Skip to content

Neurovascular Anatomy

Hand neurovascular anatomy: variations (median artery, DCBUN), nerve loops, and implications for nerve/vascular repair & transfers.

Overview

Symptomatic neural loops represent a rare anatomic variation capable of causing hemidigital anesthesia [1]. Diagnosis presents a significant challenge and functions as a diagnosis of exclusion [1]. Microvascular decompression may be considered for symptomatic neural loops only when other etiologies are absent [1]. In Dupuytren’s disease, the neurovascular bundle exhibits spiralling characteristics [2]. Surgeons must identify and dissect the neurovascular bundle proximally and distally throughout its entire course to prevent injury [2].

Vascular insufficiency of the upper extremity requires a thorough understanding of vascular anatomy, diagnostic modalities, and medical and surgical management options [4]. Vascular injuries occur in 13% of patients with peripheral nerve suture [3]. Most nerve lacerations should be repaired soon after injury, and current widespread application of microsurgical techniques leads to reasonable results in most individuals [52]. However, many patients with nerve lacerations do not have ideal outcomes and are often left with permanent sequelae [52]. Definitive nerve repair should be deferred until after the third week following injury [3]. Nerves should be resected proximal to gross pathological change during repair [3].

Despite advances in nerve transfers and microvascular free functioning muscle transfers, restoration of full function remains unachievable [9]. Late exploration of nerve injuries is difficult due to scarring, and intact branches may be damaged during this process [6]. Surgery for nerve injuries should be performed only by surgeons familiar with the nerve anatomy [6]. For adult isolated digital nerve injuries, surgical repair does not consistently yield better functional outcomes than leaving the injury unrepaired [26]. There is a paucity of evidence to support the universal recommendation for prompt microsurgical repair of these injuries [26]. Caution is advised when using conduits to repair large-diameter nerves due to failed clinical outcomes [10].

Specific anatomical considerations include a constant identifiable vascular pedicle to the median nerve in the distal forearm [27]. A dissection technique exists that enables adequate mobilization of the median nerve while preserving vascularity and achieving tensionless repair [27]. It may be possible to advance the median nerve at the wrist while retaining the vascular connection and blood supply from the radial artery [28]. Retaining this vascular connection maintains the vascularity of the median nerve at the common site of nerve repair in the distal forearm [28].

Anatomy & Pathophysiology

Vascular & Neural

Anomalous muscles in the forearm can be present concomitantly [8]. The palmar type of median artery can serve as a source for the superficial palmar arch [11]. Digital artery intravascular myopericytoma is a rare cause of painful finger [38]. Spontaneous intraneural hematoma can cause acute neuropathy of the median nerve [45]. Hypothenar hammer syndrome can lead to permanent impairment if not diagnosed and prevented early [46]. The plastic-injection technique can elucidate the relative vascularity of the component parts of the normal and abnormal hand [51]. Neural loops are a common occurrence in humans and should be considered a normal phenomenon rather than a little-known variation in the palm [54].

Musculoskeletal & Innervation

Intrinsic hand muscles have motor endplates (MEPs) at consistent distances from bony landmarks on both dorsal and volar aspects [33]. The thumb trapeziometacarpal joint ligaments possess an abundance of nerve endings in the dorsal ligaments [37]. The thumb trapeziometacarpal joint ligaments have little to no innervation in the anterior oblique ligament [37].

Classification

Neural Loop Variations: Symptomatic neural loops represent a rare anatomic variation that presents as a diagnostic challenge and is a diagnosis of exclusion [1]. These loops can cause hemidigital anesthesia [1].

Dupuytren’s Disease Neurovascular Bundles: Neurovascular bundles exhibit spiralling in Dupuytren’s disease [2].

Peripheral Nerve Suture Complications: Vascular injuries occur in 13% of patients with peripheral nerve suture [3].

Upper Extremity Vascular Insufficiency: Vascular insufficiency of the upper extremity is categorized into five major diagnostic groups: traumatic, compressive, occlusive, tumoral (malformation), and vasospastic [22].

Intraneural Microcirculation: Intraneural microvessels have a structure and function related to trauma, edema formation, and nerve function [7]. Temporary or permanent interference with intraneural microcirculation may cause disturbances in nerve function [7].

Median Artery and Arch Variations: The palmar type of median artery can serve as a source of the superficial palmar arch [11].

