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Bainha do flexor infectada (Tenossinovite flexora piogênica)

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Updated Oct 2026
Illustration: Bainha do flexor infectada (Tenossinovite flexora piogênica)

Esta página foi traduzida automaticamente e ainda não foi verificada por um médico. A versão em inglês é a versão oficial.

O que você está sentindo

Uma infecção da bainha do tendão flexor é uma infecção no túnel pelo qual desliza o tendão que dobra o dedo. Todo o dedo geralmente incha de forma uniforme, ao longo de todo o seu comprimento, em vez de em um único ponto dolorido. O dedo pode ficar em posição ligeiramente dobrada e ser difícil de esticar. Esticá-lo, ou alguém esticá-lo delicadamente por você, geralmente é o que mais dói, especialmente perto da base do dedo, onde o inchaço pode ficar visível.

A dor é sentida ao longo da linha do tendão, da base do dedo em direção à palma da mão, e não sobre uma única articulação. Ela tende a estar presente o tempo todo e piora quando o dedo é forçado a ficar esticado. Dobrar um pouco o dedo costuma aliviá-la, e é por isso que o dedo fica encolhido. O inchaço e a dor podem dificultar as tarefas do dia a dia: segurar uma chaleira, girar uma chave, abotoar roupas, segurar uma caneta ou segurar um corrimão.

Essa infecção pode avançar rapidamente, e não é do tipo que pode esperar. Se o seu dedo ou a sua mão ficar quente, vermelho, inchado e dolorido, especialmente com febre, vá a um pronto-socorro no mesmo dia. Você não precisa de encaminhamento do médico de família antes. O mesmo vale se o seu dedo ficar pálido, frio, branco ou azulado, ou se você perder subitamente a sensibilidade ou o movimento nele.

O que está realmente acontecendo

Ao longo da face inferior de cada dedo passa um tendão que dobra o dedo, um cordão forte que puxa a ponta do dedo em direção à palma da mão. Esse tendão desliza dentro de um túnel fechado chamado bainha do tendão flexor. O túnel é revestido por uma camada escorregadia que mantém o tendão nutrido, lubrificado e deslizando livremente, um pouco como um cabo que passa por uma capa lubrificada com graxa.

Quando bactérias entram nessa capa, geralmente por um corte, um ferimento perfurante ou uma mordida, o espaço fechado se enche de pus. Como a capa é vedada, o pus fica sob pressão contra a própria superfície sobre a qual o tendão precisa deslizar. A pressão comprime o suprimento de sangue do tendão e dá início à formação de cicatrizes entre o tendão e o seu revestimento. É por isso que todo o dedo incha de forma uniforme, por isso ele fica encolhido e por isso esticá-lo dói tanto: todas as partes do túnel estão inflamadas ao mesmo tempo.

A infecção pode se propagar. O túnel do polegar se conecta a um espaço com líquido na palma da mão chamado bursa radial, e o do dedo mínimo se conecta a um espaço chamado bursa ulnar. Em muitas pessoas, esses espaços se estendem até perto do punho; assim, a infecção em um dedo pode se espalhar em direção à palma da mão ou até atravessar para o polegar ou para o dedo mínimo, formando o que se chama de abscesso em ferradura.

O que está em jogo depende do momento do tratamento. O tendão depende do deslizamento, e o pus retido contra ele causa danos duradouros quanto mais tempo permanece ali. Quando tratada cedo, a maioria dos dedos se recupera bem. Se a espera for longa demais, o próprio tendão pode morrer, o dedo pode ficar rígido por causa das cicatrizes e, em casos graves, o dedo pode ser perdido. Mesmo com antibióticos e cirurgia imediatos, é comum haver alguma rigidez no dedo depois, porque o tecido em cicatrização tende a aderir em vez de deslizar.

O seu cirurgião vai verificar até onde a infecção se espalhou antes de decidir com que urgência drená-la.

O que podemos fazer a respeito

O Dr. Kieran Hirpara, cirurgião de membros superiores no Mater Private Hospital Rockhampton, trata a infecção da bainha do tendão flexor como uma emergência e inicia o tratamento imediatamente. Essa infecção não espera, e você também não deve esperar. O objetivo é eliminar a infecção antes que ela danifique o tendão que permite que o seu dedo se dobre.

