly location on this diagram
00:16:13
of extensive mechanism there's your i hope your um romp us if you
00:16:18
pull one t. v. c. which has six to ten millimetre glide accord to
00:16:21
doctor merit this is then you will see that the wrong visible narrow
00:16:26
so you would get a raising of the let it list the lateral bands up you can imagine that from a two d. to three picture
00:16:34
now at the t. i. p. joint it's only want to three millimetre quite so he doesn't
00:16:38
feel that if you do deity function it actually lives up the level bands that much
00:16:43
so the e. d. c. pension is really important in getting that
00:16:46
robust it's get smart uh to leave the lateral bands up
00:16:51
so this is the explanation that is around and uh of course
00:16:55
be low relative motion function but it doesn't always work
00:16:58
sometimes there's so much damage that it will not go up and even when you
00:17:03
block hyper extension you will not have a extension of the p. l. p.
00:17:07
and the other thing is if you have the more than twenty degrees flexion contract sure the joint is stuck in
00:17:13
p. i. p. flexion that lateral band if you pull on that e. c. you can look at the picture
00:17:18
it's never gonna go up i mean everybody understands that if you have a stiff p. l. p. joint
00:17:23
so you need that passive p. l. p. extension for this where sorry i'm not the best has that
00:17:30
doctor long and i feel and this is already done by therapist for
00:17:34
ages i mean uh julie how what i used to work
00:17:37
with document we always put the pencil and there were talking late you just look if you put the time waiting there
00:17:42
you can see if they can still extend or not so you're looking at if they can
00:17:46
still extend through the change balance in the extension mechanism i don't care for something
00:17:51
cut but if it's cut and you can still extend then you can use wrote that
00:17:55
much inflection okay so there's still parts of the extent to make isn't working
00:18:01
now this is the therapy sessions i'm gonna go a little bit more into how to do this you do the pencil test
00:18:06
directly post injury and you look at what's happening if there's no extension
00:18:11
then you do first three to four weeks of the mobile station in extension
00:18:16
and then after that for three to six weeks or maybe even longer used about abortion flexion spot
00:18:21
if you do have extension then you could still opt for seven days of rest in
00:18:25
extensions point or you could just directly started about a motion flexion that's up to
00:18:29
the clinician over the surgery therapist was looking at it but apart
00:18:33
from this you always need a nighttime extension split because
00:18:37
they sleep with band fingers and i don't think it's very comfortable to sleep with a relative motion functions point
00:18:43
so you have a next point and how does the official protocol work
00:18:48
the first two weeks or an extension and you can leave the d. i. p. free if the level bands are intact
00:18:53
the next two weeks you still have your resting spent in extension but
00:18:57
it will be removable the other one should not be removal really
00:19:01
and you exercise with the relative motion flexion spent four five times a day for about half an hour you just do
00:19:06
your things you don't have to do a real exercises just move your hand upon some activity with the splint on
00:19:12
and the surgeons are a little worried about that flexion then you can put a little stop on it you can
00:19:18
see that blue splint here and it's really a clip on split the decision but the motion flexion splint
00:19:24
and this is the clip on and this is the short arc motion that i discussed earlier
00:19:29
so you have a block you go to flexion you can extend the flexion or you can increase the flexion down
00:19:35
and they were the the relative motion is to make sure that you have the
00:19:38
full extension of the p. i. p. joint when you have correct extension
00:19:42
so that's what you do and and the four to six weeks of course you have all data relative motion no uh p.
00:19:48
i. p. resting spent during the day anymore you can put a block down to more flexion down to sixty and
00:19:53
then you stop it you can do they can do light activities as the spent allows because you can do a lot
00:19:58
of things with the splints on even though you had that little block there and again the next point an extension
00:20:03
and then the last thing is sixty eight plus weeks and make sure you see the plus there because
00:20:08
you sometimes have to go for three four months and if you have for p. i. p. extension
00:20:14
what about the motion at they time you can increase flexion take the block away
00:20:20
the questions you should ask as a surgeon and as a therapist you wanna
00:20:23
know the answers how much p. l. p. flexion is safer to repair
00:20:27
and you can check that with well launched but if not then you have to ask assertion but he feels comfortable with
00:20:32
is there p. i. p. extension possible passive at least twenty
00:20:37
degrees should be uh up to twenty decreases okay
00:20:40
and this is an important one you really have to have d. i. p. flexion and extension
00:20:45
should be lose the l. p. especially if you work with chronic put in your
00:20:49
if you have a chronic good near you can still do conservatively and then you will have to pass a p. x. p. l. p.
00:20:55
extension coming up to less than twenty degrees and the d. i.
