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Mucous Cyst Excision (with Local Flap)

37 citationsUpdated Oct 2026
Illustration: Mucous Cyst Excision (with Local Flap)

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Excision with local flap cover is the preferred surgical approach for mucous cysts of the distal interphalangeal joint, offering a reduced recurrence rate compared to other methods [1, 2]. This technique is particularly valuable in cases where the cyst has caused marked thinning of the overlying skin [1, 2]. Surgical excision combined with a local advancement skin flap demonstrates a recurrence rate of 1.4% for digital mucous cysts [3]. Patient satisfaction regarding the resulting scar and willingness to undergo the procedure again are high [3].

Flap selection for coverage after excision may be guided by surgeon preference, anatomical considerations, and patient expectations [31]. Specifically, a simple modification of the rotation flap originally described by Kleinert et al is used for coverage after excision of large mucous cysts [9]. Excision using flap surgery allows better visualization, easy exploration, and excellent outcome for periungual myxoid cysts [10]. Current evidence indicates that flap selection between biquadrangular and Hueston dorsal flaps does not appear to influence scar quality or postoperative complications in digital mucous cyst surgery [31].

While literature often reports glowing results, surgical treatment of mucous cysts is not a totally benign procedure, and complications occur contrary to these optimistic reports [19].

Anatomy & Pathophysiology

Clinical Presentation and Etiology

The mucous cyst presents as a small, firm, cystic mass located just distal to the distal interphalangeal joint [17]. The lesion is always located to one side of the mid-line and is rarely greater than fifteen millimeters in diameter [17]. Mucous cysts are usually small and located to one side as they emerge from the joint beside the extensor mechanism [24]. The skin over the mucous cyst is thinned out and occasionally may be ulcerated [17]. The overlying skin of the mucous cyst is frequently thin and minimal trauma may result in rupture [24]. Pressure on the mucous cyst does not usually result in a decrease in its size [17]. Longitudinal grooving of the nail may be noted, occasionally occurring prior to the appearance of the cyst [17]. Degenerative arthritis of the distal interphalangeal joint is a frequent associated finding with an incidence of 78 per cent reported [17].

The etiology of the lesion is indicated to arise from the joint capsule [17]. Studies suggest that mucous cysts arise due to excessive hyaluronic acid production from a degenerate distal interphalangeal joint [24]. Proposed theories on the pathogenesis of mucous cysts include myxoid degeneration, repeated local trauma, vascular insufficiency, and synovial herniation [24].

Histology

The histological appearance of the mucous cyst is essentially identical to that of ganglions, synovial cysts, and similar lesions appearing on other areas of the extremities [17]. The lesion is surrounded by an undemarcated fibrous capsule [17]. The basic structure of the mucous cyst is myxomatous with interspersed fibroblasts [17]. Areas of myxomatous degeneration tend to coalesce to form a multiloculated cyst [17]. An epithelial lining has not been reported for the mucous cyst [17].

Local Anatomy and Skin Characteristics

The dorsal covering of the interphalangeal articulations of the digits forms a unique cutaneous unit characterized by a considerable excess of skin when the digits are in extension [48]. The dorsal integument of the distal phalanx is very special because of the nail bed with its matrix [48]. The histological features of the dorsal skin include a thin epidermis lined by a horny layer that is only 0.02 mm thick [58]. The dermis of the dorsal skin is thinner and less resistant, with only loose connections to the deeper planes over which it can move freely [58]. The dorsal skin possesses a normal pilosebaceous system, unlike the palm [58]. Owing to the thinness of the epidermis and dearth of connective and elastic tissue elements in the dermis, the dorsal skin becomes fragile in old age and has greater vulnerability to factors causing cutaneous atrophy, such as steroid therapy [58].