O primeiro passo são antibióticos administrados por gotejamento em uma veia do braço. Os antibióticos atuam junto com a drenagem, e não no lugar dela. Como a bainha é um túnel vedado, os antibióticos sozinhos muitas vezes não conseguem eliminar a infecção. Drenar o pus alivia a pressão sobre o tendão e permite que os antibióticos alcancem toda a região.

A maioria dos casos precisa de cirurgia para drenar a bainha. Fazemos pequenas incisões, pequenos cortes na pele, para podermos abrir o túnel e lavar o pus para fora. Lavar a bainha rapidamente protege a superfície de deslizamento de que o seu tendão precisa. O momento exato e o tipo de cirurgia dependem de até onde a infecção se espalhou e de quão cedo você chega.

Após a cirurgia, o seu dedo pode precisar de uma tala para ficar em repouso. A sua terapia da mão após a cirurgia é feita com Ruby Doolan, da Extend Rehabilitation. A Ruby é terapeuta da mão: ela orienta os seus exercícios e confecciona qualquer tala de que você precise. O foco dela é fazer o tendão voltar a deslizar, porque as cicatrizes entre o tendão e o seu revestimento são o que limita o movimento mais tarde.

Algumas infecções são causadas por germes incomuns, como micobactérias ou fungos, que precisam de um tratamento específico com antibióticos ou antifúngicos por um período mais longo. Se a infecção tiver danificado gravemente o tendão, reconstruí-lo é uma operação separada, que pode ser feita depois que a infecção tiver se resolvido por completo.

O prognóstico depende muito do momento do tratamento. Chegar cedo é o que mais protege o seu dedo; por isso, se o seu dedo estiver quente, vermelho, inchado e dolorido, especialmente com febre, vá a um pronto-socorro no mesmo dia.

O que esperar

O prognóstico de uma infecção da bainha do tendão flexor depende principalmente da rapidez com que ela é tratada. Chegar cedo dá ao seu dedo a melhor chance de voltar a dobrar normalmente. Esperar deixa o pus sob pressão contra o tendão, e essa pressão causa danos que não podem ser desfeitos depois.

Com tratamento imediato, a maioria dos dedos melhora e começa a se mover novamente nas semanas e meses seguintes. Mesmo assim, é comum haver alguma rigidez depois, mesmo em pessoas saudáveis que receberam antibióticos e cirurgia rapidamente. O tecido em cicatrização tende a aderir em vez de deslizar, por isso o dedo pode não dobrar nem esticar tão livremente quanto antes. A terapia da mão trabalha isso, mas exige tempo e esforço constante.

Se a infecção for grave ou ficar sem tratamento por tempo demais, o prognóstico é mais difícil. O túnel ao redor do tendão pode ser destruído, e as cicatrizes podem deixar o dedo permanentemente rígido. Em alguns casos, o inchaço fica tão intenso que comprime o suprimento de sangue do próprio dedo, um problema chamado síndrome compartimental. Nas infecções mais graves, o dedo pode morrer e precisar ser amputado, mesmo quando o tratamento foi feito a tempo e de forma completa.

Algumas situações menos comuns também podem acontecer. Às vezes, a infecção não se resolve por completo e é necessária uma segunda lavagem. Raramente, um germe incomum pode aparecer no dedo semanas após o tratamento e exigir cuidados adicionais.

A única coisa que você pode controlar é o momento. Se o seu dedo ou a sua mão ficar quente, vermelho, inchado e dolorido, especialmente com febre, vá a um pronto-socorro no mesmo dia. Você não precisa de encaminhamento do médico de família antes. O mesmo vale se o seu dedo ficar pálido, frio, branco ou azulado, ou se você perder subitamente a sensibilidade ou o movimento nele.

Quando procurar ajuda médica

Essa infecção é uma emergência e avança rapidamente. Vá a um pronto-socorro no mesmo dia se o seu dedo ou a sua mão ficar quente, vermelho, inchado e dolorido, especialmente com febre. O mesmo vale se o seu dedo ficar pálido, frio, branco ou azulado, ou se você perder subitamente a sensibilidade ou o movimento nele. Você não precisa de encaminhamento do médico de família antes. Se você não conseguir contato com a clínica, por exemplo fora do horário de atendimento ou em um fim de semana, vá ao pronto-socorro mais próximo.

