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Drainage of an Infected Flexor Sheath

39 citationsUpdated Aug 2026

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Overview

Septic flexor tenosynovitis is a surgical emergency requiring prompt intervention to preserve digital function. Surgical decompression remains the treatment of choice for nearly all cases [1]. Expediency in treatment directly improves final motion and function [1]. Early diagnosis of purulent flexor tenosynovitis followed by drainage through small incisions and continuous postoperative irrigation leads to the best functional outcome [3]. Similarly, early treatment of acute suppurative flexor tenosynovitis with limited incisions, catheter irrigation, and systemic antibiotics generally results in successful resolution of infection and return of digital motion [2].

The presence of pus within the flexor sheath is the only significant predictive factor for repeated flexor tendon washout [4]. For uncomplicated pyogenic flexor tenosynovitis, a single open debridement with irrigation and primary wound closure followed by 10 days of antibiotic therapy is sufficient to resolve the infection [5]. Treatment of acute hand infections requires a combination of surgical intervention (incision and drainage) and appropriate antibiotic therapy tailored to the organism and infection severity [10]. The procedure for flexor tenosynovitis can be expected to provide lasting benefit provided there is no recurrence of the condition [11].

Despite aggressive and prompt antibiotic therapy and surgical intervention, patients can expect some residual digital stiffness following flexor tendon sheath infection [6]. Continuous catheter irrigation can effectively manage infection of a silicone rod during two-stage flexor tendon reconstruction and maintain the reconstructed tendon sheath [7]. Standard two-stage flexor tendon reconstruction is a reasonable option once tuberculous infection has been adequately treated and is not associated with recurrence of that infection [8]. Modifications exist to simplify cannulation and passage of a fine feeding catheter for closed irrigation of infective flexor tenosynovitis, aiming to ease the procedure and improve intrathecal lavage [13]. The WALANT technique can be used for flexor tendon sheath incisions in the setting of infection [14].

Anatomy & Pathophysiology

Hand and upper-extremity infections are primarily clinical diagnoses, though imaging and laboratory evaluation aid in confirmation [19]. Acute pyogenic flexor tenosynovitis (PFT) swelling is distinguished by differential volar versus dorsal radiographic soft tissue thickness at the level of the proximal phalanx [16]. Ultrasound measurements for diagnosing pyogenic flexor tenosynovitis are reproducible, with an intraclass coefficient of 0.910 for symptomatic fingers and 0.928 for healthy contralateral fingers [29]. Clinical prediction algorithms combining relevant factors may be helpful in developing clinical prediction tools and educational materials for optimizing emergency hand care systems [33].

Early diagnosis and prompt treatment of pyogenic flexor tenosynovitis are required to preserve the digit and prevent morbidity and loss of hand function [27]. Despite timely and thorough treatment, severe pyogenic flexor tenosynovitis can lead to impaired function or even amputation of the affected digit [22]. Delayed diagnosis of hand infections can result in amputation or death [36]. Hand infections are associated with a high rate of complications that are often difficult to manage [17]. The procedure for treating flexor tenosynovitis can be expected to provide lasting benefit provided there is no recurrence of the condition [11].

Risk Factors: Diabetic patients with limited joint mobility have a significantly higher risk of stenosing flexor tenosynovitis involving multiple digits [39]. Complications of the fingers and hand after arthroscopic rotator cuff repair, including flexor tenosynovitis, easily occurred in patients with a past history of carpal tunnel syndrome or tenosynovitis and in patients with edema as per subjective assessment [35].

Pediatric Considerations: Physicians managing pediatric hand infections should bear in mind unique characteristics including the frequency of fingers in mouths, open growth plates, and typically more robust circulation with fewer systemic comorbidities [37].

Classification

Pyogenic flexor tenosynovitis is an aggressive closed-space bacterial infection of the flexor tendon synovial sheath, comprising 2.5%–9.4% of all hand infections [9]. The infection occurs between the visceral layer on the flexor tendon and the parietal layer [21]. The sheath extends from the distal interphalangeal joint proximally to the A1 pulley [21]. Staphylococcus aureus is the most common pathogen following penetrating trauma [21].

