Education
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Anaesthesiology, Ganga
Medical Centre and Hospitals
Pvt Ltd, Coimbatore, Tamil
Nadu, India
Correspondence to
Dr J Balavenkatasubramanian,
Anaesthesiology, Ganga
Medical Centre and Hospitals
Pvt Ltd, Coimbatore, Tamil
Nadu, India;
​drbalavenkat@​gmail.​com
Received 18 June 2020
Revised 14 September 2020
Accepted 16 September 2020
Published Online First
13 October 2020
© American Society of Regional
Anesthesia & Pain Medicine
2021. No commercial re-­use.
See rights and permissions.
Published by BMJ.
To cite: Sonawane K,
Balavenkatasubramanian J,
Dixit H, et al.
Reg Anesth Pain Med
2021;46:344–349.
344    Sonawane K, et al. Reg Anesth Pain Med 2021;46:344–349. doi:10.1136/rapm-2020-101819
Regional anesthesia for scapular fracture surgery: an
educational review of anatomy and techniques
Kartik Sonawane  ‍ ‍, J Balavenkatasubramanian, Hrudini Dixit, Harshitha Tayi,
Vipin Kumar Goel
ABSTRACT
Scapular fractures are very rare, and those requiring
surgical interventions are even rarer. Most scapula surgeries
are done under general anesthesia with or without the
regional anesthesia (RA) technique as an adjunct. Since
scapular innervation is complicated, a thorough review
of the relevant anatomy is warranted. In this RAPM
educational article, we aimed to summarize the target
nerves and blocks needed to optimize analgesia or even
to provide surgical anesthesia for scapula surgeries. In this
review, we are describing an algorithmic “identify-­select-­
combine” approach, which enables the anesthesiologist
to understand detailed innervation of the scapula and
to obtain a procedure-­specific RA technique. Procedure-­
specific RA would probably be the way forward for defining
future RA practices.
INTRODUCTION
Scapular fractures are rare, making up only 1% of all
fractures.1 Typically, patients are an average age of 35
years (range 25–50 years) with up to 96% incidence
of associated injuries.2 The most common mechanism
of injury for scapular fractures involve direct trauma
related to motor vehicle accidents (MVA).
General anesthesia (GA) is an attractive option
for surgical interventions of the scapula given the
complex innervation of the scapular region, the exten-
siveness of surgery, and challenging positioning of the
patient. Many regional anesthesia (RA) technique
have been used for scapular fracture surgeries, and
usually as an adjunct to GA. These techniques include
cervical epidural anesthesia,3 intrapleural block,3
selective dorsal scapular nerve block,4 erector spinae
plane block,5 interscalene block,5 suprascapular nerve
block,6 serratus anterior plane block,7 thoracic para-
vertebral block,8 and rhomboid intercostal block.9
For procedure-­specific anesthesia/analgesia for any
surgery, it is essential to know the functional anatomy,
nature of fractures, associated fractures, surgical steps,
pain generating structures, and their innervations, all
of which play a crucial role in achieving optimal and
satisfactory results. Herein, we describe an algorithmic
“identify-­select-­combine” approach of RA, which can
be considered for all types of scapular surgeries. In this
approach, the anesthesiologist should be able to take
into account all of the dermatomes, myotomes and
osteotomes involved in scapular surgeries.
FUNCTIONAL ANATOMY OF SCAPULA
The scapula, also called the shoulder blade, is
an irregular, triangular flat, cancellous bone on
the posterolateral aspect of the thoracic cage. It
connects upper limbs to the axial skeleton through
the clavicle, acromioclavicular joint, sternoclavic-
ular joint and glenohumeral joint. The scapula plays
a key role in upper-­limb function and stability. It
has two surfaces, three borders, three angles, three
processes, two joints, and five ligaments, as shown
in figure 1A.
►► Two surfaces
1. The costal surface or subscapular fossa is con-
cave and directed medially and forwards.
2. The dorsal surface gives attachment to the spine
of the scapula, which divides the body into
smaller supraspinatus fossa and larger infraspi-
natus fossa. The two fossae are connected by the
spinoglenoid notch, situated lateral to the root
of the spine.
►► Three borders
1. The thin superior border with the suprascapular
notch on it.
2. Thick lateral (axillary) border with infraglenoid
tubercle.
3. Thin medial (vertebral) border.
►► Three angles
1. The upper (superior) angle covered by trapezius.
2. Inferior angle covered by latissimus dorsi.
3. The lateral (glenoid) angle.
►► Three processes
1. The spine/spinous process.
2. The coracoid process.
3. The acromion process.
►► Two joints
1. Glenohumeral joint.
2. Acromioclavicular joint.
►► Five ligaments
1. Shoulder joint capsule.
2. Acromioclavicular ligament.
3. Coracoclavicular ligament.
4. Coracoacromial ligament.
5. Superior transverse scapular ligament.
The scapula provides attachment to the muscles of
the upper arm, upper back, neck, and chest helping
in raising arms and shoulders as well as bending the
neck backward and sideways. The scapula has complex
innervation from the suprascapular nerve, subscapular
nerve, axillary nerve, musculocutaneous nerve, lateral
pectoral nerve, as described in later sections of this
article. The healing ability of the scapula is robust due
to the rich blood flowing through the vascular anasto-
moses between branches of the first part of the subcla-
vian artery and the third part of the axillary artery,10 as
shown in figure 1B.

