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Home / Median Nerve Compression Secondary to 35 Fractures of the Distal Radius

Median Nerve Compression Secondary to 35 Fractures of the Distal Radius

Posted on May 1, 2000 by Badia Hand to Shoulder Center

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Fractures of the distal radius and carpal tunnel syndrome are both commonly occurring entities seen in the wrist. The latter condition is an occasional complication that should be well recognized as a result of the former traumatic condition. While treatment of distal radius fractures is currently undergoing a treatment revolution, the complication of carpal tunnel syndrome should be similarly recognized and given the respect that it deserves. Once significant median nerve injury or compression occurs as a result of a fracture of the distal radius, it can be much more difficult to treat, and the final outcome may be much less predictable than its idiopathic counterpart.

Abraham Colles first described the fracture of the distal radius in 1814 but maintained that functional deficiency or complications were surprisingly rare after this common traumatic injury [6]. Similarly, carpal tunnel syndrome associated with this fracture was given little attention and initially felt to be a rare sequela. Early textbooks discussing complications of Colles fractures rarely mentioned this nerve compression, and it was not until the classic paper by Abbott and Saunders in 1933 that this complication was clearly recognized as being not as rare as initially thought [1].

The first case report was actually a direct traumatic injury to the median nerve as recognized by Gensoul in 1836 where he had performed an autopsy on a young girl who died of tetanus following an open fracture of the distal forearm [12]. It was found that the median nerve was caught in the fracture site of the radius. Many of these early reports focused on the direct compression or contusion of the median nerve as a result of bony impalement or stretching of the nerve, rather than the more commonly seen secondary compression as a result of edema and swelling from this fracture.

It was not until the review by Abbott and Saunders that the popular Cotton-Loder position for immobilization of distal radius fractures was discredited.

They first recognized the anatomical course of the median nerve at the wrist, noting that the flexed position of the wrist will lead to direct compression of the median nerve by the proximal edge of the transverse carpal ligament. They also recognized that the median nerve carries with it the majority of sympathetic nerve innervation to the hand and that this can cause the other commonly recognized complication of carpal tunnel syndrome: Complex Regional Pain Syndrome Type I. This was the first time it was recommended that conservative treatment of Colles fracture allow for immobilization of the wrist in a neutral position, mainly to avoid median nerve entrapment. However, despite elucidating this important concept, they went on to say that if median nerve symptoms persist even after 4 months of closed treatment, surgical exploration of the median nerve is warranted. This underscored the prevailing concept that median nerve compression should not be treated as aggressively as we now recognize. Hence, more aggressive treatment of displaced distal radius fractures should go hand-in-hand with decompression of the median nerve.

Meadoff wrote in 1949 that injuries of the median nerve in fractures about the wrist are not uncommon and that good reduction and immobilization of the wrist in the neutral position are the best means of preventing median nerve injury [17]. He also felt that the majority of patients with median nerve injury recover completely without surgery. In 1952, Mark Mason reviewed 100 cases of Colles fractures requiring closed reduction and found only one case developing a carpal tunnel syndrome [16]. However, his study had an average follow-up period of only 22 months since the time of the fracture, which this supports the notion that perhaps many carpal tunnel syndrome complications may occur years after the initial fracture event. Much like Abraham Colles, he found only five patients had any complications whatsoever and supported the existing belief that complications were exceedingly rare after this common fracture. Later studies countered this popular belief.

It was not until 1963 that Lynch and Lipscomb reported 3.3% of their patients with distal radius fractures developing carpal tunnel syndrome [14]. In a retrospective review of 600 distal radius fractures seen over 10 years at the Mayo Clinic, they found that 20 wrists developed this complication in 19 of their pa- tients. Hence, they concluded that carpal tunnel syn- drome is indeed frequently associated with a Colles fracture, and they supported the notion that this often occurs after immobilization in the Cotton-Loder posi- tion. They also emphasized that carpal tunnel syndrome following a Colles fracture can be classified as primary, when the median nerve is actually caught or directly contused between the fracture ends of the radi- us, and secondary when edema, hand position, and tenosynovitis lead to secondary compression within the carpal tunnel. Phalen himself noted in 1951 that a tardy median palsy might be associated with Colles fractures [22]. He stated that any condition which either in-creased the volume of structures within the tunnel or anatomic factors that decreased the diameter of the tunnel would lead to compression of the median nerve. Therefore, it is only logical that carpal tunnel syn- drome would be a commonly seen complication after fracture of the distal radius, and it is an entity that should have a low threshold for consideration in post-fracture management.