Bifid Median Nerve Abnormalities: A classification of associated abnormalities for the bifid median nerve highlights the risk of missing the small ulnar division when surrounded by vascular malformations [13].

Aberrant Musculature: An aberrant flexor digiti minimi brevis manus muscle is a potential cause of neurovascular compression syndromes of the hand and wrist [14].

Vascular Anomalies: Vascular anomalies of the upper limb are relevant to pathogenesis, genetics, classification systems, diagnosis, and treatment [19].

Posterior Interosseous Nerve Variations: Anatomical variations of the posterior interosseous nerve are useful to know during operations in the vicinity of the nerve and when repairing nerve injuries [24].

Carpal Tunnel Median Nerve Classifications: Existing anatomical classifications of the median nerve in the carpal tunnel cannot be relied upon entirely due to variations such as high division with unusually high origin of the 3rd space common digital nerve [48].

Clinical Presentation

Symptomatic neural loops can cause hemidigital anesthesia [1]. Palmar cutaneous branches of the digital nerves are a constant anatomical feature that can be mistaken for proper digital nerves, potentially leading to inadvertent injury [21]. Spiralling of the neurovascular bundle occurs in Dupuytren’s disease [2]. Retrovascular fasciectomy facilitates dissection of the neurovascular bundles in Dupuytren’s fasciectomy [5].

Knowledge of anatomical variations is critical for safe practice. Anatomic variations of the hand, such as concomitant anomalous muscles, require surgeon awareness for comfortable surgical practice [8]. Palmar type median artery patterns are clinically significant for hand surgeons [11]. The bifid median nerve carries a risk of missing the small ulnar division when surrounded by vascular malformations [13]. Aberrant muscles, such as an aberrant flexor digiti minimi brevis manus muscle, should be considered in the differential diagnosis of neurovascular compression syndromes of the hand and wrist [14]. A rare anatomical variant of dual radial digital nerves in the right ring finger requires careful management to ensure successful surgical outcome without neurologic compromise [16].

Diagnostic Modalities: Ultrasound and magnetic resonance neurography are the most far-reaching modalities for peripheral nerve imaging [20]. Vascular insufficiency of the upper extremity requires understanding of vascular anatomy, diagnostic modalities, and management options [4].

Vascular Compromise and Injury: The nutrient vessel is often the only vessel supplying the head of the proximal phalanx, making this area particularly susceptible to vascular compromise [23]. Temporary or permanent interference with intraneural microcirculation may cause disturbances in nerve function [7]. Vascular injuries occur in 13% of patients with peripheral nerve suture [3]. Ischemic monomelic neuropathy requires prompt recognition, diagnosis, and correction of the underlying vascular embarrassment for any chance of recovery [36].

Classification and Pathogenesis: Most vascular abnormalities of the upper extremity can be categorized into five major diagnostic groups: Traumatic, Compressive, Occlusive, Tumoral (malformation), and Vasospastic [22]. Vascular anomalies of the upper limb involve advances in pathogenesis, genetics, classification systems, diagnosis, and treatment [19].

Acute Injury Management: Early exploration of supracondylar fractures allows direct visualization of the extent of neurovascular injury and immediate intervention [18]. Knowledge of anatomical variations of the posterior interosseous nerve is useful during operations in the vicinity of the nerve and when repairing nerve injuries [24]. The peripheral nervous system includes nerve fiber classification, receptor types, blood supply, and pharmacological agents affecting nerve function [12].

Investigations

Plain radiography: Radiographic imaging is utilized to assess fascicular damage in simulated peripheral nerve lacerations, revealing damage that extends beyond the surgeon's visual assessment of epineural injury [56].

MRI: Magnetic resonance neurography (MRN) and ultrasonography are the most far-reaching modalities for peripheral nerve imaging, often providing complementary information [20]. These modalities are appropriate for visualizing fascicular abnormalities in spontaneous posterior interosseous nerve palsy [55]. Three-dimensional proton density MRI can evaluate spinal nerve roots in infants with brachial plexus birth palsy without the need for radiation, contrast agents, or sedation [66].

Other Considerations: Symptomatic neural loops represent a rare diagnostic challenge and are a diagnosis of exclusion [1]. Clinicians should consider microvascular decompression for symptomatic neural loops if other etiologies are absent [1]. Vascular insufficiency of the upper extremity requires a thorough understanding of vascular anatomy, diagnostic modalities, and medical and surgical management options [4].