The dorsal skin owes its suppleness and mobility to its relative thinness and loose connections with deeper planes, allowing free gliding and full flexion at the digital joints [58]. Flexion of the fingers produces a significant lengthening of the dorsal skin, with an average increase of 3 cm in the middle finger as it goes from extension to full flexion [58]. Flexion at the metacarpophalangeal joint alone requires an average skin lengthening of 1.25 cm [58]. The dorsal and palmar areas of skin are independent because of a system of adhesions that anchors their common boundary to the underlying plane [58]. In the proximal part of the first phalanx, fixation occurs almost in a straight line in the plane of the commissural crest, taking the form of small fibrils arranged in a fan shape that unite the deep aspect of the skin and the digital fascia [58]. More distally, especially opposite the middle and distal phalanges, the adhesion band is more tightly packed and lies just posterior to the palmar collateral neurovascular bundle on the lateral side [58]. This distal adhesion band corresponds to the reinforcement in the digital fascia known as the digital band and to the point of attachment of the osteocutaneous ligaments [58]. These deep attachments stabilize the skin in relation to the skeleton and prevent the integument from sliding freely over the motor system like the finger of a glove [58].

The skin covering each finger is 7 cm by 10 cm on both the palmar and dorsal aspects [51]. The necessary skin to cover the thumb distal to the metacarpophalangeal joint is about 9 cm wide and 8 cm long [51].

Classification

Clinical Presentation: The mucous cyst presents as a small, firm, cystic mass appearing just distal to the distal interphalangeal joint [17]. The lesion is always located to one side of the mid-line [17] and is usually small, emerging from the joint beside the extensor mechanism [24]. It is rarely greater than fifteen millimeters in diameter [17], though mucous cysts may occasionally spread across the whole of the dorsum of the digit between the distal interphalangeal joint and nail fold [24].

Physical Examination: The skin over the mucous cyst lesion is thinned out and occasionally may be ulcerated [17]. This overlying skin is frequently thin, and minimal trauma may result in rupture [24]. Pressure on the mucous cyst lesion does not usually result in a decrease in its size [17].

Associated Pathology: Degenerative arthritis of the distal interphalangeal joint is a frequent associated finding with an incidence of 78 per cent [17].

Histological Features: The mucous cyst is surrounded by an undemarcated fibrous capsule [17].

Clinical Presentation

The mucous cyst presents as a small, firm, cystic mass located just distal to the distal interphalangeal joint [17]. The lesion is always situated to one side of the mid-line [17], usually emerging from the joint beside the extensor mechanism [24]. While these cysts are rarely greater than fifteen millimeters in diameter [17], they may occasionally spread across the entire dorsum of the digit between the distal interphalangeal joint and the nail fold [24].

Inspection reveals that the skin overlying the lesion is thinned out [17] and frequently thin, such that minimal trauma may result in rupture [24]. In some cases, the skin may be ulcerated [17].

Palpation demonstrates that pressure on the lesion does not usually result in a decrease in its size [17].

Degenerative arthritis of the distal interphalangeal joint is a frequent associated finding [17, 24]. An incidence of 78 per cent has been reported for degenerative arthritis of the distal interphalangeal joint associated with mucous cysts [17].

Investigations

Other Considerations: The scientific data regarding mucous cysts consist almost entirely of retrospective studies, and much of what is done or recommended is based on expert opinion [32]. A careful physical examination is essential to direct care and future testing if indicated [33]. Diagnostic tests such as imaging and serum laboratory studies are useful in this determination but can be expensive, time consuming, and often nonspecific [33].

Physical Examination: The lesion presents as a small, firm, cystic mass which appears just distal to the distal interphalangeal joint [17]. It is always located to one side of the mid-line and it is rarely greater than fifteen millimeters in diameter [17].

Histology: The histological appearance is essentially identical to that of ganglions, synovial cysts, and similar lesions appearing on other areas of the extremities [17]. The basic structure is myxomatous with interspersed fibroblasts [17]. An epithelial lining has not been reported [17].

Ultra-sonography: Ultra-sonography provides a new ability to study the complex anatomical structures of the hand, with the technique being quick and simple to perform [21].

Treatment

Non-Operative

Aspiration with injection of steroid is associated with a recurrence rate of 50% [24]. Surgical treatment demonstrates a higher cure rate than aspiration with injection of steroid [24].

Operative

Indications: Surgical treatment is indicated when conservative measures are insufficient, as it offers a higher cure rate than aspiration with injection of steroid [24].