Anatomical continuity dictates potential spread patterns. The thumb flexor tendon sheath is contiguous with the radial bursa, and the small finger sheath is contiguous with the ulnar bursa [21]. The radial and ulnar bursae communicate via Parona's space and extend to the carpal tunnel in up to 80% of individuals [21]. Infections may spread to these bursae; specifically, spread from the small finger flexor tendon sheaths can result in a horseshoe abscess, while proximal spread into Parona's space is also possible [21].

Diagnosis relies on clinical assessment. Kanavel’s four cardinal signs include: exquisite tenderness over the course of the sheath limited to the sheath; semiflexed position of the finger; exquisite pain on extension, most marked at the proximal end where definite swelling often may be seen; and symmetrical swelling of the entire finger [21]. Not all Kanavel’s signs will be present in pyogenic flexor tenosynovitis [21]. Acute swelling is distinguished by differential volar versus dorsal radiographic soft tissue thickness at the level of the proximal phalanx [16].

Three-Tier Clinical Classification: This system is based on preoperative clinical assessment to aid in prognosis and guide treatment [31]. Early cases that do not yet show a rise in white blood cell count and lack systemic symptoms may warrant a different treatment approach from fulminant cases [9].

Purulence Definitions: Frank purulence is defined as draining purulence from a wound or the presence of a diffuse subcutaneous and/or palpable abscess [18]. Purulence after incision and drainage is defined by the clinical provider as an overt thick, white, odorous fluid expressed from the hand [18]. Other fluid types, including dark, cloudy, bloody, or clear fluid, are deemed nonpurulent and represent a possible manifestation of early flexor tenosynovitis [18].

Clinical Presentation

Pyogenic flexor tenosynovitis most commonly follows penetrating trauma and is associated with Staphylococcus aureus [21, 26]. Other frequently encountered pathogens include polymicrobial infections, methicillin-resistant Staphylococcus aureus (MRSA), Staphylococcus epidermidis, Pseudomonas aeruginosa, and Streptococcus species [26]. Rare organisms isolated from cultures include Eikenella corrodens, Pasteurella multocida, Kingella kingae, Listeria monocytogenes, Neisseria gonorrhoeae, Clostridium difficile, and Mycobacterium species [26].

Immunocompromised patients may present with a more indolent and chronic course, potentially lacking a remote or absent history of trauma [26]. Atypical hand infections are difficult to recognize due to this indolent nature and nonspecific symptoms [30].

Kanavel’s four cardinal signs include: Exquisite tenderness over the course of the sheath. Semiflexed position of the finger. Exquisite pain on extension, most marked at the proximal end. Symmetrical swelling of the entire finger [21].

Not all Kanavel signs are present in every case [21]. Cases presenting early without a rise in white blood cell count or systemic symptoms may warrant a different treatment approach from fulminant cases [9]. Prompt diagnosis and early treatment are essential to avoid complications such as tendon adhesions, necrosis, impaired function, or amputation [21, 23, 32].

Investigations

Septic flexor tenosynovitis is usually a clinical diagnosis [19]. Imaging and laboratory evaluation aid in the diagnosis of hand and upper-extremity infections [19].

Ultrasound: Ultrasound is useful as a diagnostic tool for managing early pyogenic flexor tenosynovitis due to its excellent negative predictive value and specificity [42]. Point-of-care ultrasound can identify fluid surrounding the tendon and purulence at operation in patients presenting without all four of Kanavel's signs [25].

MRI: MRI may aid in the preoperative diagnosis of vascular malformations in tendon sheaths that present as tenosynovitis [41]. Early advanced imaging is required for successful management of flexor tenosynovitis caused by Mycobacterium heraklionense [24].

CT: Contrast-enhanced computed tomography can be used to diagnose acute pyogenic flexor tenosynovitis, with diagnosis established in the operating room based on purulence and positive culture growth [20].