Pre-operative Planning and Anatomical Variants: Surgeons should identify and dissect the neurovascular bundle proximally and distally throughout its course to prevent injury [2]. The retrovascular exposure allows access to the neurovascular bundle via the thinnest plane of dissection, is easy and atraumatic, reduces the risk of damage to the neurovascular bundle, and permits identification of retrovascular disease [5]. Hand surgeons should be well informed about anatomic variations of the hand to be comfortable during surgical practice [8]. Palmar type median artery patterns as a source of superficial palmar arch are important to hand surgeons [11]. A classification of abnormalities associated with bifid median nerve highlights clinical relevance, particularly the risk of missing the small ulnar division of the nerve when surrounded by vascular malformations [13]. The potential existence of anomalous muscles, such as an aberrant flexor digiti minimi brevis manus muscle, should be considered in the differential diagnosis of neurovascular compression syndromes of the hand and wrist [14]. Identifying and carefully managing anatomic variants, such as dual radial digital nerves in the right ring finger, ensures a successful surgical outcome without neurologic compromise [16]. Palmar cutaneous branches of the digital nerves are a constant anatomical feature but can be mistaken for proper digital nerves, potentially leading to inadvertent injury [21]. The nutrient vessel is often the only vessel supplying the head of the proximal phalanx, making the head of the proximal phalanx particularly susceptible to vascular compromise [23]. Recognition of ulnar nerve anatomical details and variations is essential for accurate diagnosis and surgical decompression to avoid iatrogenic injury [57]. A clear understanding of acetabular osseous anatomy and surrounding soft tissues is essential for evaluation and management [65].

Timing of Intervention: Early exploration of supracondylar fractures allows direct visualization of the extent of neurovascular injury and immediate intervention [18]. Late exploration of nerve injuries is difficult due to scarring, and intact branches may be damaged during late exploration [6]. Surgery for nerve injuries should be performed only by surgeons familiar with the nerve anatomy [6]. Definitive nerve repair should be deferred until after the third week following injury [3]. Nerves should be resected proximal to gross pathological change [3]. Vascular injuries occur in 13% of patients with peripheral nerve suture [3].

Treatment

Non-Operative

Nonoperative management is rarely successful for thoracic outlet syndrome in pediatric and young adult populations, with few patients achieving success through activity modification and physical therapy alone [63].

Operative

Indications: Symptomatic neural loops represent a rare diagnostic challenge and are a diagnosis of exclusion; clinicians should consider microvascular decompression only if other etiologies are absent [1]. For thoracic outlet syndrome, nonoperative failure often necessitates surgical intervention.

Surgical Approach / Technique: Surgeons must identify and dissect the neurovascular bundle proximally and distally throughout its course to prevent injury in Dupuytren’s disease [2]. Retrovascular exposure allows access to the neurovascular bundle via the thinnest plane of dissection, which is easy and atraumatic [5]. Retrovascular fasciectomy reduces the risk of damage to the neurovascular bundle and permits identification of retrovascular disease [5]. Identifying and carefully managing the rare anatomical variant of dual radial digital nerves in the right ring finger ensures a successful surgical outcome without neurologic compromise [16]. A dissection technique exists that enables adequate mobilization of the median nerve while preserving vascularity and achieving tensionless repair, supported by the existence of a constant identifiable vascular pedicle to the median nerve in the distal forearm [27].

Implant Selection: Outcomes of digital nerve reconstruction using processed nerve allograft (PNA) were consistent and significantly better than those of conduits across all groups [41]. Clinically reported levels of meaningful recovery for processed nerve allografts greater than 40mm are comparable to nerve autografts with both sensory and motor function outcomes [47]. Caution is advised when using conduits to repair large-diameter nerves due to failed clinical outcomes [10].

Adjuncts: Immediate post-operative re-learning following nerve repair may enhance early sensory outcomes [60].