00:20:58
p. should be free otherwise it really doesn't work that well
00:21:03
with the acute injuries you needful passive p. x. p. extension in a normal d. i. p. but that would be normal if you
00:21:09
have an acute injury because there's nothing wrong with your finger before you hit and again increased p. i. p. flexion carefully
00:21:17
just to remind you this protocol is no our cities there's no publications
00:21:22
it's a work in progress and really assertion that therapist together can
00:21:26
work their protocol out if you just keep to the general idea that why i presented here so you have to customise it
00:21:34
ideally uh the the problem is easy i mean you just correct it but we see
00:21:40
so many times that these thinkers even if you haven't straight in your splint
00:21:44
or with surgery that these p. l. p. flexion contractors come back so wise is
00:21:49
happening keep couple of treatment tricks here i talked earlier about this the
00:21:54
surgeon as therapist have to be teachers and coaches and learn about how to finger moves you don't want to have
00:22:01
things are moving in the wrong pattern so you have to observe how they move and i call this the cortex effect
00:22:06
and you have to make sure that you see happening that if they have a p. i. p. get stiff
00:22:11
that they don't going to hyper extension at the m. c. p. joint because that's what's happening
00:22:16
and we know this because whiteboard on two thousand eleven he found that after seventy two hours
00:22:22
of the molestation you already lost the cortex um uh
00:22:27
s. according to your really lost your uh in control of your p. l. p. extension
00:22:33
the normal pattern so you have a change pattern and that becomes the normal
00:22:37
and don't underestimate is cortex effect you see this all the time hyper extension set of exchange of the
00:22:42
p. i. p. you'll never get p. l. p. extension if you don't move the right way
00:22:47
what happens to rest a day if we do our standard exercise as well that's all fine and dandy
00:22:52
twelve hours stopped you exercise five minutes per hour so that's in our data you exercise
00:22:58
the rest of the day we do all this stuff p. i. p. extension you
00:23:02
rarely do pure peaks angie do p. l. p. flexion all day long
00:23:05
and if these people extend they'll extent with n. p. hyper extension and not p. i. p. extension
00:23:11
so this is what you wanna stop because the rest of the day they're doing this kind of stuff and these are exercises too
00:23:17
so your little exercise once in our couple of repetitions is not gonna cut it so what you wanna do
00:23:23
is use not that much inflection they can exercise all they they don't have to think about it
00:23:28
it will be on there because it doesn't bother them so the key to spend on and they'll have
00:23:32
a full time on used often don't need additional therapy they can do it all by themselves
00:23:40
and the other way around if you going to flexion you can see here
00:23:43
they start moving from the m. p. join so they get an intrinsic
00:23:47
muscle dominance when they close their hand and then you'll see this happening when they try to
00:23:51
make flexion with their p. i. p. d. n. people going to way too much flexion
00:23:57
we can do all kinds of exercises but what you wanna do is you wanna
00:24:01
avoid forceful uh flexion because then they going to this change the pattern
00:24:06
uh that you can do exercises with a little bit of the just a little
00:24:10
bit of force you put a little line here you put your finger
00:24:13
down there you have to pull the thing you're back and scratch are slight
00:24:16
back so it's no forced just easy moving and that will work better
00:24:20
and then of course you can use both of motion extension and the same thing happens here while they want to flex
00:24:27
the relative motion extensions point will give the block to the wrong movement as in too much hype
00:24:32
hyper flexion or too much flexion of the n. p. join so it blocks the m. p. flexion
00:24:37
and they use it all day and all they do their activities in every remote movement
00:24:42
is actually an exercise so wedded motion extension can be really great to correct that
00:24:48
last slide this is an interesting one because we all know that they
00:24:52
don't all work so we end up with these put nears that are basically horrible
00:24:57
and the only thing you can do is you can't use route to
00:25:01
most inflection because they're down into much flexion remember you have to
00:25:04
have some passive p. l. p. extension so what you have to do is you get to pass appeared extension so you start casting
00:25:10
plaster of paris a hundred percent full time i put a little piece of tape on
00:25:14
there so they can't take it off because the the castle stick to the tape
00:25:17
um you reduce it to twenty degrees and you also have to pay
00:25:22
special care to d. i. p. joint get that first into flexion
00:25:27
and once you've done that that's hard and then you can use that cast to straighten
00:25:30
out the p. of digits it's like a two parts plant here are cast
00:25:34
and then once you get the extension then you can go to the next step where you test and if they have
00:25:41
active extension with the pencil test then by all means just go straight to that but probably with these old news that's not gonna work
00:25:48
so then at eight weeks if you do not have that active extension then you go for another eight weeks
00:25:54
but this time it's a cast that you can move your d. r. p. m. because you did get it straight so now you can exercise
00:26:00
if you do have extension then you'd put on the relative motion extensions point
00:26:03
night time spent in extension is important and sometimes endured is both splints
00:26:09
on for six months to a year because it takes that long to wait
00:26:13
for the p. i. p. to actually you'll so it doesn't recur
00:26:16
a full year yes the nature of p. l. p. faction contract raise it comes back with a vengeance it's
00:26:22
just horrible it just won't stop you have to wait a long time before that stops coming back
00:26:27
and because of the way we use our hands be two more flexion and extension
00:26:30
so it will come back if you stop to early with your splints
00:26:35
so yes why not put about of motion factions point on doesn't bother them
00:26:39
let them wear it and at night the night time extensions point
00:26:43
so there it is uh a lot of little splits and i think it's
00:26:47
important to know that if you pay attention to the little details
00:26:52
you will get more better you get better results so attention to detail is good
00:26:57
alright doctor my doctor
Conference Program
A-1181 Active extensor tendon rehabilitation for zones 3-7; short arc motion and relative motion – two different approaches
Gwendolyn van Strien, The Netherlands
June 15, 2018 · 2:05 p.m.
1240 views
A-1182 Solving boutonniere, PIP joint extensor lag and hand pain problems with relative motion splinting
Donald Lalonde, Canada
June 15, 2018 · 2:32 p.m.
600 views