Surgical Approach / Technique: Excision with local flap cover offers a reduced recurrence rate compared to simple excision [1]. Surgical excision with a local advancement skin flap demonstrates a low recurrence rate of 1.4% [3]. The Zitelli design for a bilobed flap improves reliability and helps the hand surgeon complete the self-closing flap faster on the first attempt [22]. This bilobed flap allows radical excision with primary skin healing [23]. Excision using flap surgery allows better visualization, easy exploration, and excellent outcome [10]. Performing a flap does not require advanced microsurgical skills [4], and a second operation for the division of the flap is not necessary [4]. An unipedicled flap allows coverage of larger defects [11], while alternative regional flaps that do not sacrifice a major limb vessel can be useful options for patients with less extensive defects [6]. Selection of the specific free flap is determined by the size and location of the defect to restore functional and aesthetic deficits [16]. Reconstructive surgery can seldom be standardized, since trauma is usually a precursor [14]. Surgeons must be keenly aware of all possible approaches to ensure the safest and most satisfactory results [14]. Knowledge and execution of the details largely determine the outcome for flaps [13]. Both flaps are quick to raise and very reliable, providing their nutrient vessel is retained [20]. A staged approach ensures that each step is only taken if absolutely needed [11].

Alternative Techniques: Total dorsal capsulectomy alone is a simple treatment for mucous cysts that did not lead to any recurrence [18]. Osteophyte excision without cyst excision allows for less invasive surgery and avoids causing damage to friable skin [26, 39]. It was possible to not make an incision on the mucous cyst itself in most cases using osteophyte excision without cyst excision [26, 39]. The incision for osteophyte excision without cyst excision was on the skin crease, not transversing Langer's line [26, 39]. The incision for osteophyte excision without cyst excision was short enough not to expose the cyst [26, 39]. Total dorsal capsulectomy resulted in complete elimination of the mucous cysts without damaging the skin [26, 39]. The principle of not doing more damage to the friable skin is applied because the skin is not the culprit of the cyst [26, 39].

Outcomes and Complications: Surgical excision with a local advancement skin flap results in high patient satisfaction regarding the scar and willingness to undergo the procedure again [3]. There is no loss of flexion at the distal interphalangeal joint following treatment with a bilobed flap [23]. Cosmesis is excellent following treatment with a bilobed flap [23]. The absence of recurrence of the cyst at a minimum follow-up of 1 year following radical excision and flap cover is encouraging [23]. The absence of recurrence following radical excision and flap cover probably depends more upon complete excision and debridement of osteophytes than the method of achieving skin cover [23]. Radical treatment with complete excision of the stalk and underlying osteophytes seems to reduce recurrence rates [24]. Surgical treatment of mucous cysts is not a totally benign procedure, and complications do occur [19]. Complications of surgical treatments include infection, recurrence, nail deformity, swelling, stiffness, and pain [24]. All flaps survived completely after division using the conservative 50% flow criteria [7]. There were no problems of flap viability although several patients were smokers [8]. Alternative regional flaps that do not sacrifice a major limb vessel offer less donor morbidity and improved aesthetics [6]. All flaps survived and no secondary procedures were necessary [12]. The flaps have proved safe, reliable, and mobile [15]. No signs of flap ischemia were recorded [28]. In one patient an epidermal inclusion cyst developed and was excised [30].

Complications

Wound complications: Surgical treatment of mucous cysts is not a totally benign procedure, and complications do occur contrary to literature reporting glowing results [19]. Minimal trauma may result in rupture of the mucous cyst due to frequently thin overlying skin [24]. In one series, all wounds healed uneventfully with no cases of dehiscence, delayed healing, skin flap necrosis, or wound infection [41]. Flap selection does not appear to influence scar quality or postoperative complications [31].

Recurrence: Excision with local flap cover offers benefit in terms of a reduced recurrence rate [1, 2]. Most recurrences occur early after initial surgery [45]. The absence of recurrence of the cyst at a minimum follow-up of 1 year is encouraging and probably depends more upon complete excision and debridement of osteophytes than the method of achieving skin cover [23].

Recovery

Light activity (weeks): The evidence provided does not specify a typical week range for desk work, driving, or light activities of daily living.

Full activity (months): The evidence provided does not specify a month range for manual work, sport, or full range of motion and strength return.