Smaill from New Zealand continued to reiterate Colles’ belief that patients would regain full, painless function irrespective of how the fracture was treated [24]. He felt operative treatment or aggressive manipulation was unwarranted and only reported two complications in his series, both ruptures of the extensor pollicis longus, and no carpal tunnel syndrome. It is apparent in reviewing his treatise that many authors shared an acceptance of relatively poor outcomes after these fractures. Cole and Obletz in 1966 reviewed the end results of 33 cases of distal radius fractures treated by pins- and-plaster technique [5]. They found only one case of a transient median “neuritis,” but the longest follow-up in their study was 5 years, with the shortest being only 18 months. They did recognize, however, that many of their patients had poor functional outcomes, and they agreed with Gartland and Werley, who determined that closed immobilization led to inadequate results in their 60 patients treated for Colles fractures [8].

During these years, carpal tunnel syndrome was frequently thought of as a chronic condition.

It was not until 1970, when Adamson presented his paper, “The Acute Carpal Tunnel Syndrome,” it was generally accepted that this condition can occur acutely [2]. They reported nine cases of acute carpal tunnel syndrome, of which one was after a severe Colles fracture from a fall on the wrist while ice skating. They concluded that acute carpal tunnel syndrome was much more common than ordinarily thought and, therefore, one can conclude that the Colles fractures would likely play a role in the etiology of this acute nerve compression. A similar report on acute carpal tunnel syndrome was written by McClain and Wissinger in 1976 [18]. They too presented nine different case reports; but in their study, four of the nine cases occurred from fractures of the distal radius. Two of these were classic, extra-articular Colles fractures; one was a Salter-Harris II fracture of the distal radius in an adolescent, and the last report involved an intra-articular fracture of the distal radius. They concluded that immediate surgical decompres- sion was the most favored option. Bauman and Gelber- man also published a paper entitled, “The Acute Carpal Tunnel Syndrome,” and they presented five different cases of acute carpal tunnel syndrome in 1981 [3]. Of these, four cases involved distal radius fractures, and their review of the literature concluded that fractures of the distal radius were the leading cause of acute median nerve compression.

Gelberman went on to look at carpal tunnel pressures and wrist positions in patients with Colles fractures and stated that an awareness of the magnitude of increased interstitial fluid pressure should lead to an alternate method of treatment in many cases of distal radius fractures [4]. They found that intracarpal canal in- terstitial fluid pressures were highest in extreme flexion after Colles fractures. In contrast, similar studies in patients with no fractures have demonstrated that extreme extension actually produces the most intracarpal pressure [9, 15]. This underscores the importance of maintaining the wrist in a relatively neutral position during immobilization for this injury.

Besides causative factors such as hyperflexion of the wrist and direct entrapment of the median nerve at the time of fracture, a third cause of median nerve compression can occur by volarly displaced fragments. Paley and McMurtry first described compression of the median nerve against the proximal edge of the transverse carpal ligament by a volarly displaced fragment in this fracture pattern [21]. They concluded that not only was reduction of this fragment necessary, but that carpal tunnel decompression is also necessary. They presented nine patients with markedly displaced volar fragments in a distal radius fracture, with eight of these patients developing either acute or delayed carpal tunnel syn- drome. They first described the concept that median neuropathy can occur acutely, subacutely, or late after Colles fractures. They further noted that compression from a volar displaced fragment was a much less com- mon phenomenon but, nevertheless, should be recognized. Other authors have described late median nerve symptoms after displaced volar fragments with Lewis and Miller describing a case where a carpal tunnel syndrome developed 18 years after a Smith fracture [13]. Watson-Jones described a similar case [26], while Coo- ney reported that six out of 565 patients reviewed at the Mayo Clinic developed a late carpal tunnel syndrome directly attributed to a volar fragment compression [7]. Although this fracture pattern necessitates an open re- duction, it should also be done for the reason of decompressing the median nerve since any attempt at closed reduction can cause further injury to the nerve due to the presence of this fragment against the nerve itself.

