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Pag-drain ng Acute Paronychia

PDF Evidence Consent
Updated Sep 2026
Illustration: Pag-drain ng Acute Paronychia

Ang pahinang ito ay isinalin ng makina at hindi pa nasusuri ng isang doktor. Ang bersyong Ingles ang siyang opisyal.

Bakit iminungkahi ang operasyong ito

Si Dr Kieran Hirpara, isang upper-limb surgeon sa Mater Private Hospital Rockhampton, ay nagsisimula sa mga opsyon na hindi gaanong invasive na angkop sa iyong kondisyon. Ang acute paronychia ay isang impeksyon sa balat sa tabi o sa ilalim ng kuko ng daliri. Karaniwan itong nagdudulot ng pamumula, init, pamamaga, at matinding tenderness. Ang mga maagang impeksyon ay maaaring gumaling sa pamamagitan lamang ng mga antibiotic. Ang mga mas advanced na impeksyon ay nangangailangan ng incision and drainage, na nangangahulugang paggawa ng maliit na butas upang palabasin ang nana. Ang mga antibiotic ay madalas na hindi na kailangan pagkatapos para sa mga straightforward na kaso sa mga taong walang risk.

Ang mga pasyente ay karaniwang nirerefer sa aming klinika ng kanilang GP; kung ang isang physiotherapist ang nagmungkahi na magpatingin sa amin, kakailanganin mo pa rin ng referral mula sa iyong GP upang maging eligible para sa Medicare rebate. Sinusuri namin ang iyong history, sinusuri ang iyong daliri, at nag-aayos ng imaging kung kinakailangan. Kung ang impeksyon ay nakakolekta na ng nana, o patuloy itong lumalala habang umiinom ka ng mga antibiotic tablet, karaniwan naming irerekomenda ang drainage. Layunin naming maibsan ang sakit nang mabilis at pigilan ang pagkalat ng impeksyon nang mas malalim sa daliri, kung saan maaari nitong mapinsala ang tendon o buto. Pag-uusapan namin ang plano kasama ka bago ang anumang hakbang.

Bago ang operasyon

Karamihan sa paghahanda ay simple lamang. Kakailanganin mong itigil ang pagkain at pag-inom pitong oras bago ang operasyon. Humihingi kami ng pito sa halip na anim upang maaari ka naming mauna kung maagang matapos ang listahan sa theatre. Sasabihin sa iyo ng iyong surgeon kung alin sa iyong mga regular na gamot ang dapat laktawan sa araw na iyon, at makatutulong kung magdadala ka ng nakasulat na listahan ng lahat ng iyong iniinom. Mag-ayos ng taong maghahatid sa iyo pauwi pagkatapos, at magsuot ng maluwag at komportableng damit. Ang imaging tulad ng X-ray, ultrasound o MRI scan ay maaaring gamitin upang planuhin ang operasyon. Kung mayroon kang iba pang kondisyong medikal, maaaring kailanganin mo ng mga blood test o pagsusuri kasama ang anaesthetist, ngunit karamihan sa mga tao ay hindi nangangailangan ng alinman dito.

Sa araw ng operasyon

Darating ka sa surgical admissions unit ng ospital, kung saan ka ire-rehistro at ihahanda para sa theatre. Pagkatapos ay makikipagkita ka sa anaesthetist, ang doktor na magpapatulog sa iyo at titiyak sa iyong kaligtasan habang isinasagawa ang operasyon. Ang operasyong ito ay ginagawa sa ilalim ng general anaesthetic. Minsan ay nagdaragdag ng regional nerve block para sa pagbawas ng sakit pagkatapos ng operasyon; tatalakayin ito ng anaesthetist sa iyo sa araw na iyon.

Pagkatapos nito, dadalhin ka sa operating theatre, kung saan isasagawa ang operasyon. Kapag natapos na ito, magigising ka sa recovery area. Mananatili ang mga nurse kasama mo roon habang nawawala ang bisa ng anaesthetic. Kapag stable ka na, ililipat ka sa isang ward o uuwi sa araw ding iyon, depende sa procedure at kung paano ang iyong paggaling.