Complete recovery / outcome plateau (months): The evidence provided does not specify a month range for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: The modified 'radial extended' Hueston flap facilitates early recovery [81]. For the reverse-flow digital artery cross-finger flap, a second operation for division is not necessary [4]. In parascapular free flap reconstruction, no secondary procedures were necessary [12].

Functional milestones: In a series of segmental V-Y flaps for longitudinal digit defects, flap success was 100% [38]. Recovery of mobility was unimpaired by longitudinal contracting scars [38]. Two-point discrimination was satisfactory compared with other nonneurotised flaps [38]. The modified 'radial extended' Hueston flap provides better functional and cosmetic results [81].

Other Considerations: The modified 'radial extended' Hueston flap avoids scars on contact areas subject to frequent use [81]. All flaps survived completely after division using the conservative 50% flow criteria in a preliminary assessment of laser Doppler flowmetry [7]. Performing a reverse-flow digital artery cross-finger flap does not require advanced microsurgical skills [4]. There were no problems of flap viability in V-Y advancement of the entire volar soft tissue of the thumb, although several patients were smokers [8]. Both flaps are quick to raise and very reliable, providing their nutrient vessel is retained, in basal flexion-crease resurfacing [20]. All flaps survived in parascapular free flap reconstruction of post-traumatic extremity defects [12]. The flaps have proved safe, reliable, and mobile in single-stage reconstruction of the subtotally amputated thumb [15].

Key Evidence

  • [L4] Excision with local flap cover would seem to offer benefit in terms of a reduced recurrence rate, and is particularly valuable where the cyst has caused marked thinning of the skin. [1] (10.1016/0266-7681_90_90064-b)
  • [L4] Excision with local flap cover offers benefit in terms of a reduced recurrence rate and is particularly valuable where the cyst has caused marked thinning of the skin. [2] (10.1016/0266-7681(90)90064-b)
  • [L4] Surgical excision with a local advancement skin flap is a reliable treatment for digital mucous cysts, demonstrating a low recurrence rate of 1.4% and high patient satisfaction regarding the scar and willingness to undergo the procedure again. [3] (10.1177/1753193413508540)
  • [L4] Performing flap does not require advanced microsurgical skills, and a second operation for the division of the flap is not necessary. [4] (10.1097/bth.0b013e3180cabc97)
  • [L5] Alternative regional flaps that do not sacrifice a major limb vessel can be useful options for patients with less extensive defects, offering less donor morbidity and improved aesthetics. [6] (10.1016/j.jhsa.2006.02.024)
  • [L4] All flaps survived completely after division using the conservative 50% flow criteria. [7] (10.1016/0363-5023(90)90011-f)
  • [L4] There were no problems of flap viability although several patients were smokers. [8] (10.1016/0266-7681(93)90073-o)
  • [L4] The authors present a simple modification of the rotation flap originally described by Kleinert et al after excision of large mucous cysts. [9] (10.1097/bth.0b013e31803c4e19)
  • [L4] Excision using flap surgery is an excellent mode of treatment allowing better visualization, easy exploration and excellent outcome. [10] (10.21276/aimdr.2017.3.5.dt1)
  • [L5] An unipedicled flap allows coverage of larger defects, while a staged approach ensures that each step is only taken if absolutely needed. [11] (10.1177/17531934211069894)
  • [L4] All flaps survived and no secondary procedures were necessary. [12] (10.1016/s0266-7681(96)80280-4)
  • [L4] As with all flaps, knowledge and execution of the details largely determine the outcome. [13] (10.1016/j.jhsa.2006.06.015)
  • [L5] Reconstructive surgery can seldom be standardized, since trauma is usually a precursor, and surgeons must be keenly aware of all possible approaches to ensure the safest and most satisfactory results. [14] (10.1016/s0363-5023(81)80002-0)
  • [L4] The flaps have proved safe, reliable, and mobile. [15] (10.1016/s0363-5023(81)80014-7)
  • [L4] Selection of the specific free flap is determined by the size and location of the defect to restore functional and aesthetic deficits. [16] (10.1016/j.injury.2013.01.021)
  • [L4] [17] (10.2106/00004623-197254070-00008)
  • [L4] A total dorsal capsulectomy alone was a simple treatment for mucous cysts and did not lead to any recurrence. [18] (10.1016/j.jhsa.2014.03.004)
  • [L4] Surgical treatment of mucous cysts is not a totally benign procedure, and complications do occur contrary to literature reporting glowing results. [19] (10.1016/s0266-7681(97)80067-8)
  • [L4] Both flaps are quick to raise and very reliable, providing their nutrient vessel is retained. [20] (10.1016/0266-7681(91)90135-b)
  • [L4] Ultra-sonography provides a new ability to study the complex anatomical structures of the hand, with the technique being quick and simple to perform. [21] (10.1016/0266-7681(90)90133-o)
  • [L4] The simple geometric design improves reliability, and helps the hand surgeon to successfully complete the self-closing flap faster, right from the first attempt. [22] (10.1097/bth.0b013e3182560336)
  • [L4] [23] (10.1054/jhsb.1998.0191)
  • [L4] [24] (10.1177/1753193408103498)
  • [L5] [26] (10.1177/1753193414546443)
  • [L4] No signs of flap ischemia were recorded. [28] (10.1016/s0363-5023(03)80451-3)
  • [L4] In one patient an epidermal inclusion cyst developed and was excised. [30] (10.1016/0363-5023(92)90375-y)
  • [L4] Flap selection does not appear to influence scar quality or postoperative complications and may therefore be guided by surgeon preference, anatomical considerations and patient expectations. [31] (10.1177/17531934261433822)
  • [L4] The scientific data regarding mucous cysts consist almost entirely of retrospective studies, and much of what is done or recommended is based on expert opinion. [32] (10.1016/j.jhsa.2010.01.029)
  • [L4] In this series flap success was 100%, 2-point discrimination satisfactory compared with other nonneurotised flaps and most importantly recovery of mobility was unimpaired by longitudinal contracting scars. [38] (10.1097/bth.0000000000000080)
  • [L5] [39] (10.1177/1753193414546990)
  • [L4] All wounds healed uneventfully with no cases of dehiscence, delayed healing, skin flap necrosis, or wound infection. [41] (10.1177/1753193415625397)
  • [Paper] Most recurrences occur early after initial surgery. [45] (10.1016/j.otsr.2014.05.014)
  • [L4] The modified 'radial extended' Hueston flap allows primary closure of the donor site, avoiding scars on contact areas subject to frequent use, and provides early recovery with better functional and cosmetic results. [81] (10.1055/s-0038-1636833)