Figure 1  Functional anatomy of scapula and vascular anastomoses
around scapula. (A) Various surfaces, processes and angles of scapula.
(B) Vascular anastomoses around scapula.
SCAPULA FRACTURES
Incidence
►► Scapula fractures account for 3%–5% of all fractures of the
shoulder girdle and comprise 0.4%–1% of all fractures. 11
►► About 45% of all scapula fractures occur in the body,
35% involve the glenoid process (25% glenoid neck, 10%
glenoid cavity), 8% the acromion, and 7% the coracoid
process.12
Classification
►► Scapula fractures are classified into three major types. Type
A (extra-­ articular not involving glenoid), type B (partial
articular involving glenoid) and type C (total articular).
►► Extra-­articular fractures are further classified as A1 (acro-
mion), A2 (coracoid), and A3 (body).
►► Partial articular fractures are classified as B1 (anterior rim),
B2 (posterior rim) and B3 (inferior rim).
►► Total articular fractures are further classified as C1 (extra-­
articular glenoid neck), C2 (intra-­articular with the neck)
and C3 (intra-­articular with the body).
Associated fractures/injuries
►► Scapular fractures are associated with other major injuries in
the shoulder, clavicle and ribs, or damage to the head, lungs
or spinal cord.
►► Associated injuries include rib fractures (25%–45%), pulmo-
nary injury (15%–55%), humeral fractures (12%), skull frac-
tures (25%), CNS deficits (5%), major vascular injury (11%)
and splenic injury (8%).13
►► Brachial plexus injury (5%–13%) is the most important
prognostic factor concerning the final clinical outcome.13
►► The reported mortality rate of patients with scapular frac-
tures from the concomitant injuries varies between 2% and
15%.13
Mechanism
►► Scapular fractures are uncommon, mainly caused by high-­
energy direct blunt trauma associated with MVA.
►► They can also occur from a fall on an outstretched arm if the
humeral head impacts on the glenoid cavity.
►► Convulsions or electrical shock are associated with an avul-
sion fracture of acromion or coracoid due to traction by
muscles/ligaments.
►► Other causes include falls from heights, crush injuries or
sporting activities (horseback riding, skiing and contact
sports).
Sonawane K, et al. Reg Anesth Pain Med 2021;46:344–349. doi:10.1136/rapm-2020-101819
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Management
►► The majority of scapular fractures remain undisplaced due to
the strong supporting soft-­tissue structures and surrounding
muscles.
►► Most of the scapula fractures are managed conservatively
with nonoperative treatments like the use of a sling or
shoulder immobilizer, ice, and pain killers.
►► Surgical fixation is required if there is an associated gleno-
humeral joint displacement or at least, a double disruption in
any of two structures forming the superior shoulder suspen-
sory complex, the term coined by Goss14 in 1993. It is an
osteoligamentous connection of the acromion, coracoid, and
glenoid processes of the scapula.
►► Only about 10% of scapula fractures involving the neck
or glenoid or with severe displacement require surgical
intervention.
►► Scapular fracture repair surgery has historically been
performed through a large, open incision.15
►► Newer, minimally invasive techniques have evolved, and
surgery to repair scapular fractures can now be performed
through arthroscopy.15
SURGICAL STEPS FOR SCAPULA SURGERY
Since 62%–98% of scapula fractures involve the scapula body/
neck, the posterior surgical approach is the most common for scap-
ular surgeries.16 17 The Judet (posterior) approach allows access to
the entire posterior aspect of the scapula body but requires a large
skin incision and extensive muscular disruption.18 An anterior
approach is needed in type 1A fractures (anterior rim injuries) of
the glenoid cavity.
1. Posterior approach: the patient is positioned in a lateral de-
cubitus position with the operative side up. The incision is
made over the lateral one-­third of the scapular spine along
the posterior aspect of the acromion to its lateral tip and then
distally in the mid-­lateral line for 2.5 cm.
2. Anterior approach: the patient is placed in a beach-­chair po-
sition. The incision is made in Langer lines, centered over
the glenohumeral joint and running from the superior to the
inferior margins of the humeral head.
3. Superior approach: it is an additional approach for anterior
or posterior exposure. The incision is extended over the su-
perior aspect of the shoulder.
The surgical steps usually involved in scapular surgery with
the posterior approach are,
a. Incision—from the posterolateral tip of acromion extending
in line with the tip of the scapula parallel and lateral to the
medial scapular border.
b. Superficial dissection—through the skin, subcutaneous tis-
sue, and fat, exposing posterior deltoid muscle belly. Deltoid
muscle is dissected off the scapular spine and retracted to
reveal underlying infraspinatus and teres minor muscle.
c. Deep dissection—after retracting teres minor inferiorly and
infraspinatus superiorly posterior glenoid capsule is exposed
deep to the musculature.