Other Considerations: Definitive nerve repair should be deferred until after the third week following injury [3]. Nerves should be resected proximal to gross pathological change during repair [3]. Vascular injuries occur in 13% of patients with peripheral nerve suture [3]. Vascular insufficiency of the upper extremity requires a thorough understanding of vascular anatomy, diagnostic modalities, and medical and surgical management options [4]. Late exploration for nerve injury is difficult due to scarring and intact branches may be damaged [6]. Nerve surgery should be performed only by surgeons familiar with the nerve anatomy [6]. Restoration of full function remains unachievable despite advances in nerve transfers and microvascular free functioning muscle transfers [9]. Significant advances using microsurgical techniques for nerve repair have led to improved results after peripheral nerve surgery [43]. Microsurgical techniques have extended the types of nerve repair that can be accomplished [43]. Available treatments for peripheral nerve injuries remain suboptimal [58].

Successful arterial reconstruction in symptomatic posttraumatic ulnar artery thrombosis decreases symptoms, improves function and microvascular physiology, and has a positive effect on health-related quality of life [15]. Contralateral C7 transfer demonstrates significant improvements in upper limb function, confirming the procedure's safety and efficacy [39]. Donor site morbidity from contralateral C7 transfer is typically mild and transient [39]. Short-term improvement in nerve function was seen in over half the cohort of patients with gunshot-related upper extremity nerve injuries, suggesting a predominance of neuropraxic effects [17]. Surgical repair does not consistently yield better functional outcomes than leaving an adult isolated digital nerve injury unrepaired [26]. There is a paucity of evidence to support the universal recommendation for prompt microsurgical repair of digital nerves [26]. Hand surgeons must be aware of acute hand ischemia as a rare but potentially devastating complication of elective venous sclerotherapy for dorsal hand varicose veins to allow for immediate diagnosis and expedient treatment [61].

Complications

Nerve palsy: Symptomatic neural loops represent a rare anatomic variation that can cause hemidigital anesthesia [1]. Diagnosis is a challenge and serves as a diagnosis of exclusion [1]. Microvascular decompression may be considered for symptomatic neural loops if other etiologies are absent [1]. Spiralling of the neurovascular bundle occurs in Dupuytren’s disease [2]. Injury to the neurovascular bundle can be prevented by identifying and dissecting the bundle proximally and distally throughout its course [2]. Temporary or permanent interference with intraneural microcirculation may cause disturbances in nerve function, as intraneural edema pathophysiology is related to the structure and function of intraneural microvessels [7].

Vascular injury: Vascular injuries occur in 13% of patients with peripheral nerve suture [3]. Vascular insufficiency of the upper extremity requires a thorough understanding of vascular anatomy, diagnostic modalities, and management options [4]. Successful arterial reconstruction in symptomatic posttraumatic ulnar artery thrombosis decreases symptoms, improves function and microvascular physiology, and positively affects health-related quality of life [15]. Arteriography and the timed Allen test are useful for assessing arterial anatomy and flow to determine if operative reconstruction is necessary for pseudoaneurysm of the superficial palmar arch [31].

Nerve repair challenges: Definitive nerve repair should be deferred until after the third week following injury [3]. Nerves should be resected proximal to gross pathological change during repair [3]. Late exploration of nerve injuries is difficult due to scarring, and intact nerve branches may be damaged during late exploration [6]. Surgery for nerve injuries should be performed only by surgeons familiar with nerve anatomy [6]. Restoration of full function remains unachievable despite advances in nerve transfers and microvascular free functioning muscle transfers [9]. Caution is advised when using conduits to repair large-diameter nerves due to failed clinical outcomes [10]. Short-term improvement in nerve function was seen in over half of patients with gunshot-related upper extremity nerve injuries, suggesting a predominance of neuropraxic effects [17].

Other Considerations: The provided evidence focuses on specific neurovascular complications and management principles rather than general orthopaedic complications such as infection, loosening, or instability.

Recovery

Light activity (weeks): Early management of nerve injuries requires careful timing. Definitive nerve repair should be deferred until after the third week following injury [3]. For supracondylar fractures, early exploration allows direct visualization of the extent of neurovascular injury and immediate intervention [18]. In pediatric peripheral nerve injury, surgical repair with long-term hand therapy results in excellent functional outcomes [25].

Full activity (months): The choice of surgical technique and timing for peripheral nerve injury of the upper extremity depends on the type of trauma, site of injury, and time elapsed since injury [67]. Spontaneous recovery occurs in 70%–88% of radial nerve injuries [67]. Short-term improvement in nerve function was seen in over half of the cohort with gunshot-related upper extremity nerve injuries, suggesting a predominance of neuropraxic effects [17].