Treatment

Non-Operative

The role of antibiotics and non-surgical management in pyogenic flexor tenosynovitis is not clearly established, with little consistency in antibiotic use or timing [9]. In the studied protocol, no patients with suspicion for pyogenic flexor tenosynovitis were managed with antibiotics alone [18].

Operative

Indications: Patients with frank purulence, defined as draining purulence from a wound or diffuse subcutaneous/palpable abscess, require immediate incision and drainage and flexor sheath washout in the operating room [18]. Patients with pyogenic flexor tenosynovitis but without frank findings of purulence on examination may undergo limited bedside flexor sheath incision and drainage in the emergency department [18]. Some patients presenting without all four of Kanavel's signs have ultrasound findings of fluid surrounding the tendon and purulence at operation [25].

Surgical Approach / Technique: Treatment of pyogenic flexor tenosynovitis requires a combination of surgical intervention (incision and drainage) and appropriate antibiotic therapy tailored to the organism and infection severity [10]. Expediency in surgical decompression potentially improves final motion and function [1]. For bedside procedures, a digital nerve block using lidocaine with epinephrine is performed for local anesthesia and hemostatic effect [18]. An oblique Bruner incision is made over the area of concern, followed by blunt subcutaneous dissection to expose the flexor sheath while protecting neurovascular bundles [18]. A longitudinal incision is made along the most volar aspect of the flexor sheath, taking care to protect the underlying flexor tendon [18]. Abnormal fluid expressed from within the flexor sheath or subcutaneously is cultured [18]. The wound is irrigated with sterile saline fluid and a bulky soft dressing is applied after bedside incision and drainage [18]. If purulence is encountered during bedside incision and drainage, patients are taken to the operating room [18]. Purulence after incision and drainage is defined as overt thick, white, odorous fluid expressed from the hand [18]. Fluid types other than purulent (dark, cloudy, bloody, or clear) are deemed nonpurulent and may manifest early flexor tenosynovitis [18]. The metal ear suction catheter is simple and effective for irrigation in flexor tenosynovitis, allowing insertion under direct vision without buckling [40].

Adjuncts: Continuous catheter irrigation effectively deals with infection of a silicone rod during two-stage flexor tendon reconstruction and maintains the reconstructed tendon sheath [7].

Other Considerations: The described procedure for flexor tenosynovitis provides lasting benefit provided there is no recurrence of the infection [11].

Complications

Infection: Septic flexor tenosynovitis is an aggressive closed-space infection of the flexor tendon synovial sheath that can cause substantial morbidity if not treated effectively [9]. Prompt diagnosis and early debridement are of the utmost importance to improve outcomes for invasive Group A Streptococcus hand infections, which are often limb- and life-threatening [15].

Stiffness / Arthrofibrosis: Even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection despite aggressive and prompt antibiotic therapy and surgical intervention [6].

Recovery

Expediency in surgical decompression potentially improves final motion and function in septic flexor tenosynovitis [1]. Early diagnosis of purulent flexor tenosynovitis followed by drainage through small incisions and continuous postoperative irrigation appears to lead to the best functional outcome [3].

Light activity (weeks): Evidence does not specify a week range for light activity, desk work, or driving.

Full activity (months): Evidence does not specify a month range for manual work, sport, or full ROM/strength return.

Complete recovery / outcome plateau (months): Even with aggressive and prompt antibiotic therapy and surgical intervention, otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection [6]. The procedure for flexor tenosynovitis can be expected to provide lasting benefit provided there is no recurrence of flexor tenosynovitis [11].

Rehabilitation protocol: Continuous catheter irrigation can effectively deal with infection of a silicone rod during two-stage flexor tendon reconstruction and maintain the reconstructed tendon sheath [7].

Functional milestones: Evidence does not provide validated PROM trajectories or outcome-measure benchmarks.

Other Considerations: Successful management of Mycobacterium heraklionense flexor tenosynovitis requires early advanced imaging, serial debridement to establish local control, and a multidisciplinary approach with tailored antimicrobial therapy [24]. Complete resolution of Nocardia flexor tenosynovitis often requires a combination of repeated surgical debridement and prolonged targeted antimicrobial therapy [43].