Ano ang kinapapalooban ng operasyon

Simple lamang ang layunin ng operasyon: ang gumawa ng maliit na butas sa tabi o sa ilalim ng iyong kuko upang mailabas ang nana at mawala ang pressure. Gagawa ang iyong surgeon ng maliit na hiwa sa balat sa tabi ng kuko, sa bahaging kung saan naipon ang impeksyon. Ilalabas ang nana, at huhugasan ang espasyo. Karamihan sa mga tao ay nakararamdam ng ginhawa mula sa tumitibok na sakit agad pagkatapos nito.

Mayroong higit sa isang paraan upang buksan ang espasyo, at walang iisang napagkasunduang teknik. Pipiliin ng iyong surgeon ang approach na angkop para sa iyong daliri. Kung ang impeksyon ay kumalat na sa skin fold sa kabilang panig ng kuko, maaaring gumamit ng teknik na ginagamot ang parehong nail fold nang sabay. Kung ang nana ay naipon sa ilalim mismo ng nail plate, maaaring gumawa ng maliit na butas sa pamamagitan ng kuko upang hayaan itong dumaloy palabas.

Kung ang impeksyon ay mas malala, o kung nagkaroon ito ng makapal at bukol-bukol na tissue sa gilid ng kuko, maaaring alisin din ng iyong surgeon ang tissue na iyon, upang ang bahaging iyon ay kumalma at gumaling nang malinis. Ang hiwa ay karaniwang hinahayaang nakabukas o bahagyang isinasara upang ang anumang natitirang impeksyon ay makalabas, at lalagyan ng dressing ang daliri. Uuwi ka na may nakalagay na dressing na ito.

Para sa mga simpleng impeksyon sa mga taong walang risk, madalas na hindi na kailangan ng antibiotics pagkatapos ng drainage. Kung ang iyong impeksyon ay mas kumplikado, maaaring magreseta ang iyong surgeon ng course ng antibiotic tablets pagkatapos upang tulungan itong mawala nang lubusan.

Pagkatapos ng operasyon

Magigising ka sa recovery area, kung saan sasamahan ka ng mga nurse habang nawawala ang bisa ng anaesthetic. Magkakaroon ng dressing ang iyong daliri, at maaaring makaramdam ka ng pamamanhid kung gumamit ng nerve block. Aayusin ang pain relief upang manatili kang komportable. Maaari ka nang gumalaw sa oras na maramdaman mong matatag ka na, at gagamitin mo ang iyong kamay nang dahan-dahan sa loob ng mga limitasyon ng dressing. Dapat may kasama ka sa unang 24 oras pagkauwi mo sa bahay. Sasabihin sa iyo ng iyong team kung uuwi ka sa araw ring iyon o mananatili ng isang gabi sa ospital. Iniiwan namin ang dressing sa loob ng humigit-kumulang 10 araw; pakiusap na huwag itong tanggalin bago ang panahong iyon maliban kung sinabi namin sa iyo. Papalitan o tatanggalin namin ito kapag nakita ka na namin.

Paggaling

Ang tumitibok na sakit na nagdala sa iyo rito ay karaniwang mabilis na humuhupa kapag nailabas na ang nana. Mananatiling maselan at namamagâ ang daliri sa loob ng ilang oras, at ang balat sa tabi ng kuko ay maaaring magmukhang pula habang ito ay gumagaling. Ang pagpapanatiling nakataas ng iyong kamay sa unan kapag ikaw ay nagpapahinga ay nakatutulong upang mabawasan ang pamamaga. Ang pain relief na inayos namin para sa iyo ay magpapanatili sa iyong komportable habang humuhupa ito.

Uuwi ka na may nakalagay na dressing, at pananatilihin namin itong nakalagay sa loob ng humigit-kumulang 10 araw. Mangyaring huwag itong tanggalin nang mag-isa; kami ang magpapalit o magtatanggal nito kapag nakita ka namin. Hanggang sa oras na iyon, gamitin ang iyong kamay nang dahan-dahan sa loob ng limitasyon ng dressing. Panatilihin itong malinis at tuyo. Maaari mong gawin ang karamihan sa mga magagaan na pang-araw-araw na gawain sa bahay, ngunit iwasang ibabad ang daliri at iwasan ang anumang bagay na bumabangga o pumipiga sa gumagaling na nail fold.