Secondary carpal tunnel syndrome is not limited to adults as Binfield from London described three cases of Salter-Harris type II fractures of the distal radius lead- ing to median nerve complaints [4]. As often done in children, the fractures were treated closed and once reduction was obtained, the symptoms quickly resolved. They were quick to conclude that adult management of a median nerve palsy associated with distal radius frac- ture usually necessitated exploration and decompression of the carpal canal. However, with children this de- cision is more controversial, and they supported the concept of closed reduction and close follow-up of the clinical symptoms over time.

Just as median nerve compression has been managed with increasing vigilance, we have also gradually come to a point where the distal radius fracture is treated much more aggressively. Due to the relative frequency of median nerve compression in these fractures, as we have seen with literature review, we might also conclude that perhaps median nerve compression should be im- plied once distal radius surgical management is under- taken. It is only in recent years that distal radius frac- tures are commonly being treated by open means due to the accepted notion that a more anatomic reduction will lead to a better clinical result [11]. Although there is still a role for the use of external fixation, it is becoming in- creasingly accepted that an open reduction with plates and screws is indicated. During this open reduction, it is often prudent to release the median nerve in that same sitting. This becomes even more intuitive when the ap- proach for the fracture is performed in a volar fashion. Recent papers indicate that the distal radius anatomy and biomechanics dictate that a plate be placed on the volar side [19]. Consequently, this allows for a median nerve decompression since it can be done through the same volar side and perhaps even the same incision if it is approached in a more extensile manner.

Internal fixation of the distal radius through a volar approach is usually performed through a more distal Henry approach between the flexor carpi radialis (FCR) and the radial artery. In complex fractures, this approach can be extended more distally to better allow reduction of the articular surface, and the incision can be extended directly over the carpal tunnel to allow for open release of the transverse carpal ligament. This ex- tension should be done in a zig-zag manner to avoid a longitudinal scar over the volar wrist creases. More complex fractures (Fig. 35.1) that require articular ele- vation may be approached through the extended FCR approach [20]. This was first described by Orbay and allows one to reduce the fracture through an intrafocal approach. This way the critical volar ligaments are not violated in reducing the articular surface. I also recom- mend arthroscopic assistance in many of these articu- lar fractures in the younger, high-demand patient. Be- cause of the amount of postoperative swelling that may occur after this aggressive approach, it may also be pru- dent to decompress the median nerve as a consequence of the surgical technique itself. It is my preference to perform the carpal tunnel release endoscopically. Hence, I make a separate, small, transverse incision in the midline to the wrist directly over or just ulnar to the palmaris longus tendon (Fig. 35.2). This tends to be several centimeters ulnar to the distal extent of the ap- proach for distal radius volar open reduction. The en- doscopic technique obviously results in less surgical trauma being a minimally invasive approach and is ad- equate in cases where reduction of associated fractures in the carpus are not necessary.

My Preferences

My personal preference is to decompress the median nerve first in fractures of mild-to-moderate displace- ment, and then perform the open reduction through the previously described volar approach through a sep- arate longitudinal incision. More severely displaced fractures should be reduced first, prior to the median nerve decompression, since the severity of fracture dis- placement may place the median nerve in a much less predictable position, making endoscopic release more technically challenging. In these markedly displaced cases, I perform volar plating first, and then once the anatomy has been restored, it is much easier to release the transverse carpal ligament through the endoscopic approach (Fig. 35.3). I have frequently noted that the carpal tunnel is not tight once the fracture is reduced, although there is almost always blood within the carpal canal. Irrigating this out can also minimize neuritis from the effect of blood around the nerve. Despite the obvious advantages of decompressing the median nerve at the time of surgery, I have also found there to be other direct benefits. Besides preventing or revers- ing the effects of median nerve compression from the fracture, I also find that postoperative rehabilitation is much easier once the transverse carpal ligament is di- vided. This is because of the empiric observation that the patient can flex and extend the fingers much easier once the confines of the carpal tunnel are decompres- sed. We must realize that not only does the median nerve run within the carpal tunnel, but nine flexor ten- dons pass through this very narrow canal as well. Due to either anatomic variation in the carpal tunnel due to the fracture or the effects of swelling from interstitial edema or direct bleeding, the flexor tendons are nar- rowly constricted within the tunnel. Once the ligament is divided, the flexor restriction, and this allows for the patient to fully ex- tend and flex the fingers immediately in the recovery room after open reduction/internal fixation. This has not only the advantage of allowing improved and less painful rehabilitation, but likely diminishes the possi- bility of developing a complex regional pain syndrome.