See Also

References

[1] Mucous Cyst of the Distal Interphalangeal Joint: Treatment by Simple Excision or Excision and Rotation Flap. Journal of Hand Surgery. 1990. DOI: 10.1016/0266-7681_90_90064-b

[2] Mucous cyst of the distal interphalangeal joint: Treatment by simple excision or excision and rotation flap. The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand. 1990. DOI: 10.1016/0266-7681(90)90064-b

[3] A reliable surgical treatment for digital mucous cysts. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413508540

[4] The Versatile Reverse-flow Digital Artery Cross-finger Flap. Techniques in Hand & Upper Extremity Surgery. 2007. DOI: 10.1097/bth.0b013e3180cabc97

[6] Reconstruction of Hand Soft-Tissue Defects: Alternatives to the Radial Forearm Fasciocutaneous Flap. The Journal of Hand Surgery. 2006. DOI: 10.1016/j.jhsa.2006.02.024

[7] Preliminary assessment of laser Doppler flowmetry for determining timing of division of the cross-finger flap. The Journal of Hand Surgery. 1990. DOI: 10.1016/0363-5023(90)90011-f

[8] V-Y Advancement of the Entire Volar Soft Tissue of the Thumb in Distal Reconstruction. Journal of Hand Surgery. 1993. DOI: 10.1016/0266-7681(93)90073-o

[9] Flap Advancement Coverage After Excision of Large Mucous Cysts. Techniques in Hand & Upper Extremity Surgery. 2007. DOI: 10.1097/bth.0b013e31803c4e19

[10] Excision of Periungual Myxoid Cyst Using Proximal Nail Fold Flap. Annals of International medical and Dental Research. 2017. DOI: 10.21276/aimdr.2017.3.5.dt1

[11] Re: Martins A, Artuso M, Claise JM. Bipedicle strap flaps for reconstruction of longitudinal dorsal finger defects: a review of 42 cases. J Hand Surgery Eur. 2021, 46: 873–6. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934211069894