Kapag natanggal na ang dressing, ang layunin ay maibalik ang paggalaw at normal na paggana ng daliri. Ang iyong rehabilitasyon pagkatapos ng operasyon ay kasama si Ruby Doolan sa Extend Rehabilitation. Si Ruby ay isang hand therapist: gagabayan niya ang iyong mga ehersisyo at gagawa ng anumang splint na kakailanganin mo. Maaari siyang magturo sa iyo ng banayad na stretching at strengthening upang hindi tumigas ang daliri habang ito ay gumagaling. Habang humuhupa ang pamamaga at bumabalik ang paggalaw, unti-unti mo nang magagawa ang higit pa gamit ang kamay. Kapag kaya mo nang humawak (grip) at kumurot (pinch) nang walang sakit, ang karamihan sa mga pang-araw-araw na aktibidad ay magmumukhang normal muli.

Ang paggaling ay nag-iiba sa bawat tao. Maaaring magkaiba ang iyong timeline, at gagabayan ka ng iyong surgeon at therapist sa prosesong ito.

Ano ang maaaring maging problema

Karamihan sa mga pasyente ay gumagaling, ngunit paminsan-minsan ay maaaring magkaroon ng mga problema. Binabantayan ka nang maigi ng iyong surgeon at ng team upang maagapan ang anumang isyu.

Ang pangunahing alalahanin sa impeksyong ito ay ang patuloy na pagpapatuloy nito o ang pagbalik nito. Kung ang pamamaga, pamumula, at pananakit sa tabi ng iyong kuko ay hindi humuhupa, o lumalala pagkatapos ng gamutan, ang impeksyon ay maaaring lumalim. Sa paglipas ng panahon, maaari itong bumaba hanggang sa maliit na kasukasuan (joint) ng daliri. Maaari kang makaramdam ng sakit na mas malalim kaysa dati, daliring hindi maibabaluktot nang walang matalas na sakit, o kasukasuan na mukhang namamagâ at mainit hipuin. Kung mapansin mo ang alinman sa mga ito, tumawag sa klinika sa halip na maghintay para sa iyong susunod na bisita.

Mas nagiging posible ito kung hindi maayos ang paggaling at kung huli na ang paghingi ng tulong medikal. Kung ang sugat ay hindi humuhupa sa paraang inaasahan mo, o kung ipinagpaliban mo ang pagpapagamot, banggitin ito sa iyong susunod na review upang masuri namin ito nang maayos.

Mahalaga ang pagpapanatiling malinis ng daliri habang ito ay gumagaling. Ang mabuting kalinisan ng kamay (hand hygiene) ay tumutulong sa paggaling ng balat at nagpapababa ng pagkakataon na muling sumiklab ang impeksyon. Kung hindi ka sigurado kung paano aalagaan ang daliri kapag tinanggal na ang dressing, itanong sa amin sa iyong review at ituturo namin ito sa iyo.

Ang ilang impeksyon sa kuko ay sanhi ng cold sore virus sa halip na bacteria, at ang mga ito ay maaari ring magkaroon ng bulsa ng nana. Kung iyon ang iyong nararanasan, drainage pa rin ang gamutan. Maaaring mag-alala ka na babalik ang virus kalaunan o magdudulot ng pangmatagalang problema sa daliri. Sa mga kasong tulad nito, ang mga taong sinubaybayan sa mahabang panahon ay walang naranasang pagbalik ng virus at walang pangmatagalang problema mula sa drainage mismo. Kung mapansin mo ang mga bagong paltos o maliliit na maselang bahagi malapit sa kuko pagkatapos mong gumaling, banggitin ito sa iyong review.

Ang table ng mga komplikasyon sa pahinang ito ay naglilista ng mga tipikal na rate kung nais mo ang mga detalye.

Kailan dapat tumawag sa amin

Tumawag sa amin kung magkaroon kayo ng lagnat, kung lumala ang pamumula o ang discharge mula sa daliri, o kung ang sakit ay biglang naging matindi. Pumunta sa emergency kung may pamamaga ng binti, paninikip ng paghinga, kawalan ng pakiramdam sa daliri, o kung hindi niyo ito maigalaw. Ang mga palatandaang ito ay kailangang masuri agad. Kung mayroong anuman tungkol sa daliri na nakababahala sa inyo at ito ay labas na sa oras ng klinika, pumunta sa pinakamalapit na emergency department sa halip na maghintay.