It is my current practice to perform an endoscopic carpal tunnel release in all patients who undergo open reduction/internal fixation for displaced distal radius fractures (Fig. 35.4). The vast majority of these patients undergo volar fixation using a subchondral peg sup- port, but on rare occasions a shear articular fracture of the distal radius may require the application of an exter- nal fixator and concomitant arthroscopic reduction of the articular surface for management of this fracture. In these cases, once the external fixator is placed, a sepa- rate incision is made for endoscopic carpal tunnel re- lease at that time. It has been my experience that these patients have much less pain and better digital function in the postoperative period as a direct result of median nerve decompression at the initial time of surgery.

Conclusion

In conclusion, it is now a well-accepted fact that car- pal tunnel syndrome is a frequently seen complication of distal radius fractures, either in the acute period or delayed as a consequence of the swelling and deformity of the wrist. It might also be concluded that decompres- sion of the median nerve should be done in conjunc- tion with the ever-increasing operative treatment of displaced distal radius fractures. This has many bene- fits besides avoiding carpal tunnel syndrome which al- lows our patient with this common fracture to rehabili- tate the hand in a more rapid and less painful fashion.tendons can glide free of relative


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Roxie Romney
Roxie Romney
16:01 07 Oct 21
Hello I would just like to share what it is I have experience here with Dr. Bhatia’s facility and would like to... emphasize the fact that this is an incredible facility for the injury I had which was a rotator cuff tear. From the time that I actually arrived with the injury I was put in the capable hands at their facility then when I had the shoulder surgery it was a huge success for me, I also received the bedded attention with care and support that was equally as incredible……I can’t speak enough about the therapy facility as well which is also located at the same location at Dr. Badia’s Office…….They have my full respect and appreciation for their outstanding work and service as I am living proof of what I experience hand benefited from and will not hesitate to refer anyone to them cheersread more
Jordan Knight
Jordan Knight
12:56 04 Oct 21
Simply incredible, I was in awe of how organized and structured the whole clinic is. Dr. Badia gave me another chance... at playing my favorite sport, by repairing my shoulder, and for that I am forever grateful.read more
Catalina De Armas
Catalina De Armas
14:39 26 Aug 21
Best doctor ever . They took care of my daughters elbow fracture and assisted us in finding a follow up appointment in... México. The treatment for international patients was VIP. We felt heard and guided throughout the process. The team communicated efficiently and made the process very simple .read more
Jamee Wilson
Jamee Wilson
19:01 15 Jul 21
We brought our 17 year old son to Dr. Badia for a hand injury suffered playing baseball. From the moment we walked in... to the office, everyone was kind and attentive. He ended up needing surgery and the entire process was extremely smooth and again, everyone we came in contact with was amazing. The office and surgery center are in the same building so it is very convenient. We had been to other doctors for this same injury several years ago and the injury kept getting misdiagnosed so it was great that Dr. Badia diagnosed the problem and took care it so my son doesn’t have to deal with it anymore.read more
Willy G.
Willy G.
15:19 12 Jul 21
I had a really severe thumb break into 3 PCs. My Finger was in the shape of a Z. I remembered OthroNow and went to Dr... Badia. Was best decision I could make, had surgery next day and was successful. My thumb looks great and doing great. Their staff is amazing from full service of urgent care, to his doctor office staff, surgery center, and their therapy staff is amazing. I would highly recommend them especially for full service from beginning to end.read more
Lia L
Lia L
18:00 25 Jan 21
Not good for pediatric patients . Long wait time, so had a lot of ppl waiting. Would not let me wait on chaira... outside of xray room but rather in the outside waiting room even though my child was only 10. Don’t take pediatric patients if you can’t properly accommodate one guardian.read more
Maria Santos
Maria Santos
01:45 06 Nov 20
I am really satisfy with my hand surgery that was done by Dr. Alejandro Badia, and I want to thanks all the... professional personal and staff that always are very kind. I highly recommended!read more