Key Evidence

  • [L5] Surgical decompression is the treatment of choice for nearly all cases of septic flexor tenosynovitis, with expediency potentially improving final motion and function. [1] (10.1016/j.jhsa.2010.11.033)
  • [L5] The results of early treatment of acute suppurative flexor tenosynovitis with limited incisions, catheter irrigation, and systemic antibiotics are generally good, with successful resolution of infection and return of digital motion. [2] (10.1016/s0749-0712(21)00418-2)
  • [L4] Early diagnosis of purulent flexor tenosynovitis followed by drainage through small incisions and continuous postoperative irrigation appear to lead to the best functional outcome. [3] (10.1177/1753193408087071)
  • [Paper] The presence of pus within the flexor sheath is the only significant predictive factor for repeated flexor tendon washout. [4] (10.1055/s-0040-1715556)
  • [L4] A single open debridement with irrigation and primary wound closure followed by 10 days of antibiotic therapy resolved uncomplicated pyogenic flexor tenosynovitis. [5] (10.1007/s00402-016-2587-5)
  • [L5] Despite aggressive and prompt antibiotic therapy and surgical intervention, even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection. [6] (10.5435/jaaos-20-06-373)
  • [L5] Continuous catheter irrigation can effectively deal with infection of a silicone rod during two-stage flexor tendon reconstruction and maintain the reconstructed tendon sheath. [7] (10.1055/s-0039-1688510)
  • [L4] Standard two-stage flexor tendon reconstruction is a reasonable option once the tuberculous infection has been adequately treated and is not associated with recurrence of that infection. [8] (10.1177/1753193409360604)
  • [L3] [9] (10.1177/1753193415570248)
  • [L5] Treatment requires a combination of surgical intervention (incision and drainage) and appropriate antibiotic therapy tailored to the organism and infection severity. [10] (10.1016/j.jhsa.2014.03.031)
  • [L4] The procedure described can be expected to provide lasting benefit provided there is no recurrence of flexor tenosynovitis. [11] (10.2106/00004623-197658060-00010)
  • [L4] The authors describe two modifications to simplify cannulation and passage of a fine feeding catheter for closed irrigation of infective flexor tenosynovitis, aiming to ease the procedure and improve intrathecal lavage. [13] (10.1007/s11552-013-9591-9)
  • [L4] WALANT technique can be used for flexor tendon sheath incisions in the setting of infection. [14] (10.1177/15589447211030695)
  • [L4] Prompt diagnosis and early debridement are of the utmost importance to improve outcomes for these often limb- and life-threatening infections. [15] (10.1177/17531934241268983)
  • [L4] Acute PFT swelling is distinguished by differential volar versus dorsal radiographic soft tissue thickness at the level of the proximal phalanx. [16] (10.1016/j.jhsa.2019.01.013)
  • [L5] Hand infections are associated with a high rate of complications that are often difficult to manage. [17] (10.1016/j.hcl.2020.03.010)
  • [L4] [18] (10.1177/1558944721999729)
  • [L5] Hand and upper-extremity infections are usually a clinical diagnosis, but imaging and laboratory evaluation aid in diagnosis. [19] (10.1016/j.hcl.2020.03.002)
  • [L3] [20] (10.1177/15589447221092058)
  • [L5] [21] (10.1016/j.jhsa.2011.05.035)
  • [Paper] Despite timely and thorough treatment, severe infection can nevertheless lead to impaired function or even amputation of the affected digit. [22] (10.1055/s-0039-1700370)
  • [L5] Patients with suspected flexor tenosynovitis should be referred and treated early to avoid significant morbidity, especially when risk factors for poor prognosis are present. [23] (10.1136/bcr-2012-006778)