Complete recovery / outcome plateau (months): Restoration of full function remains unachievable despite advances in nerve transfers and microvascular free functioning muscle transfers [9]. Nerve transfers have revolutionized care for peripheral nerve injuries, but additional long-term follow-up and case series are warranted [30]. Further studies with long-term follow-up are needed to determine whether grafted areas in autologous matrix-induced chondrogenesis will maintain structural and functional integrity over time [29].

Rehabilitation protocol: Surgeons should identify and dissect the neurovascular bundle proximally and distally throughout its course to prevent injury in Dupuytren’s disease [2]. When repairing large-diameter nerves, caution is advised when using conduits due to reported failed clinical outcomes [10]. It may be possible to advance the median nerve at the wrist while retaining the vascular connection and blood supply from the radial artery to maintain vascularity at the common site of nerve repair in the distal forearm [28].

Functional milestones: Successful arterial reconstruction in symptomatic posttraumatic ulnar artery thrombosis decreases symptoms, improves function and microvascular physiology, and positively affects health-related quality of life [15]. At long-term follow-up, patient-reported outcome measures and objective outcomes of homodigital unipedicle neurovascular island flaps for fingertip coverage are satisfactory, making it a safe and reliable flap [62]. Searching for veins between the 3 to 5 o'clock or 7 to 9 o'clock positions is feasible and presents a reliable option for microsurgeons in fingertip replantation at the eponychial level, offering adequate venous drainage with reduced operating time [64].

Other Considerations: Symptomatic neural loops are a rare anatomic variation that presents as a diagnostic challenge and diagnosis of exclusion [1]. Clinicians should consider microvascular decompression for symptomatic neural loops if other etiologies are absent [1]. Vascular injuries occur in 13% of patients with peripheral nerve suture [3]. Late exploration of nerve injuries is difficult due to scarring and risks damaging intact branches [6]. Surgery for nerve injuries should be performed only by surgeons familiar with nerve anatomy [6]. Temporary or permanent interference with intraneural microcirculation may cause disturbances in nerve function [7]. Arteriography and the timed Allen test are useful for assessing arterial anatomy and flow to determine if operative reconstruction is necessary for pseudoaneurysm of the superficial palmar arch [31]. A persistent median artery helped maintain blood flow to a nearly amputated hand after complete transection of the radial and ulnar arteries, preserving hand viability [59].