Os sinais de alerta acompanham a forma da infecção: todo o dedo incha de forma uniforme, fica dobrado, dói ao longo da linha do tendão, e esticá-lo é muito doloroso. Você não precisa ter todos esses sinais para procurar avaliação. Um dedo que mostre apenas alguns deles ainda pode ter essa infecção.

Consulte o seu médico de família ou peça uma avaliação com especialista se os sintomas não estiverem melhorando, estiverem piorando ao longo de semanas ou impedirem você de usar a mão.

Em maior profundidade

Advanced reading: the deeper science (optional)

Esta seção aborda temas que vão além do necessário para suas próprias decisões de tratamento. A bainha do flexor infectada merece uma leitura mais atenta, pois é a única infecção na mão que constitui uma verdadeira emergência; além disso, dois dos fatores que mais determinam o desfecho do caso já foram decididos antes mesmo de o paciente chegar ao hospital — um deles, anos antes.

O diagnóstico baseia-se em quatro sinais descritos na década de 1930 que nunca foram devidamente testados

Allen Kanavel descreveu quatro sinais de infecção na bainha do flexor: um dedo inchado em toda a sua extensão, e não apenas num ponto; mantido ligeiramente dobrado; tendo sensibilidade dolorosa ao longo de toda a bainha do tendão, e não apenas numa articulação; e, o mais útil dos quatro sinais, dor intensa quando alguém estica o dedo suavemente [1].

Quase um século depois, esses quatro sinais ainda são utilizados para o diagnóstico; contudo, a sua sensibilidade, especificidade e confiabilidade interobservador nunca foram devidamente comprovadas [1]. Trata-se de uma lacuna notável para um diagnóstico cujo atraso pode levar à perda do dedo.

A consequência prática mais relevante é a seguinte: nem todos os quatro sinais aparecem em todos os casos, especialmente em crianças; a ausência de um ou mais sinais não exclui o diagnóstico [1]. Um dedo que falha apenas num dos testes de Kanavel não pode ser considerado livre de infecção.

A forma de drenagem influencia diretamente a amplitude de movimento do dedo posteriormente

Após o diagnóstico, é necessário descomprimir a bainha tendinosa; existem duas abordagens principais para isso: realizar uma incisão cirúrgica na bainha ou inserir um cateter fino nela e realizar a irrigação através de uma incisão muito menor.

Uma revisão sistemática envolvendo 763 pacientes constatou que a irrigação com cateter proporciona melhor amplitude de movimento do que a lavagem aberta, e que o uso de antibióticos como parte do tratamento, em vez de depender apenas do drenagem, também melhora a mobilidade [2].

Vale ressaltar que isso é o oposto do que ocorre no caso do felon: um abscesso na polpa do dedo, quando devidamente drenado, não necessita de antibióticos. A diferença reside na anatomia: o felon é uma cavidade fechada que pode ser completamente esvaziada, enquanto a bainha tendinosa é um tubo longo revestido pela superfície sobre a qual o tendão desliza. Não é possível limpar essa área sem danificar o que se pretende preservar; por isso, os antibióticos exercem um papel que a cirurgia não consegue cumprir.

O risco de perder o dedo depende principalmente do paciente

Este é o achado menos confortável, porém o mais útil. Na análise conjunta dos dados, as taxas de amputação foram influenciadas quase exclusivamente pelo estado de saúde geral do paciente, e não pela técnica cirúrgica: 39% em pacientes com diabetes, 64% em pacientes com insuficiência renal e 71% em pacientes com doença vascular periférica, todos valores estatisticamente significativos [2].

Esses números descrevem uma situação patológica distinta daquela vivenciada por uma pessoa saudável com uma pequena lesão por espinho. É por isso que uma infecção na bainha tendínea em diabéticos ou em pessoas com má circulação é tratada com maior urgência e exige lavagens repetidas mais frequentemente. Da mesma forma, a resposta honesta à pergunta “eu vou manter o dedo?” depende muito mais do estado geral de saúde do paciente do que de qualquer procedimento realizado durante a cirurgia.