Najlaa Bayram
Najlaa Bayram
03:45 02 Nov 20
Dr. Badia is an outstanding Dr and surgeon. I first sought his expertise, in late 2013, after a misdiagnosis and a... botched surgery by another Dr that left me with unbearable pain and unable to move my right hand for months.After doing some research online, looking for some excellent hand surgeons, a lot of articles came up praising Dr. Badia's expertise and competence. I sent him an email explaining what happened, how the pain started and asked for his opinion. To my surprise,I received a thorough response the same day with detailed information.I right then decided to drive 4hours to go see him; I must say it was the best decision I made. From the 1st visit, Dr. Badia performed surgery to fix the initial issue and later did another surgery to correct the botched one; I couldn't be happier with the results.Earlier this year, I slipped and injured my left wrist. I made another trip to Miami and once again Dr. Badia came to the rescue. He did surgery on my left wrist after the conservative treatment didn't fully help and at the same time did a cubital nerve release on my right elbow that instantly stopped the pain I've been having.I HIGHLY recommend Dr. Badia; he's a true expert and an outstanding surgeon. His staff is very kind, professional, friendly and truly cares.read more
danadenni
danadenni
21:18 17 Oct 20
My husband and I contacted Dr Badia for my hand issues. I had researched approximately five hand specialists in... Florida and one in New York city before I found Dr Badia about an hour away from us.My husband and I went to Doral, Florida and the minute I met Dr Badia I knew he was going to do my surgery.He has personality plus !!! and loves what he does. He is kind, patient and listens to his patients. He respects your hands !Dr Badia was highly recommended and I am so glad that we found him. He did the surgery on my hand and with a bit of rehab it healed better than I expected and my pain was gone !Dr Badias office personnel are wonderful ! It is quite obvious that they love working there with him and that they love their jobs. My husband and I have never experienced an office with so many helpful and caring people.We both recommend Dr Badia. We still drive to his office for anything to do with hand issues and he takes care of whatever it is. We both trust our hands ONLY to him ! He is a gem.read more
Yohann Dessureault
Yohann Dessureault
02:25 01 Oct 20
I first contacted Dr. Badia's clinic after I injured my hamate bone. I needed a surgery and someone in my family that... knew Dr. Badia convinced me that he was one of the best if not the best hand surgeon in the world. I am a high level Baseball player so I needed treatments in order to get back on the field as soon as possible. I have been able to book an appointment the next week which was great. I'm Canadian which made it tougher with my insurance company, but Dr. Badia's team has been really helpful with that, they sent numerous emails and even made some calls with the company to make sure I would not have any fees related to the consultation and surgery. The surgery went really well, without any complication and I don't think it would have been as quick and easy with anyone else than Dr. Badia and his team. I would definitively recomand Badia Hand to Shoulder Center to anyone in the need of treatments.read more
David Carvallo
David Carvallo
15:29 31 Aug 20
I injured my shoulder right as we entered into a lockdown due to a pandemic. It was next to impossible to get anyone to... see me and assess my injury. Dr. Badia and his team, following carefully laid out safety protocols, were able to bring me in, have x-rays, MRI and thorough review of the findings all in ONE visit!!! I was given an interim treatment plan to bridge the gap as surgeries were restricted due to COVID-19. As soon as surgeries resumed, I was scheduled for my procedure. To say that both Dr. Badia and his team are amazing is an understatement.They helped me handle a difficult insurance approval process to ensure I had the best surgeon treating me and my procedure at The Surgery Center at Doral and communication with my PCP and Cardiologist was excellent.Everyone made me feel very safe and confident that I was in the best possible setting where I wouldn’t be exposed to needless risk in a traditional hospital. The results of my surgery so far have been amazing. I’ve had next to no pain post-op and my recovery is coming along at lightning speed thanks Dr. B’s amazing talent and the dream team he has at OrthoNow where I have been undergoing physical therapy. I couldn’t say enough good things about him and the team. His expertise and dedication to providing the best possible care using cutting edge technology make for patient centered care and well being vs. insurance driven red tape so often seen today. Highly recommend Dr. Badia!read more