[12] The parascapular free flap for reconstruction of post-traumatic defects of the extremities. Journal of Hand Surgery. 1996. DOI: 10.1016/s0266-7681(96)80280-4

[13] Homodigital Antegrade-Flow Neurovascular Pedicle Flaps for Sensate Reconstruction of Fingertip Amputation Injuries. The Journal of Hand Surgery. 2006. DOI: 10.1016/j.jhsa.2006.06.015

[14] Flaps old and new. The Journal of Hand Surgery. 1981. DOI: 10.1016/s0363-5023(81)80002-0

[15] Single-stage reconstruction of the subtotally amputated thumb: A synchronous neurovascular flap and Z-plasty. The Journal of Hand Surgery. 1981. DOI: 10.1016/s0363-5023(81)80014-7

[16] Microsurgical reconstruction of soft-tissue defects in digits. Injury. 2013. DOI: 10.1016/j.injury.2013.01.021

[17] Etiology and Treatment of the So-Called Mucous Cyst of the Finger. The Journal of Bone & Joint Surgery. 1972. DOI: 10.2106/00004623-197254070-00008

[18] Total Dorsal Capsulectomy for the Treatment of Mucous Cysts. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.03.004

[19] Complications Following Mucous Cyst Excision. Journal of Hand Surgery. 1997. DOI: 10.1016/s0266-7681(97)80067-8

[20] Two Flaps to Resurface the Basal Flexion-Crease of the Finger Area. Journal of Hand Surgery. 1991. DOI: 10.1016/0266-7681(91)90135-b

[21] Diagnostic medical ultrasound in the management of hand injuries. The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand. 1990. DOI: 10.1016/0266-7681(90)90133-o

[22] The Zitelli Design for Bilobed Flap Applied on Skin Defects After Digital Mucous Cyst Excision. A Review of 9 Cases. Techniques in Hand & Upper Extremity Surgery. 2012. DOI: 10.1097/bth.0b013e3182560336

[23] The Bilobed Flap in Treatment of Mucous Cysts of the Distal Interphalangeal Joint. Journal of Hand Surgery. 1999. DOI: 10.1054/jhsb.1998.0191

[24] Use of Wolfe Graft for the Treatment of Mucous Cysts. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193408103498

[26] Re: Lee HJ, Kim PT, Jeon IH, et al. Osteophyte excision without cyst excision for a mucous cyst of the finger. J Hand Surg Eur. 2014, 39: 258–61. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414546443

[28] The eponychial flap: A new technique to restore the length of a short nail. The Journal of Hand Surgery. 2003. DOI: 10.1016/s0363-5023(03)80451-3

[30] Deepithelialized pedicle flap placed subcutaneously for fingertip reconstruction. The Journal of Hand Surgery. 1992. DOI: 10.1016/0363-5023(92)90375-y

[31] Aesthetic outcome of biquadrangular and Hueston dorsal flaps in digital mucous cyst surgery. Journal of Hand Surgery (European Volume). 2026. DOI: 10.1177/17531934261433822

[32] Mucous Cysts. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.01.029

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

[38] Segmental V-Y Flaps for Reconstruction of Longitudinal Defects in the Digit. Techniques in Hand & Upper Extremity Surgery. 2015. DOI: 10.1097/bth.0000000000000080

[39] Re: Lee, H.-J., Kim, P.-T., Jeon, I.-H., Kyung, H.-S., Ra, I.-H. and Kim, T.-K. Osteophyte excision without cyst excision for a mucous cyst of the finger. J Hand Surg Eur. 2014, 39: 258–61. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414546990

[41] The dorsal distally based flap: a novel approach to the distal interphalangeal joint. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193415625397

[45] Focal periosteal chondroma of the hand: A review of 24 cases. Orthopaedics & Traumatology: Surgery & Research. 2014. DOI: 10.1016/j.otsr.2014.05.014

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

[51] Exam Of The Hand Wrist 2Ed. Planning skin cover of the hand and forearm.

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

[81] Extended Hueston Flap: New Solution for Primary Closure. Journal of Hand and Microsurgery. 2018. DOI: 10.1055/s-0038-1636833

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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.