Por que o atraso é mais importante do que quase qualquer outro fator

A bainha tendínea é um espaço fechado com baixo suprimento sanguíneo, contendo um tendão que depende de movimentos de deslizamento para funcionar. O pus acumulado sob pressão nesse espaço produz dois efeitos simultâneos: interrompe o fluxo sanguíneo para o tendão e gera aderências que posteriormente limitam os movimentos. Ambos os efeitos dependem do tempo decorrido; por isso, o tratamento precoce melhora consistentemente os resultados [2], e por isso a recomendação padrão para essa infecção específica é procurar o pronto-socorro em vez de marcar consulta com um clínico geral [3].

Mesmo quando tudo é feito corretamente e rapidamente, a rigidez pós-tratamento é comum. O grau dessa rigidez depende, em grande parte, de quanto tempo a bainha tendínea ficou sob pressão – fator que o paciente pode influenciar ao procurar atendimento precocemente.

Referências

[1] Kennedy CD, Huang JI, Hanel DP. Resumo: Sinais de Kanavel e tenossinovite flexora piogênica. Clin Orthop Relat Res. 2016;474(1):280-284. https://doi.org/10.1007/s11999-015-4367-x

[2] Giladi AM, Malay S, Chung KC. Revisão sistemática sobre o tratamento da tenossinovite flexora piogênica aguda. J Hand Surg Eur Vol. 2015;40(7):720-728. https://doi.org/10.1177/1753193415570248

[3] Goyal K, Speeckaert AL. Tenossinovite flexora piogênica: avaliação e tratamento. Hand Clin. 2020;36(3):323-329. https://doi.org/10.1016/j.hcl.2020.03.005

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.

Overview

  • Pyogenic flexor tenosynovitis is an uncommon closed-space infection of the hand [2].
  • Pyogenic flexor tenosynovitis can result in severe stiffness and other sequela [2].
  • Acute flexor tendon sheath infections are associated with significant morbidity [3].
  • 43% of patients with acute flexor tendon sheath infections have a poor result [3].
  • The consequences of pyogenic flexor tenosynovitis can include destruction of the tendon sheath [6].
  • The consequences of pyogenic flexor tenosynovitis can include scarring and inflammation causing oedema of the soft tissues of the finger [6].
  • The consequences of pyogenic flexor tenosynovitis can include resultant finger stiffness [6].
  • The consequences of pyogenic flexor tenosynovitis can occasionally include compartment syndrome [6].
  • Sonographic evidence of a swollen tendon and fluid in the flexor sheath correlates strongly with the diagnosis of acute suppurative tenosynovitis [4].
  • Sonographic evidence of a swollen tendon and fluid in the flexor sheath should prompt early surgical drainage [4].
  • Any suspicion of flexor tendon sheath phlegmon should lead to urgent surgical exploration [10].
  • Any suspicion of flexor tendon sheath phlegmon should not lead to blind antibiotic prescription [10].
  • The absence of pain on passive extension in advanced stages is a grave prognostic sign indicating tissue necrosis rather than improvement [7].

Anatomy & Pathophysiology

Flexor Tendon Anatomy and Sheath Structure

  • The extrinsic finger flexors consist of the flexor digitorum profundus and the flexor digitorum superficialis [13].
  • The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx, flexing the distal interphalangeal joint as well as the proximal interphalangeal and metacarpophalangeal joints [13].
  • The flexor digitorum superficialis acts as a flexor of the proximal interphalangeal and metacarpophalangeal joints [13].
  • As flexor tendons pass distal to the metacarpal neck, they enter the fibroosseous tunnel, or digital flexor sheath [24].
  • The fibroosseous tunnel extends distally to the proximal aspect of the distal phalanx [24].
  • The tendinous sheath consists of annular pulleys, which provide mechanical stability, and cruciate pulleys, which provide flexibility [24].
  • The first, third, and fifth annular pulleys (A1, A3, and A5) are located over the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints, respectively [24].
  • The second and fourth pulleys (A2 and A4) are situated over the middle portion of the proximal and middle phalanges [24].
  • The A2 and A4 pulleys are the most essential in maintaining the mechanical advantage of the flexor tendons [24].
  • The tenosynovium that lines the fibroosseous tunnel supplies both nutrition and lubrication to the poorly vascularized flexor tendons [24].
  • Within the sheath, tendon vascularity is supplied via the vincula system: the vinculum longus and brevis [24].
  • The tenosynovial sheath of the flexor pollicis longus is continuous with the radial bursa [24].
  • The tenosynovial sheath to the little finger is continuous with the ulnar digital bursa [24].
  • In some patients, the radial and ulnar bursae communicate, allowing a so-called horseshoe abscess to spread between the thumb and little finger if infection occurs in the flexor tendon sheath of either one of these digits [24].