d. Joint access: after incising the posterior capsule, the glenohu-
meral joint is exposed.
e. Reduction and plating: after achieving reduction and proper
alignment of bone, the plating is done.
PAIN GENERATIONS IN SCAPULA SURGERY
Factors producing pain before and after surgery are different. Pain
before surgery is due to traumatic tissue and bone damage, whereas
after surgery, it is due to surgical incisions, soft tissue damage,
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Table 1  Muscles attachments to the scapula with their innervation
Muscles connecting scapula to Innervation
spine
1 Trapezius Spinal accessory nerve
2 Levator scapulae C3–C4 and dorsal scapular nerve (C4–C5)
3 Latissimus dorsi Thoracodorsal nerve (C6–C8)
4 Rhomboid major Dorsal scapular nerve (C4–C5)
5 Rhomboid minor Dorsal scapular nerve (C4–C5)
Muscles connecting scapula to Innervation
arm
1 Supraspinatus Suprascapular nerve (C5–C6)
2 Infraspinatus Suprascapular nerve (C5–C6)
3 Teres major Thoracodorsal nerve (C5–C7) or
Lower subscapular nerve (C5–C6)
4 Teres minor Axillary nerve (C5–C6)
5 Long head of triceps Radial nerve (C6–C8)
6 Subscapularis Upper subscapular nerve (C5–C6)
Lower subscapular nerve (C5–C6)
7 Coracobrachialis Musculocutaneous nerve (C5–C7)
8 Deltoid (middle and posterior Axillary nerve (C5–C6)
head)
9 Biceps brachii Musculocutaneous nerve (C5–C7)
Muscles connecting scapula to Innervation
ribs
1 Serratus anterior Nerve serratus anterior (C5–C7)
2 Pectoralis minor Medial pectoral nerve (C8–T1)
Lateral pectoral nerve (C5–C7)
Muscles connecting scapula to Innervation
hyoid
Figure 2  Dermatomes, myotomes and osteotomes of scapula. (A)
Dermatomal innervations of scapula (source: nysora.com). (B) Muscles 1 Omohyoid (inferior belly) Ansa cervicalis (C1–C3)
attached to the Scapula (source: anatomyqa.com). (C) Osteotomal
innervations of the scapula (source: nysora.com).
analgesia for patients undergoing scapular surgery. Innervation of
scapula (figure 2) includes.
postsurgical inflammation, and microfractures. Knowledge of the
pain generating structures is essential to identify target nerves to be Dermatomes
blocked. For multifactorial pain, multimodal analgesia is considered The skin over the back of the scapula (figure 2A) is supplied by
as the best modality, of which RA is one of the key components. 1. Supraclavicular nerve (C3–C4).
2. Suprascapular nerve (C5–C6).
INNERVATIONS OF SCAPULA 3. Superior lateral cutaneous nerve (C5–C6).
Since scapular innervation is complicated, it is helpful to format an 4. Dorsal Rami C6–T5.
algorithm to identify the target nerves and target blocks needed to Target dermatomes to cover surgical area: C3–T5.
achieve optimum analgesia. The aim is to find a procedure-­specific
RA technique for scapular fractures. After a detailed study of
dermatomes, myotomes, and osteotomes of the proposed surgery, Table 2  Procedure-­specific target innervations
target nerves to be blocked are identified. Later, target blocks Surgical steps Structures involved Target innervations
involving those target nerves are selected and combined. The 3-­step 1. Incision Skin from the tip of the Supraclavicular nerve (C3–C4)
algorithm includes acromion to the tip of Superior lateral cutaneous
1. Identify: identifying target nerves as per innervation of the the scapula nerve (C5–C6)
scapula. Dorsal rami T1–T5
2. Select: selecting procedure-­specific target blocks to include 2. Superficial Deltoid muscle Axillary nerve (C5–C6)
identified target nerves. dissection Teres minor muscle Suprascapular nerve (C5–C6)
3. Combine: combining selected target blocks using different Infraspinatus muscle
approaches. 3. Deep dissection Posterior glenoid Axillary nerve (C5–C6)
capsule Suprascapular nerve (C5–C6)
4. Joint access  Glenohumeral joint Axillary nerve (C5–C6)
Identifying target nerves for scapula surgery Suprascapular nerve (C5–C6)
The innervation of the surgical area, which includes skin Subcapsular nerve (C5–C6)
(dermatome), muscles (myotomes) and bones (osteotomes), plays Lateral pectoral nerve (C5–C7)
a crucial role in formulating any kind of block. The sensory inner- Musculocutaneous nerve
vation of the scapula arises primarily from the brachial plexus as (C5–C7)
the embryological origin of the scapula is very closely related to 5. Reduction and Dorsal scapular surface Suprascapular nerve (C5–C6)
the formation of the upper extremity.19 Thus, anesthetizing various platting Ventral scapular Subcapsular nerve (C5–C6)
surface
components of brachial plexus provides the best and suitable
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1. Anterior scapula: subscapular nerve (C5–C6).
2. Posterior scapula: suprascapular nerve (C5–C6).
3. Acromioclavicular joint: suprascapular nerve (C5–C6), later-
al pectoral nerve (C5–C7).
4. Anterior glenohumeral joint capsule:
a. Subscapular nerve (C5–C6) and axillary nerve (C5–C6)
from the posterior cord.
b. Lateral pectoral (C5–C7) and musculocutaneous nerve
(C5–C7) from the lateral cord.
5. Posterior glenohumeral joint capsule:
a. Suprascapular (C5–C6).
b. Axillary nerve (C5–C6).

