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Drainage of a Felon

49 citationsUpdated Oct 2026
Illustration: Drainage of a Felon

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Overview

A felon is a closed-space infection of the distal finger pulp that, if untreated, can progress to significant morbidity and mortality [5, 7, 15]. While early felons and paronychia may be managed with antibiotics alone [1], more advanced infections require incision and drainage [1]. The management of felon is based entirely on tradition and expert opinion, with no primary data regarding management found in the literature [3]. Although acute paronychial abscesses are generally treated operatively, there is no consensus on the best surgical technique [20]. Surgical drainage is considered the optimal treatment for any hand infection [14], and prompt diagnosis and aggressive surgical debridement are critical to reduce morbidity and mortality [5, 7].

Effective treatment is predicated upon prompt recognition, early aggressive debridement, and appropriate antimicrobial coverage [9]. The mainstay of management is extensive débridement and decompression of all necrotic tissue combined with broad-spectrum antibiotics [10]. Early surgical débridement takes precedence over transfer to prevent high rates of limb loss and mortality [10]. Treatment requires a combination of surgical intervention and appropriate antibiotic therapy tailored to the organism and infection severity [2]. In addition to surgical decompression of abscesses, broad-spectrum empiric antibiotic therapy is necessary [22]. Diagnosis relies on Gram stain and cultures [6], and treatment requires incision and drainage with prolonged antibiotic management [6].

Conservative management with close follow-up would have prevented adverse clinical events, costly workup, and hospitalization [19]. Treatment principles include evacuation of the infection and tailored postoperative antibiotic treatment with close monitoring [18]. Antibiotics are not needed in the postoperative phase after excision of uncomplicated paronychia and felon in patients who are not at risk [4]. Adequate drainage is obtained and the wound heals in a shorter period of time, and there is an absence of scarring on finger as the nail regenerates completely and covers the scar [11]. Treatment of such infections can be challenging and must be individualized, with a significant incidence of prolonged and, often, permanent morbidity [8].

Anatomy & Pathophysiology

Fingertip Anatomy

The pulp of the digit is compartmentalized by fibrous septae that connect the periosteum to the skin [34]. Kanavel identified the pulp volar to the terminal phalanx as a closed compartment separate from the rest of the finger [24]. The dorsal integument of the distal phalanx is characterized by the presence of the nail bed with its matrix [55]. The tissues surrounding the nail, including the hyponychium, paronychium, and eponychium, form a barrier against infectious organisms [34]. The digital neurovascular structures are surrounded by a diffuse network of thin transverse oblique fibers; fibers dorsal to the bundle are called the Cleland ligament, while those palmar to the bundle are called the Grayson ligament [66]. Unlike the palmar skin, the dorsal skin of the hand possesses a normal pilosebaceous system [65].

Pathophysiology

Disruption or inoculation of the nail barrier allows entry of infectious organisms into fingertip tissues [34]. Infections in the fingertip pulp region can lead to considerable pain from the build-up of pressure in the area [34]. Due to the close proximity of bone in the fingertip, osteomyelitis is a potential concern in either acute or chronic settings [34]. Early sections of the distal portion of the phalanx in felon reveal polymorphonuclear exudation into the marrow [12]. Roentgen examination does not reveal bone destruction in early stages because osteomyelitis is visible only after sufficient accumulation of microscopic inflammation and necrosis produces a gross lesion [12]. In advanced felon infections, the tuft and shaft of the phalanx can be destroyed, and in late cases, the entire phalanx can become necrotic [12].

Pus is composed of bacterial virulence factors, neutrophil-derived degranulation and netosis, dead and dying pathogens, defensive neutrophils, other immune cell types, and dead and dying host structural cells [17]. In the antibiotic era, the majority of hand infections are due to gram-positive organisms, with almost 90% being staphylococci [24]. Methicillin-resistant Staphylococcus aureus is an increasingly prevalent nosocomial pathogen that presents therapeutic challenges [24]. The morbidity of hand infections can be decreased with understanding of the different types of hand infections often unique to the particular anatomy of the hand [46].