Pathophysiology of Pyogenic Flexor Tenosynovitis

  • Pyogenic flexor tenosynovitis (PFT) is an uncommon closed-space infection of the hand that can result in severe stiffness and other sequela [2].
  • Acute flexor tendon sheath infections are associated with significant morbidity, with 43% of patients having a poor result [3].
  • The consequences of pyogenic flexor tenosynovitis can be destruction of the tendon sheath, scarring and inflammation causing oedema of the soft tissues of the finger with resultant finger stiffness or, occasionally, compartment syndrome [6].
  • Sonographic evidence of a swollen tendon and fluid in the flexor sheath correlates strongly with the diagnosis of acute suppurative tenosynovitis and should prompt early surgical drainage [4].
  • Any suspicion of flexor tendon sheath phlegmon should lead to urgent surgical exploration, not blind antibiotic prescription [10].
  • Although unusual, nonsuppurative tenosynovitis secondary to foreign body migration may occasionally account for an otherwise unexplained mild but persistent tenosynovitis [11].

Classification

  • Nonsuppurative tenosynovitis secondary to foreign body migration may occasionally account for an otherwise unexplained mild but persistent tenosynovitis [11].

Investigations

  • A careful physical examination is essential to direct care and future testing if indicated [12].
  • Diagnostic tests such as imaging and serum laboratory studies are useful in the determination of pathology but can be expensive, time consuming, and often nonspecific [12].

Treatment

Operative

  • A minimally invasive, ultrasound-guided, percutaneous flexor tendon sheath lavage technique was effective in 65% of cases [1].
  • A minimally invasive, ultrasound-guided, percutaneous flexor tendon sheath lavage technique was safe in 100% of cases [1].
  • Any suspicion of flexor tendon sheath phlegmon should not be managed with blind antibiotic prescription [10].
  • Placement of irrigation catheters in ulnar or radial bursitis may be facilitated by passing an irrigation catheter over a previously placed guide wire [9].

Outcomes and Prognosis

  • No patient had a recurrence of the infection following closed tendon sheath irrigation for pyogenic flexor tenosynovitis [5].
  • Use of a protocol for the treatment of severe infections of the hand resulted in a shorter hospital stay compared with patients treated before the protocol's institution [8].
  • Use of a protocol for the treatment of severe infections of the hand resulted in faster healing compared with patients treated before the protocol's institution [8].
  • Use of a protocol for the treatment of severe infections of the hand resulted in fewer complications, including recrudescence of infection, reoperation, stiffness, arthritis, and osteomyelitis, compared with patients treated before the protocol's institution [8].

Complications

  • Pyogenic flexor tenosynovitis is an uncommon closed-space infection of the hand that can result in severe stiffness and other sequela [2].
  • Complications associated with severe hand infections include recrudescence of infection, reoperation, stiffness, arthritis, and osteomyelitis [8].

Recovery

  • The consequences of pyogenic flexor tenosynovitis can be destruction of the tendon sheath [6].
  • The consequences of pyogenic flexor tenosynovitis can be scarring and inflammation causing oedema of the soft tissues of the finger with resultant finger stiffness [6].
  • The consequences of pyogenic flexor tenosynovitis can occasionally be compartment syndrome [6].
  • Use of a treatment protocol resulted in a shorter hospital stay compared with patients treated before the protocol's institution [8].
  • Use of a treatment protocol resulted in faster healing compared with patients treated before the protocol's institution [8].
  • Use of a treatment protocol resulted in fewer complications, including recrudescence of infection, reoperation, stiffness, arthritis, and osteomyelitis, compared with patients treated before the protocol's institution [8].
  • No patient had a recurrence of the infection following closed tendon sheath irrigation [5].