Target nerves to cover surgical area osteotomes

Figure 3  Probe position, sonoanatomy and needle directions of “dual ►► Suprascapular nerve (C5–C6).
injection approach.” (A) Interscalene block + selective supraclavicular ►► Upper and lower subscapular nerve (C5–C6).
nerve block with probe at C7. (B) Erector spinae plane block with probe ►► Axillary nerve (C5–C6).
at the level of T2. CA, carotid artery; VA, vertebral artery; IJV, internal ►► Lateral pectoral nerve (C5–C7).
jugular vein; SCM, sternocleidomastoid muscle; ASM, anterior scalenus ►► Musculocutaneous nerve (C5–C7).
muscle; MSM, middle scalenus muscle; OHM, omohyoid muscle; SAM,
serratus anterior muscle; TZM: trapezius muscle; RHM, rhomboid muscle; Selecting procedure-specific target blocks
ESP, erector spinae muscle; T, transverse process; yellow color, roots/ Target blocks are now selected to involve all identified target
nerves/plexus; blue color, drug spread around nerves; white color, needle nerves. These selected blocks must include important innerva-
directions; LA, local anesthetic. tions of all pain generators involved in each surgical step (table 2)
to make it more procedure specific.
Myotomes
Six basic movements of the scapula are elevation, depression, Combining selected target block
upward rotation, downward rotation, protraction and retrac- The selected target blocks can now be uniquely combined. This
tion. These are coordinated by the 18 different muscles that
combination of target blocks can be given via two different
originate from or insert on the scapula. Innervations of these
approaches, that is, “dual injection approach (DIA)” or “triple
muscles are shown in table 1.
injection approach (TIA)” as per patient suitability.