Classification

Felon is classified as a non-pyogenic flexor tenosynovitis (non-PFT) finger infection in studies that differentiate pyogenic flexor tenosynovitis from other digital pathologies [25]. It represents one of two main infection types involving the distal fingertip, the other being paronychia [34]. In a cohort of 652 patients presenting with hand infections, felon was the most common type, accounting for 331 cases [84].

Anatomy and Pathophysiology

The unique anatomy of the fingertip involves tissues surrounding the nail, specifically the hyponychium, paronychium, and eponychium, which form a barrier against infectious organisms [34]. Disruption or inoculation of this barrier occurs in scenarios such as nail biting and dishwashing, allowing entry of infectious organisms into the fingertip tissues [34]. Within the pulp, fibrous septae connect the periosteum to the skin and compartmentalize the digit [34]. Infections in this region lead to considerable pain from the build-up of pressure [34]. The close proximity of bone makes osteomyelitis a potential concern in either acute or chronic settings [34].

Clinical Signs and Symptoms

Pain Character: Felons present with a cellulitic stage characterized by "prickly" pain and an abscess stage characterized by "throbbing" pain [27]. Systemic Signs: Infectious symptoms such as fevers and chills are often absent in patients with hand infections [70]. Initial laboratory evaluation of white blood cell count, erythrocyte sedimentation rate, and C-reactive protein are frequently normal [70]. Red Flags: Necrotizing fasciitis should be considered in all patients with rapid change in clinical examination [70]. Progression of erythema, tense swelling (peau d'orange skin), and pain out of proportion with the examination should raise suspicion for necrotizing fasciitis [70]. Atypical Presentation: Atypical hand infections are difficult to recognize due to their indolent nature and nonspecific symptoms [31]. Paronychia Overlap: Acute paronychia presents with erythema, swelling, and pain [34]. It involves areas adjacent to the nail fold but can spread underneath the nail plate, into the nail pulp, and wrap around to the contralateral side [34]. An infection adjacent to the germinal matrix can lead to pressure necrosis and affect subsequent nail growth [34].

Diagnosis

Diagnosis of hand and upper-extremity infections is usually clinical, based on predictable presentations and patterns [32, 70]. Imaging without contrast is valuable in the diagnosis of deep space infection, foreign bodies, and differentiation between soft tissue edema versus fluid collections [70]. For necrotizing fasciitis, which is a clinical diagnosis, a basic metabolic panel and complete blood count are useful [70]. The decision for incision in felons is often made based on clinical judgment and experience [27]. Incision should be made when the skin of the distal phalanx is tense, whether or not there is an abscess, to relieve vascular congestion in the fingertip [27]. Outcome is usually determined by the rapidity of the diagnosis and initiation of appropriate treatment [21]. Early identification through appropriate laboratory testing and surgical treatment paired with medical management is imperative for eradication of the causative organism in atypical hand infections [31].

Other Considerations

Treatment of fingertip infections can be challenging and must be individualized, with a significant incidence of prolonged and often permanent morbidity [8]. Hand infections include a diverse array of entities with potential for serious morbidity [28]. Treatment should always be based on the correct classification of the fracture and the corresponding soft tissue injury, but needs to be adapted to the individual patient considering general health status, secondary diagnoses and currently available treatment options [49].

Investigations

Hand and upper-extremity infections are usually a clinical diagnosis, but imaging and laboratory evaluation aid in diagnosis [32]. A careful physical examination is essential to direct care and future testing if indicated [36]. 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 [36].

Laboratory: Diagnosis of acute felon relies on Gram stain and cultures [6]. Early identification of atypical hand infections is imperative through appropriate laboratory testing [31].

Imaging: Radiographic soft tissue thickness can differentiate pyogenic flexor tenosynovitis from other finger infections, including felon [25]. High resolution ultrasound offers a superior form of diagnostic imaging to MRI for hand conditions, allowing for preoperative or diagnostic aspirate [71].