Key Evidence

  • [Case_report] Symptomatic neural loops are a rare, diagnostic challenge and diagnosis of exclusion; clinicians must be aware of this anatomic variation and consider microvascular decompression if other etiologies are absent. (10.1016/j.jhsa.2012.07.012)
  • [L4] Surgeons should identify and dissect the neurovascular bundle proximally and distally throughout its course to prevent injury. (10.1177/1753193409349855)
  • [L5] Vascular insufficiency of the upper extremity requires a thorough understanding of vascular anatomy, diagnostic modalities, and medical and surgical management options, with promising advances continuing to be made in treatment. (10.1016/j.jhsa.2010.06.011)
  • [L4] The retrovascular exposure allows access to the neurovascular bundle via the thinnest plane of dissection which is easy and atraumatic, reduces the risk of damage to the neurovascular bundle, and permits identification of retrovascular disease. (10.1177/1753193411416425)
  • [L5] The authors agree that late exploration is difficult due to scarring and that intact branches may be damaged, recommending surgery only by surgeons familiar with the nerve anatomy. (10.1054/jhsb.2002.0846)
  • [L5] The article reviews the structure and function of intraneural microvessels and the pathophysiology of intraneural edema, emphasizing that temporary or permanent interference with intraneural microcirculation may cause disturbances in nerve function. (10.2106/00004623-197557070-00011)
  • [L4] Hand surgeons should be well informed about anatomic variations of the hand to be comfortable during surgical practice. (10.1007/s11552-007-9033-7)
  • [L5] Despite advances in nerve transfers and microvascular free functioning muscle transfers, restoration of full function remains unachievable. (10.1016/j.jhsa.2014.06.126)
  • [L4] The authors advise caution when using conduits to repair large-diameter nerves based on the failed clinical outcomes reported. (10.1007/s11552-008-9158-3)
  • [L4] These vascular patterns are important to hand surgeons. (10.1007/s11552-009-9197-4)
  • [L4] A classification of associated abnormalities is offered to highlight clinical relevance, particularly the risk of missing the small ulnar division of the nerve when surrounded by vascular malformations. (10.1177/1753193408089572)
  • [L5] The potential existence of this or other anomalous muscles should be considered in the differential diagnosis of neurovascular compression syndromes of the hand and wrist. (10.1016/j.jhsa.2011.09.002)
  • [L4] Successful arterial reconstruction in symptomatic posttraumatic UAT decreases symptoms, improves function and microvascular physiology, and has a positive effect on the health-related quality of life. (10.1016/j.jhsa.2008.02.011)
  • [L4] Identifying and carefully managing this anatomic variant ensured a successful surgical outcome without neurologic compromise. (10.1016/j.jhsg.2025.100906)
  • [L4] Short-term improvement in nerve function was seen in over half the cohort, suggesting a predominance of neuropraxic effects. (10.1016/j.jhsa.2021.03.020)
  • [L4] Early exploration of supracondylar fractures allows direct visualization of the extent of neurovascular injury and immediate intervention. (10.1177/17531934231201925)
  • [L5] This article aims to provide an update on vascular anomalies relevant to the upper limbs, focusing on significant advances in pathogenesis and genetics, classification systems, diagnosis and treatment. (10.1177/1753193418808130)
  • [L5] Ultrasound and magnetic resonance neurography (MRN) are the most far-reaching modalities for peripheral nerve imaging, often providing complimentary information. (10.1016/j.jhsa.2019.06.021)
  • [L5] Most vascular abnormalities of the upper extremity can be categorized into five major diagnostic groups: traumatic, compressive, occlusive, tumoral (malformation), and vasospastic. (10.5435/00124635-200211000-00004)
  • [L5] This nutrient vessel is often the only vessel supplying the head of the proximal phalanx, making this area particularly susceptible to vascular compromise. (10.1016/j.jhsa.2022.09.014)
  • [L4] Knowledge of anatomical variations is useful during operations in the vicinity of the nerve and when repairing nerve injuries. (10.1054/jhsb.2000.0399)
  • [Paper] Surgical repair with long-term hand therapy results in excellent functional outcomes following pediatric peripheral nerve injury. (10.1055/s-0039-1692928)
  • [Commentary] The author remains unconvinced that surgical repair consistently yields better functional outcomes than leaving an adult isolated digital nerve injury unrepaired, noting a paucity of evidence to support the universal recommendation for prompt microsurgical repair. (10.1177/1753193415622729)
  • [L2] The study established the presence of a constant identifiable vascular pedicle to the median nerve in the distal forearm and developed a dissection technique that enables adequate mobilization while preserving vascularity and achieving tensionless repair. (10.1016/s0363-5023(09)60086-1)
  • [L5] This cadaveric study suggests that it may be possible to advance the median nerve at the wrist while retaining the vascular connection and blood supply from the radial artery, and so maintain the vascularity of the nerve at the common site of nerve repair in the distal forearm. (10.1016/j.jhsa.2012.03.028)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
  • [Letter] The original authors state that nerve transfers have revolutionized care for peripheral nerve injuries and that additional long-term follow-up and case series are warranted. (10.1016/j.jhsa.2014.07.058)