Reviewed by AI synthesis (v2) — pending human review · 19 August 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Anatomy & Pathophysiology

General Hand Architecture

  • The hand is composed of 19 bones, 17 articulations, and 19 muscles situated entirely within the hand [2].
  • The hand contains approximately the same number of tendons activated by the forearm muscles as it has intrinsic muscles [2].
  • The open hand forms a balanced graceful oval in its longitudinal axis when fingers are extended and in contact [2].
  • The proximal carpometacarpal half of the hand is flattened and presents two faces with unique anatomical and functional significance [2].
  • The posterior or dorsal aspect of the hand is convex, while the anterior, palmar, or volar aspect is concave [2].
  • The distal half of the hand is separated into five digits that flex toward the palm [2].
  • The digits converge in closing by flexing and adducting, and diverge in opening by extending and abducting [2].
  • The thumb has a more proximal and lateral position than the other digits, allowing movement inward and outward from the palm [2].
  • The four fingers are the distal extension of the carpometacarpal part of the hand [2].
  • The hinges for finger movement are located at the thenar crease and at the transverse distal palmar crease, not at the bases of the digits [2].
  • When fingers are extended and separated, their tips lie on the circumference of a circle whose center is the head of the third metacarpal [2].

Cutaneous Units and Skin

  • The dorsal covering of the interphalangeal articulations of the digits forms a unique cutaneous unit characterized by a considerable excess of skin when the digits are in extension [3].
  • The dorsal integument of the distal phalanx is distinct due to the presence of the nail bed with its matrix [3].
  • The palm forms a cutaneous unit extending from the distal transverse crease of the wrist up to the transverse crease at the base of the digits [3].
  • The palmar integument is subdivided into two separate zones by the oppositional crease of the thumb, which constitutes the oblique axis of the hand [3].
  • The skin of the radial portion of the palm covers the thenar eminence and the external part of the palm and is relatively well vascularized and mobile [3].
  • The skin of the ulnar and distal portion covers the hypothenar eminence, where the skin has poor mobility [3].
  • The central triangular part of the palm has fixed and poorly vascularized skin that covers almost directly the superficial palmar aponeurosis [3].
  • The integument of the palmar face of the digits is subdivided into phalangeal units separated by digital flexion folds [3].
  • When a digit is completely flexed, the integument of adjacent phalanges comes into contact in the zones of the flexion creases, establishing areas of cutaneous contact in the form of a diamond [3].
  • The sides of the diamond-shaped cutaneous contact zones do not undergo variations in length during movements of flexion and extension [3].
  • Incisions made along the lines of the diamond-shaped cutaneous contact zones present a minimal chance of retraction [3].
  • The web spaces are formed from the union of two nonsymmetrical cutaneous surfaces [3].
  • The dorsal slope of the web space has a gradual incline and its supple skin is not adherent to the subjacent region [3].
  • The palmar surface of the web space is flat and precipitously interrupted, with skin densely adherent to the commissural skeleton [3].
  • The commissural skeleton is formed by the interdigital palmar (natatory) ligament between the fingers and by the distal transverse ligament at the level of the thumb web [3].