  • [L5] Successful management requires early advanced imaging, serial debridement to establish local control, and a multidisciplinary approach with tailored antimicrobial therapy. [24] (10.1016/j.jhsg.2021.12.010)
  • [L4] Some patients presenting without all four of Kanavel's signs had the US finding of fluid surrounding the tendon and purulence at operation. [25] (10.5811/cpcem.2018.3.37415)
  • [L5] [26] (10.1007/s11999-015-4367-x)
  • [L5] Early diagnosis and prompt treatment are required to preserve the digit and prevent morbidity and loss of hand function. [27] (10.1016/j.hcl.2020.03.005)
  • [L4] The measurements were reproducible with an intraclass coefficient of 0.910 for symptomatic PFTS fingers and 0.928 for healthy contralateral fingers. [29] (10.1016/j.hansur.2018.03.002)
  • [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. [30] (10.1016/j.jhsa.2025.09.023)
  • [L2] The authors propose a three-tier clinical classification system based on preoperative clinical assessment to aid in prognosis and guidance in the treatment of pyogenic flexor tenosynovitis of the upper extremity. [31] (10.2106/jbjs.f.01356)
  • [L5] Prompt diagnosis and early treatment with broad-spectrum intravenous antibiotics and surgical irrigation and debridement are essential to avoid complications and preserve hand function, though severe infection can still lead to impaired function or amputation. [32] (10.1016/j.jhsa.2019.04.011)
  • [L3] Clinical prediction algorithms that combine the relevant factors may be helpful in the development of clinical prediction tools and educational materials for optimization of emergency hand care systems. [33] (10.1177/1558944717692089)
  • [L2] Complications of the fingers and hand after arthroscopic rotator cuff repair easily occurred in patients with a past history of carpal tunnel syndrome or tenosynovitis and in patients with edema as per a subjective assessment. [35] (10.1016/j.jseint.2021.07.001)
  • [L5] Early identification and treatment of hand infections are essential to achieve optimal outcomes, as delayed diagnosis can result in amputation or death. [36] (10.1016/j.jhsa.2018.05.027)
  • [L5] Although many management principles are the same in pediatric and adult patients, physicians should bear in mind the unique environments and characteristics of the pediatric hand, including the frequency of fingers in mouths, open growth plates, and typically more robust circulation with fewer systemic comorbidities. [37] (10.1016/j.hcl.2020.03.012)
  • [L2] The study provides evidence that diabetic patients with limited joint mobility have significantly higher risk of stenosing flexor tenosynovitis involving multiple digits. [39] (10.3899/jrheum.081024)
  • [L4] The metal ear suction catheter is simple and effective for irrigation in flexor tenosynovitis, allowing insertion under direct vision without buckling. [40] (10.1177/1753193414522961)
  • [L4] Vascular malformations in tendon sheaths can present as tenosynovitis, creating a diagnostic challenge; early diagnosis and treatment are necessary to prevent complications, and MRI may aid in preoperative diagnosis. [41] (10.1007/s11552-011-9384-y)
  • [L2] Ultrasound is useful as a diagnostic tool for managing early pyogenic flexor tenosynovitis thanks to its excellent negative predictive value and specificity. [42] (10.1016/j.hansur.2017.12.004)
  • [L4] Complete resolution often requires a combination of repeated surgical debridement and prolonged targeted antimicrobial therapy. [43] (10.1016/j.jhsg.2025.100934)