  • [Case_report] Arteriography and the timed Allen test are useful for assessing arterial anatomy and flow to determine if operative reconstruction is necessary. (10.2106/00004623-199607000-00014)
  • [L5] The intrinsic hand muscles have MEPs at consistent distances from bony landmarks both dorsally and volarly. (10.1016/j.jhsa.2020.04.019)
  • [L5] Prompt recognition, diagnosis, and correction of the underlying vascular embarrassment is the only treatment strategy offering any chance of recovery. (10.1016/j.jhsa.2009.08.014)
  • [L5] The thumb trapeziometacarpal joint ligaments had an abundance of nerve endings in the dorsal ligaments but little to no innervation in the anterior oblique ligament, inferring a proprioceptive function of these ligaments in addition to their biomechanical importance. (10.1016/j.jhsa.2011.12.038)
  • [L4] Ulnar head replacement is a clinically proven means of re-establishing mechanical contact between the distal radius and ulna to restore stability of the entire forearm. (10.1177/1753193414534380)
  • [L5] Published clinical results have demonstrated significant improvements in upper limb function, confirming the procedure's safety and efficacy, with donor site morbidity that is typically mild and transient. (10.1177/17531934251314640)
  • [L3] Outcomes of digital nerve reconstruction using PNA were consistent and significantly better than those of conduits across all groups. (10.1016/j.jhsa.2020.07.016)
  • [L5] Significant advances using microsurgical techniques for nerve repair have led to improved results after peripheral nerve surgery and have extended the types of nerve repair that can be accomplished. (10.1016/j.hcl.2007.02.003)
  • [L4] A new mechanism of traumatic dynamic anterior instability of the trapeziometacarpal joint is described, distinct from the common longitudinal force injury pattern. (10.1177/1753193408100959)
  • [L4] Early diagnosis and prevention of hand trauma is the only way to stop progression of this disease, which can lead to permanent impairment. (10.1177/03635465000280052101)
  • [L3] Clinically reported levels of meaningful recovery for >40mm processed nerve allografts are comparable to nerve autografts with both sensory and motor function outcomes. (10.1016/j.jhsa.2016.07.035)
  • [L4] One cannot rely entirely on the existing anatomical classifications of the MN in the carpal tunnel. (10.1016/j.injury.2020.03.024)
  • [L5] The plastic-injection technique can be used to further elucidate the relative vascularity of the component parts of the normal and abnormal hand. (10.2106/00004623-195941040-00010)
  • [L5] Most nerve lacerations should be repaired soon after injury, and current widespread application of microsurgical techniques should lead to reasonable results in most individuals, though many patients do not have ideal outcomes and are often left with permanent sequelae. (10.1016/j.jhsa.2014.01.025)
  • [L5] Neural loops are a common occurrence in humans and should be considered a normal phenomenon rather than a little-known variation in the palm. (10.1016/j.jhsa.2010.08.025)
  • [L4] Ultrasonography and MRI are appropriate for visualizing fascicular abnormalities in spontaneous posterior interosseous nerve palsy. (10.1016/j.jhsa.2019.12.011)
  • [L5] Radiographic imaging showed fascicular damage extending beyond the surgeon's visual assessment of epineural damage, indicating that the internal damage to nerves from traumatic lacerations was underappreciated by surgeons. (10.1016/j.jhsg.2025.100833)
  • [L5] Recognition of these anatomical details and variations is essential for accurate diagnosis and surgical decompression to avoid iatrogenic injury. (10.1016/j.hcl.2007.05.001)
  • [Paper] Peripheral nerve injuries are common and debilitating, with available treatments remaining suboptimal. (10.1016/j.hcl.2013.04.002)
  • [Case_report] A persistent median artery helped maintain blood flow to a nearly amputated hand after complete transection of the radial and ulnar arteries, preserving hand viability. (10.1016/j.jhsa.2011.01.020)
  • [Commentary] The study by Rosén et al. has added to the body of literature regarding management following nerve repair and provides the opportunity for future investigations to strengthen the evidence and lead to practice changes. (10.1177/1753193414567826)
  • [L4] As dorsal hand vein sclerotherapy gains in popularity, it is essential that hand surgeons be aware of this rare but potentially devastating complication to allow for immediate diagnosis and expedient treatment. (10.1016/j.jhsa.2017.03.018)
  • [L4] At a long-term follow-up, the patient-reported outcome measures and objective outcomes of this flap are satisfactory and it is a safe and reliable flap. (10.1177/17531934231172081)
  • [L4] Few patients were successfully managed with nonoperative activity modification and physical therapy. (10.1016/j.jhsa.2023.12.013)
  • [L4] The anatomic study and clinical experience demonstrate that searching for veins between the 3 to 5 o'clock or 7 to 9 o'clock positions is feasible and presents a reliable option for microsurgeons, offering adequate venous drainage with reduced operating time. (10.1177/1753193413490653)
  • [L2] Three-dimensional proton density MRI can evaluate spinal nerve roots in infants without the need for radiation, contrast agents, or sedation. (10.1016/j.jhsa.2017.01.032)
  • [L4] The choice of surgical technique and timing depends on the type of trauma, site of injury, and time elapsed since injury, with spontaneous recovery occurring in 70%–88% of radial nerve injuries. (10.1177/17531934241240867)