Muscular Anatomy

  • There are seven interosseous muscles in the hand, consisting of four dorsal and three volar muscles [4].
  • The dorsal interossei are abductors [4].
  • The anatomic axis of the hand coincides with the axis of the third metacarpal [4].
  • The dorsal interossei lie to the radial side of the index and middle fingers and the ulnar side of the middle and ring fingers [4].
  • The little finger is abducted by the abductor digiti quinti [4].
  • The volar interossei are adductors [4].
  • The volar interossei lie to the ulnar side of the index finger and the radial side of the ring and little fingers [4].
  • The middle finger has two dorsal interossei (abductors) and no volar interossei (adductors) because the central axis of the hand lies within it [4].
  • Each dorsal interosseous muscle, with the exception of the third, has two muscle heads [4].
  • The superficial head of the dorsal interosseous muscles arises most dorsally from the shaft of the contiguous metacarpals [4].
  • The superficial head is inserted deeply by a medial tendon onto the lateral tubercle of the base of the proximal phalanx [4].
  • The superficial head abducts and weakly flexes the proximal phalanx [4].
  • The superficial head has no direct effect on the middle or distal phalanges [4].
  • The deep head of each dorsal interosseous muscle forms a lateral tendon, or lateral band, at the level of the MP joint [4].
  • The deep head flexes and weakly abducts the proximal phalanx while extending the middle and distal phalanges [4].
  • At the level of the middle of the proximal phalanx, transverse fibers arch dorsally from each lateral band to join each other over the dorsum of the finger [4].
  • These transverse fibers flex the proximal phalanx [4].
  • Oblique fibers (spiral fibers) from the lateral bands sweep over the distal third of the proximal phalanx to insert onto the lateral tubercles at the base of the middle phalanx [4].
  • The oblique fibers extend the middle phalanx at the PIP joint [4].
  • The lateral bands are joined by the lateral slips of the extensor tendon to form the conjoined lateral band [4].
  • The two conjoined lateral bands to each finger unite at the distal third of the middle phalanx to form the terminal tendon [4].
  • The terminal tendon inserts at the base of the distal phalanx to extend it [4].
  • The flexor digiti quinti brevis is structurally and functionally similar to the deep head of the dorsal interossei [4].
  • The flexor digiti quinti brevis forms the ulnar lateral band of the little finger [4].
  • Each volar interosseous muscle has only one muscle head [4].
  • None of the volar interossei insert onto the proximal phalanx [4].
  • The volar interossei form the ulnar lateral band of the index finger and the radial lateral band of the ring and little fingers [4].
  • The abductor digiti quinti and flexor digiti quinti brevis arise from the fifth metacarpal [4].
  • The abductor digiti quinti inserts onto the ulnar lateral tubercle at the base of the proximal phalanx of the little finger [4].
  • The flexor digiti quinti forms the ulnar lateral band [4].
  • The opponens digiti quinti lies deepest among the hypothenar muscles [4].
  • The opponens digiti quinti arises from the pisohamate ligament and the hook of the hamate [4].
  • The opponens digiti quinti inserts onto the ulnar side of the diaphysis of the fifth metacarpal [4].
  • The opponens digiti quinti flexes and supinates the fifth metacarpal [4].

Vascular Anatomy

  • The arteries of the thumb vary in both size and number [8].
  • The palmar aspect of the thumb can be schematized into three segments defined by the metacarpophalangeal and interphalangeal flexion creases [8].
  • In the classical layout, the "princeps pollicis" artery is the terminal branch of the radial artery [8].
  • The "princeps pollicis" artery crosses the first intermetacarpal space [8].
  • The "princeps pollicis" artery runs along the ulnar side of the first metacarpal bone and along the volar surface of the adductor muscle [8].
  • The "princeps pollicis" artery emerges onto the subcutaneous palmar tissue at the level of the cutaneous flexion crease of the metacarpophalangeal joint [8].
  • At the level of the metacarpophalangeal joint crease, the "princeps pollicis" artery divides into two terminal rami, namely the collateral palmar arteries of the thumb [8].
  • The collateral palmar arteries of the thumb run along the digital tunnel symmetrically and are of equal caliber [8].
  • The collateral palmar arteries head distally to finally unite in the pulp arcade [8].
  • During their transit in the digital tunnel, the collateral palmar arteries break off into numerous collateral branches, either cutaneous, articular, or osseous [8].
  • An arcade located deep in the flexor tendon joins together the two arteries at the level of the distal metaphysis of the first phalanx [8].
  • Vessels originating from this arcade enter the "vincula" and irrigate the flexor tendon [8].
  • Only 15% of anatomical dissections fall into the category of the classical description of the palmar arteries of the thumb [8].
  • In the first segment of the thumb (between the opposition crease and the metacarpophalangeal flexion crease), it is rare to find arteries of surgical interest on the volar surface [8].
  • The artery in the first segment is located deeply and is more easily accessible from the dorsal surface [8].
  • In the second segment, the two arteries run alongside the flexor tendon and behind the collateral nerves [8].
  • In the second segment, the main artery is the ulnar collateral artery [8].
  • The subtendinous anastomosis situated at the level of the neck of the first phalanx acts as a "moderator" between the two arteries in the second segment [8].
  • In cases where the palmar ulnar collateral artery is absent, the dorsal artery takes its place by means of a branch through the subtendinous arcade [8].
  • In the third segment (pulp segment), the two arteries are of similar size and run through the thick fatty subcutaneous padding [8].
  • In the pulp segment, the arteries cross over and convert into the ends of the digital nerves at the level of the median axis [8].
  • The posterior area of the thumb is vascularized by two arteries which originate from the palmar arteries at the level of the first metacarpal [8].
  • These dorsal arteries run laterally along the metacarpophalangeal joint and continue obliquely from volar to dorsal [8].
  • At the level of the neck of the first phalanx, an anastomosis can be found which originates from the palmar arteries for the dorsal aspect [8].
  • The dorsal arteries are joined by three arcades: one inconstant arcade located under the extensor tendon at the level of the neck of the first phalanx, the arcade of the nail matrix, and the arcade of the nailbed [8].
  • The ulnar dorso-collateral artery generally stems from the "princeps pollicis" onto the medial border of the neck of the first metacarpal [8].