See Also

References

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

[2] PYOGENIC FLEXOR TENOSYNOVITIS. Hand Clinics. 1998. DOI: 10.1016/s0749-0712(21)00418-2

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

[4] Prognostic Factors for Repeated Flexor Tenosynovitis Washout: A Retrospective Study. Journal of Hand and Microsurgery. 2022. DOI: 10.1055/s-0040-1715556

[5] Treatment of digital pyogenic flexor tenosynovitis: single open debridement, irrigation, and primary wound closure followed by antibiotic therapy. Archives of Orthopaedic and Trauma Surgery. 2016. DOI: 10.1007/s00402-016-2587-5

[6] Flexor Tendon Sheath Infections of the Hand. Journal of the American Academy of Orthopaedic Surgeons. 2012. DOI: 10.5435/jaaos-20-06-373

[7] Continuous Catheter Irrigation for the Treatment of Purulent Tenosynovitis during Two-Stage Flexor Tendon Reconstruction. Journal of Hand and Microsurgery. 2019. DOI: 10.1055/s-0039-1688510

[8] Staged flexor tendon reconstruction in a patient with caseous tuberculous tenosynovitis. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193409360604

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

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

[11] Stiffness of the proximal interphalangeal joints in rheumatoid arthritis. The role of flexor tenosynovitis. The Journal of Bone & Joint Surgery. 1976. DOI: 10.2106/00004623-197658060-00010

[13] Modifications to Simplify Intrathecal Irrigation for Pyogenic Flexor Tenosynovitis. HAND. 2014. DOI: 10.1007/s11552-013-9591-9

[14] Treatment of Pyogenic Flexor Tenosynovitis in the Emergency Department Setting With WALANT Technique. HAND. 2021. DOI: 10.1177/15589447211030695

[15] A surge in the incidence of invasive Group A Streptococcus hand infections: a single Hand Unit experience. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241268983

[16] 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

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

[18] Limited Flexor Sheath Incision and Drainage in the Emergency Department in the Management of Early Pyogenic Flexor Tenosynovitis. HAND. 2021. DOI: 10.1177/1558944721999729

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

[20] Contrast Enhanced Computed Tomography in the Diagnosis of Acute Pyogenic Flexor Tenosynovitis. HAND. 2022. DOI: 10.1177/15589447221092058

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

[22] Pyogenic Flexor Tenosynovitis: Evaluation and Treatment Strategies. Journal of Hand and Microsurgery. 2019. DOI: 10.1055/s-0039-1700370

[23] Pyogenic flexor tenosynovitis leading to an amputation. BMJ Case Reports. 2012. DOI: 10.1136/bcr-2012-006778

[24] Flexor Tenosynovitis Caused by Mycobacterium heraklionense. Journal of Hand Surgery Global Online. 2022. DOI: 10.1016/j.jhsg.2021.12.010

[25] Pyogenic Flexor Tenosynovitis by Point-of-care Ultrasound in the Emergency Department. Clinical Practice and Cases in Emergency Medicine. 2018. DOI: 10.5811/cpcem.2018.3.37415

[26] In Brief: Kanavel's Signs and Pyogenic Flexor Tenosynovitis. Clinical Orthopaedics & Related Research. 2016. DOI: 10.1007/s11999-015-4367-x

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

[29] Ultrasound for the diagnosis of pyogenic flexor tenosynovitis. Hand Surgery and Rehabilitation. 2018. DOI: 10.1016/j.hansur.2018.03.002

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

[31] Factors Affecting the Prognosis of Pyogenic Flexor Tenosynovitis. The Journal of Bone & Joint Surgery. 2007. DOI: 10.2106/jbjs.f.01356

[32] Pyogenic Flexor Tenosynovitis: Evaluation and Treatment Strategies. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2019.04.011

[33] Differentiation Between Pyogenic Flexor Tenosynovitis and Other Finger Infections. HAND. 2017. DOI: 10.1177/1558944717692089

[35] Risk factors related to complications of the fingers and hand after arthroscopic rotator cuff repair – carpal tunnel syndrome, flexor tenosynovitis, and complex regional pain syndrome. JSES International. 2021. DOI: 10.1016/j.jseint.2021.07.001

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

[37] Pediatric Hand Infections. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.012

[39] The Presence of Limited Joint Mobility Is Significantly Associated with Multiple Digit Involvement by Stenosing Flexor Tenosynovitis in Diabetics. The Journal of Rheumatology. 2009. DOI: 10.3899/jrheum.081024

[40] Simplifying irrigation in flexor tenosynovitis. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414522961

[41] Vascular Malformation of the Flexor Tendon Presenting as Tenosynovitis. HAND. 2011. DOI: 10.1007/s11552-011-9384-y

[42] Usefulness of ultrasound for the diagnosis of pyogenic flexor tenosynovitis: A prospective single-center study of 57 cases. Hand Surgery and Rehabilitation. 2018. DOI: 10.1016/j.hansur.2017.12.004

[43] Soil to Sheath: Nocardia Flexor Tenosynovitis in an Immunocompetent Pottery Artist. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2025.100934

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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.