Ruth Rheaume
Ruth Rheaume
22:34 11 Aug 20
I went to Dr. Badia with a bad infection in my nail. He is so good at what he does and took care of me with such... concern. Gigi is the sweetest, cutest thing ever, who also made sure that I was comfortable and helped so I would not be nervous. The whole staff makes you feel like family. Thank you everyone from the bottom of my heart and I would recommend Dr. Badia's expertise and his office to anyone. So, if you have an injury or a problem, please go see him.read more
Mark Ferry
Mark Ferry
20:51 05 Aug 20
Tele-med conference with Dr. Badia and staff regarding "golfer's elbow"
Richard Chung
Richard Chung
11:49 23 Jul 20
Staff was very welcoming and accommodating.. Dr. B. was very professional and caring.He seems to be a driving... innovator and in improving the lives of patients in the South Florida area.read more
julio hernandez
julio hernandez
17:05 15 Jul 20
Dr Badia is the best orthopedic surgeon in Miami hands down. I need surgery because of a multiple fracture in my left... forearm. Went to other doctors (UM, mount Sinai) and they didn’t promise me I would recover 100% of my injuries and told me I would not be able to do sports again.Dr Badia did tell me I would heal 100% and it’s true. I did a much simpler surgery and fixed me in no time.Would recommend to anyone. Two thumbs upread more
Deb Duro
Deb Duro
17:19 07 Jul 20
Wonderful practice very welcoming staff and amazing service with top notch technology. I was a patient and I am a... colleague of Dr Badia and had the best treatment for my hand injury got diagnosed in the spot with a 3D Ultrason super modern technology and treated at the same moment. Really superb experience being a physician I absolutely recommended Dr Badia Hand and Shoulder Center at OrthoNOW!read more
Leonard Wolfson
Leonard Wolfson
19:42 04 Nov 19
Excellent visit. I injured my finger yesterday and was seen today by Dr. Badia. The staff was friendly and very... efficient and the doctor spent more than enough time explaining what was going on and explaining my options. Truly a great experience.read more
Luisa Alfonso
Luisa Alfonso
16:25 06 Sep 19
The Dr and staff are professional and friendly. I’m happy I came here and I received the attention and answers I... needed. I had injured my hand and I left the office feeling better. Thank you all for everything!!!read more
Robledo Aybar
Robledo Aybar
16:30 09 Aug 19
Due to a fall, I fractured my wrist in late Nov. 2018. Dr Badia and his team helped me overcome this issue and today... I’m working, and back on my bike and running. The best service and experience!read more
Ellen Westbrook
Ellen Westbrook
23:08 29 Jul 19
Staff displayed professionalism and caring. Dr. Badia was as enthusiastic as I was about this surgery to improve the... function of my hand. The surgical day process was smooth; I was kept informed every step of the way. I felt comfortable and safe.read more
victor mendelsohn
victor mendelsohn
02:37 30 May 19
From the first call I made to Dr. Badia‘s office I was impressed by the professionalism of the person who answered the... phone. When I arrived at the office for my appointment I was once again greeted in a professional manner. This professionalism radiated through all of the team. I hadn’t seen Dr. Badia for over 10 years and he greeted me as if we’ve been in contact with each other for years.read more
Alexander Aguiar
Alexander Aguiar
18:19 24 Apr 19
From my first visit the staff as well as the Dr. Badia have been exceptionally professional and caring. I had an injury... to my pinky finger, the required a placement of a rod in order to align. The surgery went well and was scheduled right away. The office staff has been amazing with scheduling and confirming appointments. Overall I am very happy with the care i received as well as the results. My finger healed and my range of motion has also gotten much better. Thank you Dr. Badiaread more
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305 227-HAND (4263)

3650 NW 82nd Ave. Suite 103
Doral, Florida 33166
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Badia Hand to Shoulder Center
Complete Care of the Hand, Wrist, Elbow and Shoulder in one Medical Facility Dr. Alejandro Badia, M.D, F.A.C.S. Past President ISSPORTH (2011-2013)
Our Office Hours:
3650 NW 82nd Ave, Doral, FL 33166, USA - Badia Hand to Shoulder Center
Monday 8:30 AM – 5:00 PM
Tuesday 8:30 AM – 5:00 PM
Wednesday 8:30 AM – 5:00 PM
Thursday 8:30 AM – 5:00 PM
Friday 8:30 AM – 5:00 PM
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