Treatment

Non-Operative

Conservative management with close follow-up can prevent adverse clinical events, costly workup, and hospitalization in cases where it is appropriate [19]. If nonoperative management with antibiotics and elevation is trialed for a felon, appropriate antibiotics should be chosen to cover gram-positive cocci [27]. Coverage of MRSA and other pathogens should be included in nonoperative antibiotic therapy if there is reasonable suspicion of their involvement [27]. Patients undergoing a trial of nonoperative management should be followed closely to determine the need for progression to incision and drainage [27].

Operative

Indications: The primary treatment of a suspected felon is operative irrigation and debridement [85]. Treatment of fingertip infections must be individualized due to a significant incidence of prolonged and often permanent morbidity [8].

Surgical Approach / Technique: For simple abscesses, thorough incision and drainage are often adequate [85]. Incision and drainage in the perinatal setting coupled with antibiotics is curative for neonatal acute paronychia [16]. A new incision technique for closed space infection (felon) involving the distal phalanx provides adequate drainage, shorter healing time, and absence of scarring as the nail regenerates [11].

Adjuncts: Continuous catheter irrigation can be used as a minimally invasive approach to dilute pathogens, virulence factors, and products of neutrophil-driven inflammation [17]. In the described catheter irrigation technique, physiological fluid is delivered at a rate of 5–10 ml/hour by pump drivers in accompaniment with intravenous antibiotics [17]. Use of catheter irrigation rather than open washout resulted in improved range of motion outcomes for pyogenic flexor tenosynovitis [43]. Use of antibiotics as a component of therapy resulted in improved range of motion outcomes for pyogenic flexor tenosynovitis [43]. When using continuous irrigation to treat flexor sheath infections, the catheter tip must be positioned within the flexor sheath to avoid potentially digit-threatening pressure necrosis [48]. If the catheter tip is not within the flexor sheath, fluid accumulates within the subcutis, which can cause vascular occlusion, distal ischemia, and soft tissue necrosis [48]. Digital pressures of patients with flexor sheath infections have been shown to reach over 30 mm Hg, enough to cause compartment syndrome [48]. Thorough repeated debridements and the use of a rinsing drain between serial incisions, combined with broad-spectrum antibiotics, helped control severe progressive nodular lymphangitis in a case of severe cutaneous nocardiosis [47].

Antibiotic Therapy: If the infection is inadequately debrided, severe with rapid progression, or associated with systemic illness, elderly patients, comorbidities, or immunosuppression, continued antibiotic therapy is recommended [85]. Empiric antibiotic treatment should target the most likely pathogen until culture sensitivities have been obtained [85]. First-generation cephalosporins should be avoided as first-line empiric treatment of hand infections unless the local prevalence of MRSA is limited [85]. Trimethoprim-sulfamethoxazole (TMP-SMX) can be a good choice for outpatient therapy to cover MRSA in patients with minimal comorbidities [85]. The Centers for Disease Control and Prevention recommend empiric coverage for MRSA if the local prevalence exceeds 10% to 15% [85]. Treatment of atypical hand infections requires surgical treatment paired with medical management for eradication of the causative organism [31]. Treatment of Nocardia infection requires incision and drainage with prolonged antibiotic management [6].

Complications

Bone Destruction and Osteomyelitis: Hand infections carry a high rate of complications that are often difficult to manage [53]. In advanced felon infections, the tuft and shaft of the phalanx can be destroyed, and in late cases the entire phalanx can become necrotic [12]. Early sections of the distal portion of the phalanx in these cases reveal polymorphonuclear exudation into the marrow [12]. Roentgen examination at the early stage of felon infection does not reveal evidence of bone destruction because osteomyelitis is only seen after sufficient accumulation of microscopic areas of inflammation and necrosis to produce a gross lesion [12].

Necrotizing Soft-Tissue Infection: Delayed diagnosis in necrotizing soft-tissue infections can result in mortality rates exceeding 70% [15]. Early surgical débridement takes precedence over transfer to prevent high rates of limb loss and mortality in these infections [10].

Postoperative Management: Continuous postoperative irrigation is no longer used due to concerns regarding swelling and hindrance of finger motion [35].