Target nerves to cover surgical area myotomes

►► Dorsal scapular nerve (C4–C5). Dual injection approach
►► Suprascapular nerve (C5–C6). Target blocks
21 22
►► Upper and lower subscapular nerve (C5–C6). ►► Interscalene block at the level of C7 (low interscalene) and
23
►► Axillary nerve (C5–C6). selective supraclavicular nerve block in the first injection.
►► Erector spinae plane block at T2 in the second injection.
Osteotomes (figure 3, table 3)
As per Hilton Law, nerves to the muscles acting on joint give Advantages
branches to that joint as well as the skin over the area of action ►► Only two injections are required to cover most of the target
of these muscles.20 nerves causing less discomfort to the patient.

Table 3  “Dual injection approach” with target nerves and target blocks
“Dual injection Target blocks Target innervations
approach” Technique involved covered
A.First injection Patient position: supine with head turned to the opposite side ►► Dorsal scapular nerve (C5)
Ultrasound probe: high-­frequency linear ►► Interscalene block ►► Supraclavicular nerve (C3–C5)
Probe position: ►► Selective ►► Suprascapular nerve (C5–6)
Over the interscalene groove at the level of C7 supraclavicular ►► Axillary nerve (C5–6)
Possible LA volume: nerve block ►► Subscapular nerve (C5–6)
3–5 mL above C5 ►► Musculocutaneous nerve (C5–7)
3–5 mL around C6 ►► Lateral pectoral nerve (C5–7)
3–5 mL around C7 ►► Medial pectoral nerve (C5–7)
3–5 mL around the supraclavicular nerve between SCM and MSM
B.Second injection Patient position: lateral decubitus with operating side above ►► Dorsal rami of C6–T5
Ultrasound probe: high-­frequency linear ►► Erector spinae plane
Probe position: block at T2
Longitudinally at the parasagittal transverse view at the level of the T2 vertebra
Possible LA volume:
15–20 mL under erector spinae muscle and above the tip of the transverse process of
T2.
LA, local anesthetic.

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►► Mostly for analgesia rather than anesthesia due to chances
of sparing.
►► The second injection at T2 involves dorsal rami of C6–T5
supplying skin over the back, which is not covered in any of
the approaches of brachial plexus.
Disadvantages
►► Higher LA volume in the interscalene region is required to
involve C5, C6 and C7 nerve roots. This increases the inci-
dence of hemidiaphragmatic paresis (due to involvement of
phrenic nerve) and Horner’s syndrome.24
►► Lower interscalene block is associated with vertebral artery
injury.
►► Chances of sparing of innervations having contributions
from lower cervical roots (below C7) in case of variations
like postfixed brachial plexus.
►► Chances of sparing of innervations having contributions
from upper cervical roots (above C5) in case of variations
like prefixed brachial plexus. Such innervation may include
important nerves like DSN and SSN.

Triple injection approach

Target blocks
25
►► Selective upper trunk block and selective supraclavicular
nerve block in the first injection.
►► Subclavian perivascular block and suprascapular nerve
block26 in the second injection.
►► Erector spinae plane block at T2 in the third injection.
Figure 4  Probe position, sonoanatomy and needle directions of (figure 4, table 4)
“triple injection approach.” (A) Selective superior trunk block +
Advantages
selective supraclavicular nerve block with probe at C6. (B) Subclavian
►► Low LA volume in the interscalene region decreases the inci-
perivascular block +suprascapular nerve block with probe at
dence of hemidiaphragmatic paresis (phrenic nerve sparing)
supraclavicular area. (C) Erector spinae plane block with probe at the
and preserves respiratory function, and provides effec-
level of T2. A, artery; IJV, internal jugular vein; SCM, sternocleidomastoid
tive analgesia avoiding other adverse effects like Horner’s
muscle; ASM, anterior scalenus muscle; MSM, middle scalenus muscle;
syndrome.24
OHM, omohyoid muscle; SAM, serratus anterior muscle; TZM, trapezius
►► No/low risk of vertebral artery injury.
muscle; RHM, rhomboid muscle; ESP, erector spinae muscle; T, transverse
►► Additional injection in the subclavian perivascular area will
process; yellow color, roots/nerves/plexus; blue color, drug spread
around nerves; white color, needle directions; LA, local anesthetic. cover almost all the innervations having contributions from
upper or lower cervical nerve roots.