Key Evidence

  • [L5] Our results have shown that this minimally invasive, ultrasound-guided, percutaneous flexor tendon sheath lavage technique was effective in 65% of cases and safe in 100% of cases. [1] (10.1016/j.hansur.2018.12.001)
  • [L5] Pyogenic flexor tenosynovitis (PFT) is an uncommon closed-space infection of the hand that can result in severe stiffness and other sequela. [2] (10.2106/jbjs.rvw.26.00015)
  • [L4] Acute flexor tendon sheath infections are associated with significant morbidity, with 43% of patients having a poor result. [3] (10.1016/0363-5023(90)90064-x)
  • [L4] Sonographic evidence of a swollen tendon and fluid in the flexor sheath correlates strongly with the diagnosis of acute suppurative tenosynovitis and should prompt early surgical drainage. [4] (10.1016/0363-5023(89)90027-0)
  • [L4] No patient had a recurrence of the infection. [5] (10.1016/s0363-5023(78)80141-5)
  • [L5] The consequences of pyogenic flexor tenosynovitis can be destruction of the tendon sheath, scarring and inflammation causing oedema of the soft tissues of the finger with resultant finger stiffness or, occasionally, compartment syndrome. [6] (10.1016/j.jhsb.2006.02.019)
  • [L3] The absence of pain on passive extension in advanced stages is a grave prognostic sign indicating tissue necrosis rather than improvement. [7] (10.1016/j.injury.2026.113631)
  • [L3] Use of the protocol resulted in a shorter hospital stay, faster healing, and fewer complications (recrudescence of infection, reoperation, stiffness, arthritis, and osteomyelitis) when compared with 107 patients who were treated before institution of the protocol. [8] (10.1016/s0363-5023(88)80060-1)
  • [L5] Placement of irrigation catheters in other closed space infections such as in ulnar or radial bursitis may also be facilitated by passing an irrigation catheter over a previously placed guide wire. [9] (10.1016/s0266-7681(97)80290-2)
  • [L4] Any suspicion of flexor tendon sheath phlegmon should lead to urgent surgical exploration, not blind antibiotic prescription. [10] (10.1016/j.main.2011.10.025)
  • [L5] Although unusual, the situation described may occasionally account for an otherwise unexplained mild but persistent tenosynovitis. [11] (10.1016/s0363-5023(83)80176-2)

References

[1] Designing a minimally-invasive, ultrasound-guided, percutaneous flexor tendon sheath lavage technique: a cadaver study. Hand Surgery and Rehabilitation. 2019. DOI: 10.1016/j.hansur.2018.12.001

[2] Management of Pyogenic Flexor Tenosynovitis. JBJS Reviews. 2026. DOI: 10.2106/jbjs.rvw.26.00015

[3] Acute flexor tendon sheath infections. The Journal of Hand Surgery. 1990. DOI: 10.1016/0363-5023(90)90064-x

[4] Use of sonography in the early detection of suppurative flexor tensosynovitis. The Journal of Hand Surgery. 1989. DOI: 10.1016/0363-5023(89)90027-0

[5] Closed tendon sheath irrigation for pyogenic flexor tenosynovitis. The Journal of Hand Surgery. 1978. DOI: 10.1016/s0363-5023(78)80141-5

[6] MRSA Pyogenic Flexor Tenosynovitis Leading to Digital Ischaemic Necrosis and Amputation. Journal of Hand Surgery. 2006. DOI: 10.1016/j.jhsb.2006.02.019

[7] Predictive Factors for Outcomes in Pyogenic Flexor Tenosynovitis: A 10-Year Analysis of 341 Patients. Injury. 2026. DOI: 10.1016/j.injury.2026.113631

[8] A protocol for the treatment of severe infections of the hand. The Journal of Hand Surgery. 1988. DOI: 10.1016/s0363-5023(88)80060-1

[9] Passage of an Irrigation Catheter with the Aid of a Guide Wire for Pyogenic Flexor Tenosynovitis. Journal of Hand Surgery. 1997. DOI: 10.1016/s0266-7681(97)80290-2

[10] Phlegmons des gaines des tendons fléchisseurs des doigts : étude de 120 cas. Chirurgie de la Main. 2011. DOI: 10.1016/j.main.2011.10.025

[11] Nonsuppurative tenosynovitis secondary to foreign body migration. The Journal of Hand Surgery. 1983. DOI: 10.1016/s0363-5023(83)80176-2

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

[13] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > Image DISORDERS OF THE MUSCULATURE OF THE HAND.

[24] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > FLEXOR TENDON INJURY.

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Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

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.