Recovery

Other Considerations: In uncomplicated paronychia and felon cases in patients who are not at risk, antibiotics are not needed in the postoperative phase after excision [4]. The wound from a new incision for felon involving the distal phalanx heals in a shorter period of time [11]. There is an absence of scarring on the finger following the new incision for felon as the nail regenerates completely and covers the scar [11]. At 3 years' follow-up, there was no sign of adverse sequelae resulting from the incision and drainage of a herpetic whitlow with bacterial abscess [26]. At 3 years' follow-up, there was no recurrence of the herpes infection following incision and drainage of a herpetic whitlow with bacterial abscess [26]. Delayed treatment and infections with specific pathogens led to a worse outcome in septic flexor tenosynovitis [99]. The stump healed uneventfully and remained satisfactory at one year following flexor sheath infection leading to acute digital ischaemia [44].

Key Evidence

  • [L5] The review provides a focused summary of management approaches, noting that early felons and paronychia may be managed with antibiotics alone, while more advanced infections require incision and drainage. [1] (10.1016/j.jemermed.2025.07.054)
  • [L5] Treatment requires a combination of surgical intervention (incision and drainage) and appropriate antibiotic therapy tailored to the organism and infection severity. [2] (10.1016/j.jhsa.2014.03.031)
  • [L5] The management of felon is based entirely on tradition and expert opinion, with no primary data regarding management found in the literature. [3] (10.1016/j.jhsa.2012.08.002)
  • [L2] The findings confirm that antibiotics are not needed in the postoperative phase after excision of uncomplicated paronychia and felon in patients who are not at risk. [4] (10.1016/j.hansur.2015.12.003)
  • [L4] Prompt diagnosis and aggressive surgical debridement are critical to reduce morbidity and mortality. [5] (10.5435/00124635-200005000-00002)
  • [L4] Diagnosis relies on Gram stain and cultures, and treatment requires incision and drainage with prolonged antibiotic management. [6] (10.1016/j.jhsa.2018.03.039)
  • [L4] Prompt diagnosis and early debridement are of the utmost importance to improve outcomes for these often limb- and life-threatening infections. [7] (10.1177/17531934241268983)
  • [L5] Unfortunately, treatment of such infections can be challenging and must be individualized, with a significant incidence of prolonged and, often, permanent morbidity. [8] (10.1016/s0749-0712(21)00416-9)
  • [L4] Effective treatment is predicated upon prompt recognition, early aggressive debridement, and appropriate antimicrobial coverage. [9] (10.1016/j.jhsa.2018.04.034)
  • [L5] The mainstay of management is extensive débridement and decompression of all necrotic tissue combined with broad-spectrum antibiotics, with early surgical débridement taking precedence over transfer to prevent high rates of limb loss and mortality. [10] (10.5435/jaaos-d-17-00616)
  • [L4] Adequate drainage is obtained and the wound heals in a shorter period of time, and there is an absence of scarring on finger as the nail regenerates completely and covers the scar. [11] (10.1097/00000658-194001000-00013)
  • [L4] [12] (10.1001/archsurg.1942.01210240092006)
  • [Case_report] Treatment requires formal drainage and antibiotic therapy, while discontinuation of taxane therapy is typically not required. [13] (10.1007/s11552-007-9029-3)
  • [L4] Surgical drainage is the optimal treatment of any hand infection. [14] (10.1016/j.hansur.2020.12.011)
  • [L4] Early surgical intervention, including extensive débridement, is critical to ensure survival and reduce mortality rates, which can exceed 70% in cases with delayed diagnosis. [15] (10.1056/nejmra1600673)
  • [L4] Incision and drainage in the perinatal setting coupled with antibiotics is curative. [16] (10.1177/1558944717692092)
  • [L5] [17] (10.1177/17531934231174819)
  • [L5] Treatment principles include evacuation of the infection and tailored postoperative antibiotic treatment with close monitoring. [18] (10.1016/j.hcl.2020.03.005)
  • [L5] The authors conclude that conservative management with close follow-up would have prevented adverse clinical events, costly workup, and hospitalization. [19] (10.1001/jamainternmed.2015.6527)