Table 4  “Triple injection approach” with target nerves and target blocks
“Triple injection
approach” Technique Target blocks Target innervations
A.First injection Patient position: supine with head turned to the opposite side
Ultrasound probe: high-­frequency linear ►► Selective upper trunk block ►► Dorsal scapular nerve (C5)
Probe position: ►► Selective Supraclavicular ►► Supraclavicular nerve
Over the interscalene groove at the level of C6 Nerve Block (C3–C5)
Possible LA volume: ►► Suprascapular nerve (C5–6)
2–3 mL above C5
2–3 mL above C6
3–5 mL around the supraclavicular nerve between SCM and MSM
B.Second injection Patient position: supine with head turned to opposite site Ultrasound probe:
high-f­ requency linear ►► Subclavian Perivascular Block ►► Axillary nerve (C5–6)
Probe position: ►► Anterior Suprascapular Nerve ►► Subscapular nerve (C5–6)
over supraclavicular region Block ►► Musculocutaneous nerve
Possible LA volume: (C5–7)
10–15 mL in the subclavian perivascular area ►► Lateral pectoral nerve (C5–7)
2–3 mL around the suprascapular nerve below the omohyoid muscle ►► Medial pectoral nerve (C5–7)
C.Third injection Patient position: lateral decubitus with operating side above ►► Dorsal rami of C6–T5
Ultrasound probe: high-­frequency linear ►► Erector spinae plane block
Probe position: at T2
longitudinally at the parasagittal transverse view at the level of the T2 vertebra
Possible LA volume:
15–20 mL under erector spinae muscle and above the tip of T2
LA, local anesthetic.

348 Sonawane K, et al. Reg Anesth Pain Med 2021;46:344–349. doi:10.1136/rapm-2020-101819


►► Suitable to involve all the variations of the brachial plexus.
►► The third injection at T2 involves dorsal rami of C6–T5
supplying skin over the back, which is not covered in any of
the approaches of brachial plexus.
►► It can be considered for anesthesia as well as analgesia
purpose.
Disadvantages
►► May require sedation to avoid discomfort to the patient due
to the requirement of three injections to involve all target
nerves.
SUMMARY
For scapular surgeries, important target nerves are suprascapular
nerve (C5–C6), axillary nerve (C5–C6), musculocutaneous nerve
(C5–C7), lateral pectoral nerve (C5–C7), subscapular nerves
(C5–C6) along with supraclavicular nerve (C3–C4) and dorsal
rami (C6–T5) which cover most of the dermatomes, myotomes,
and osteotomes. Due to the complex innervation of the surgical
field, such unique combinations given via different approaches
are required. Using such combinations of blocks involving multi-­
injection techniques demands adequate sedation, along with
cooperation from the patient.
This “Identify-­Select-­Combine” approach can be considered
for all complexly innervated structures like scapula to find out
procedure-­specific optimal RA technique. There is still much
scope for research in RA for scapular surgery.
Correction notice  This article has been corrected. Typographical errors within the
bullet points have been corrected.
Acknowledgements  The authors thank Dheenadhayalan J., Senior Consultant,
19 Cochard L. Netter’s Atlas of Human Embryology. 1st ed. Teterboro (NJ): Icon Learning
Orthopedics and Traumatology, for sharing surgical information and radiological
images.
Contributors  KBS conceived the idea with the help of HD and HT and collaborated
with JBS in developing the manuscript. VG provided guidance throughout the entire
process.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests  None declared.
Patient consent for publication  Not required.
Provenance and peer review  Not commissioned; externally peer reviewed.
ORCID iD
Kartik Sonawane http://​orcid.​org/​0000-​0001-​9277-​5505
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Education
Reg Anesth Pain Med: first published as 10.1136/rapm-2020-101819 on 13 October 2020. Downloaded from http://rapm.bmj.com/ on October 12, 2022 by guest. Protected by copyright.
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