Skeletal and Ligamentous Architecture

  • The metacarpal arch is endowed with a great deal of adaptability because of the mobility of the peripheral metacarpals [7].
  • The peripheral metacarpals form the sides of the cup or the palmar gutter and can deepen the concavity as they approach each other [7].
  • The thumb metacarpal is independent and articulates with the trapezium [7].
  • The middle metacarpals are united to the carpus by the intrinsic interlocking encasement of the bones themselves [7].
  • The index metacarpal is the most firmly fixed [7].
  • The ring metacarpal is a transitional element to the fifth metacarpal and has about 10 degrees of mobility in flexion and extension [7].
  • The fifth metacarpal is semi-independent and articulates with the hamate [7].
  • The fifth metacarpal is restrained on its radial side by its articulation with the base of the fourth metacarpal [7].
  • The fifth metacarpal has a range of flexion–extension of approximately 20 degrees [7].
  • The second to fifth metacarpals are all bound together by various fibrous structures [7].
  • The most distal fibrous structure binding the second to fifth metacarpals is the deep transverse intermetacarpal ligament [7].
  • The deep transverse intermetacarpal ligament is better named the interglenoid ligament [7].
  • The interglenoid ligament ties together the anterior "glenoid ligaments" of the metacarpophalangeal articulations, known as the "volar plates" [7].
  • The longitudinal arches are composed of a fixed portion, the carpometacarpal, and a mobile portion, the digits [7].
  • For every ray there is a longitudinal arch [7].
  • The keystones of the longitudinal arches are the metacarpophalangeal articulations [7].
  • The thick anterior glenoid capsules, the volar plates, prevent hyperextension at the metacarpophalangeal joints [7].
  • The volar plates are interconnected by the transverse interglenoid ligament [7].
  • The stability of the metacarpophalangeal joints is essential to the support of the longitudinal arch as well as of the transverse metacarpal arch [7].
  • The five rays of the hand differ in mobility and independence [7].
  • Mobility and independence are considerable for the thumb, much less for the fifth ray, and even less for the others [7].
  • The index ray has a certain degree of independence at the phalangeal level, owing to the arrangement of its flexor and extensor muscles [7].

Investigations

  • A careful physical examination is essential to direct care and future testing if indicated [1].
  • Diagnostic tests such as imaging and serum laboratory studies can be expensive, time consuming, and often nonspecific [1].
  • An 8-MHz Doppler tone assessment may be used to identify superficially displaced neurovascular bundles when Dupuytren cords lie beneath soft fleshy prominences [11].
  • False-negatives are possible with 8-MHz Doppler tone assessment [11].
  • MRI is probably most useful in identifying additional pathology such as flexor tendon bowstringing [11].
  • MRI may be helpful in providing a quantitative noninvasive measure of cellularity of affected areas, which is an index of biologic activity [11].

References

[1] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Evaluation, Clinical Examination, and Imaging > Evaluation and Clinical Examination: Current Concepts.

[2] Exam Of The Hand Wrist 2Ed. INTRODUCTION.

[3] Exam Of The Hand Wrist 2Ed. Functional cutaneous units.

[4] Green S Operative Hand Surgery. Interosseous and Hypothenar Muscles.

[7] Exam Of The Hand Wrist 2Ed. The arches of the hand > The metacarpal arch.

[8] Exam Of The Hand Wrist 2Ed. Techniques of investigation of the arterial supply by J P Melki > Vascularization of the thumb > Palmar aspect.

[11] Dupuytren S Disease And Related Hyperproliferative Disorders. 54. The Future of Dupuytren’s Research and Treatment > 54.4 Mechanical Measurements and Procedures > 54.4.4 Imaging.

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Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.