  • [L5] While acute paronychial abscesses are generally treated operatively, there is no consensus on the best surgical technique. [20] (10.1016/j.jhsa.2011.11.021)
  • [L5] Outcome usually is determined by the rapidity of the diagnosis and initiation of appropriate treatment. [21] (10.5435/00124635-200405000-00003)
  • [L4] In addition to surgical decompression of abscesses, broad-spectrum empiric antibiotic therapy is necessary. [22] (10.1097/blo.0b013e31811f3526)
  • [L5] Drainage, debridement, and intraoperative irrigation are the initial steps along with the decision for continuous postoperative irrigation based on intraoperative findings. [23] (10.1016/j.hcl.2020.03.014)
  • [L5] [24] (10.1053/jhsu.2000.jhsu025a0173)
  • [L4] [25] (10.1016/j.jhsa.2019.01.013)
  • [L5] At 3 years' follow-up, there was no sign of adverse sequelae resulting from the incision and drainage and no recurrence of the herpes infection. [26] (10.1016/s0363-5023(10)80117-0)
  • [Paper] [27] (10.1016/j.hcl.2020.03.004)
  • [L5] Hand infections include a diverse array of entities with potential for serious morbidity. [28] (10.1016/j.jhsa.2011.05.035)
  • [L5] Management principles include good surgical debridement and culture-guided antimicrobial therapy, with antibiotic therapy typically lasting 4–6 weeks, though the optimal length and mode of administration in the hand remain under study. [29] (10.1177/1753193415612373)
  • [L4] Atypical hand infections are difficult to recognize and treat due to their indolent nature and nonspecific symptoms; early identification through appropriate laboratory testing and surgical treatment paired with medical management is imperative for eradication of the causative organism. [31] (10.1016/j.jhsa.2025.09.023)
  • [L5] Hand and upper-extremity infections are usually a clinical diagnosis, but imaging and laboratory evaluation aid in diagnosis. [32] (10.1016/j.hcl.2020.03.002)
  • [L5] [34] (10.1016/j.jhsa.2018.05.027)
  • [L5] Continuous postoperative irrigation is no longer used due to concerns regarding swelling and hindrance of finger motion. [35] (10.1016/j.jhsa.2010.11.033)
  • [L3] Use of antibiotics as a component of therapy resulted in improved range of motion outcomes, as did using catheter irrigation rather than open washout. [43] (10.1177/1753193415570248)
  • [L4] The stump healed uneventfully and remained satisfactory at one year. [44] (10.1177/1753193409344504)
  • [L5] The morbidity of hand infections can be decreased with understanding of the different types of hand infections often unique to the particular anatomy of the hand. [46] (10.5435/00124635-199607000-00006)
  • [Case_report] Thorough repeated debridements and the use of a rinsing drain between the serial incisions, combined with broad spectrum antibiotics, helped to control severe progressive nodular lymphangitis. [47] (10.1177/1753193409344814)
  • [L4] [48] (10.1177/1753193412446574)
  • [Paper] Treatment should always be based on the correct classification of the fracture and the corresponding soft tissue injury, but needs to be adapted to the individual patient considering general health status, secondary diagnoses and currently available treatment options. [49] (10.1016/j.injury.2024.111935)
  • [L5] Hand infections are associated with a high rate of complications that are often difficult to manage. [53] (10.1016/j.hcl.2020.03.010)
  • [L5] [70] (10.1016/j.hcl.2020.03.001)
  • [L5] High resolution ultrasound offers a superior form of diagnostic imaging to MRI, in that preoperative or diagnostic aspirate can be performed. [71] (10.1016/j.jhsa.2004.02.004)
  • [L3] [84] (10.1177/1753193420977791)
  • [L5] [85] (10.1016/j.hcl.2020.03.003)
  • [L4] Delayed treatment and infections with specific pathogens led to a worse outcome. [99] (10.1177/1753193408087071)

See Also

References

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[2] Acute Hand Infections. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.03.031

[3] Diagnosis and Management of the Acute Felon: Evidence-Based Review. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.08.002

[4] Acute felon and paronychia: Antibiotics not necessary after surgical treatment. Prospective study of 46 patients. Hand Surgery and Rehabilitation. 2016. DOI: 10.1016/j.hansur.2015.12.003

[5] Necrotizing Soft-Tissue Infections. Journal of the American Academy of Orthopaedic Surgeons. 2000. DOI: 10.5435/00124635-200005000-00002

[6] An Acute Nocardia Infection in a Pediatric Hand. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.03.039

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[13] Acute Felon as a Complication of Systemic Paclitaxel Therapy: Case Report and Review of the Literature. HAND. 2007. DOI: 10.1007/s11552-007-9029-3

[14] Advanced finger infection: more frequent than expected and mostly iatrogenic. Hand Surgery and Rehabilitation. 2021. DOI: 10.1016/j.hansur.2020.12.011

[15] Necrotizing Soft-Tissue Infections. New England Journal of Medicine. 2017. DOI: 10.1056/nejmra1600673

[16] Neonatal Acute Paronychia. HAND. 2017. DOI: 10.1177/1558944717692092

[17] Hand infection: a management approach based on a new understanding of combined bacterial and neutrophil mediated tissue damage. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231174819

[18] Pyogenic Flexor Tenosynovitis: Evaluation and Management. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.005

[19] Antibiotic Overuse and Paronychia. JAMA Internal Medicine. 2016. DOI: 10.1001/jamainternmed.2015.6527

[20] Acute Paronychia. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2011.11.021

[21] Spinal Epidural Abscess in Adults. Journal of the American Academy of Orthopaedic Surgeons. 2004. DOI: 10.5435/00124635-200405000-00003

[22] Microbiology of Upper Extremity Soft Tissue Abscesses in Injecting Drug Abusers. Clinical Orthopaedics & Related Research. 2007. DOI: 10.1097/blo.0b013e31811f3526

[23] Hand Abscesses. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.014

[24] Methicillin-resistant Staphylococcus Aureus in a finger felon. The Journal of Hand Surgery. 2000. DOI: 10.1053/jhsu.2000.jhsu025a0173

[25] Radiographic Soft Tissue Thickness Differentiating Pyogenic Flexor Tenosynovitis From Other Finger Infections. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2019.01.013

[26] Herpetic whitlow with bacterial abscess. The Journal of Hand Surgery. 1991. DOI: 10.1016/s0363-5023(10)80117-0

[27] Fingertip Infections. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.004

[28] Hand Infections. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.05.035

[29] Osteomyelitis of the hand. Journal of Hand Surgery (European Volume). 2015. DOI: 10.1177/1753193415612373

[31] Atypical Hand Infections. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2025.09.023

[32] Imaging and Laboratory Workup for Hand Infections. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.002

[34] Hand Infections. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.05.027

[35] Septic Flexor Tenosynovitis. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2010.11.033

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

[43] A systematic review of the management of acute pyogenic flexor tenosynovitis. Journal of Hand Surgery (European Volume). 2015. DOI: 10.1177/1753193415570248

[44] Flexor sheath infection leading to acute digital ischaemia. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193409344504

[46] Hand Infections: Treatment Recommendations for Specific Types. Journal of the American Academy of Orthopaedic Surgeons. 1996. DOI: 10.5435/00124635-199607000-00006

[47] A case of severe cutaneous nocardiosis. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193409344814

[48] Continuous flexor sheath irrigation: a cautionary tale. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193412446574

[49] Initial treatment of severe soft-tissue injuries in closed and open fractures to prevent fracture-related infection. Injury. 2024. DOI: 10.1016/j.injury.2024.111935

[53] Complications of Hand Infections. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.010

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

[65] Exam Of The Hand Wrist 2Ed. The dorsal skin.

[66] Green S Operative Hand Surgery. PERTINENT ANATOMY.

[70] Hand Infections. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.001

[71] Gouty flexor tenosynovitis of the digits: report of three cases. The Journal of Hand Surgery. 2004. DOI: 10.1016/j.jhsa.2004.02.004

[84] Factors affecting suboptimal outcomes in hand infections. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420977791

[85] Antibiotic Management and Antibiotic Resistance in Hand Infections. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.003

[99] Purulent Flexor Tenosynovitis: Factors Influencing the Functional Outcome. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408087071

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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.