See Also

References

[1] Symptomatic Neural Loop Causing Hemidigital Anesthesia: Case Report. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.07.012

[2] Spiralling of the neurovascular bundle in Dupuytren’s disease. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193409349855

[3] Peripheral Movidas: Cannibalizing Galicia. 2018.

[4] Vascular Insufficiency of the Upper Extremity. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.06.011

[5] Retrovascular fasciectomy: an approach that facilitates dissection of the neurovascular bundles in Dupuytren’s fasciectomy. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411416425

[6] Letters to the Editor. Journal of Hand Surgery. 2002. DOI: 10.1054/jhsb.2002.0846

[7] Structure and function of the intraneural microvessels as related to trauma, edema formation, and nerve function. The Journal of Bone & Joint Surgery. 1975. DOI: 10.2106/00004623-197557070-00011

[8] The Concomitant Presence of Two Anomalous Muscles in the Forearm. HAND. 2007. DOI: 10.1007/s11552-007-9033-7

[9] Peripheral Nerve Injuries: Advancing the Field Through Research, Collaboration, and Education. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.06.126

[10] Limitations of Conduits in Peripheral Nerve Repairs. HAND. 2009. DOI: 10.1007/s11552-008-9158-3

[11] Palmar Type of Median Artery as a Source of Superficial Palmar Arch: A Cadaveric Study with its Clinical Significance. HAND. 2009. DOI: 10.1007/s11552-009-9197-4

[12] Chapter 63 Peripheral Nervous System. 2019.

[13] The Bifid Median Nerve Re-Visited. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193408089572

[14] An Aberrant Flexor Digiti Minimi Brevis Manus Muscle. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.09.002

[15] Post-Traumatic Ulnar Artery Thrombosis: Outcome of Arterial Reconstruction Using Reverse Interpositional Vein Grafting at 2 Years Minimum Follow-Up. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.02.011

[16] A Rare Anatomical Variant Dual Radial Digital Nerves in the Right Ring Finger: Consideration in Hand Dissection. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2025.100906

[17] Gunshot-Related Upper Extremity Nerve Injuries at a Level 1 Trauma Center. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2021.03.020

[18] Neurovascular injury from supracondylar fractures in children: a 10-year experience of 762 cases. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231201925

[19] Vascular anomalies of the upper limb. Journal of Hand Surgery (European Volume). 2018. DOI: 10.1177/1753193418808130

[20] Imaging of the Peripheral Nerve: Concepts and Future Direction of Magnetic Resonance Neurography and Ultrasound. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2019.06.021

[21] 33. Palmar Cutaneous Branches of the Proper Digital Nerves Encountered in Dupuytren’s Surgery: A Cadaveric Study. n.d..

[22] Vascular Problems of the Upper Extremity: A Primer for the Orthopaedic Surgeon. Journal of the American Academy of Orthopaedic Surgeons. 2002. DOI: 10.5435/00124635-200211000-00004

[23] Arterial Perfusion of the Proximal Phalanx Revisited: New Insights Based on Micro-Computed Tomography. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2022.09.014

[24] Variations of the Posterior Interosseous Nerve. Journal of Hand Surgery. 2000. DOI: 10.1054/jhsb.2000.0399

[25] Long-Term Outcomes following Pediatric Peripheral Nerve Injury Repair. Journal of Hand and Microsurgery. 2020. DOI: 10.1055/s-0039-1692928

[26] Commentary on Long-term clinical outcome after epineural coaptation of digital nerves. R. M. Fakin, M. Calcagni, H. J. Klein and P. Giovanoli. J Hand Surg. 2016, 41: 148–154. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193415622729

[27] Vascularization of the Median Nerve in the Distal Forearm and its Clinical Significance. The Journal of Hand Surgery. 2009. DOI: 10.1016/s0363-5023(09)60086-1

[28] The Vascularization of the Median Nerve in the Distal Forearm and Its Potential Clinical Importance. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.03.028

[29] Mid‐term results of Autologous Matrix‐Induced Chondrogenesis for treatment of focal cartilage defects in the knee. Knee Surgery, Sports Traumatology, Arthroscopy. 2010. DOI: 10.1007/s00167-010-1042-3

[30] Letter to the Editor Regarding Phillips BZ, Franco MJ, Yee A, Tung TH, Mackinnon SE, Fox IK. Direct Radial to Ulnar Nerve Transfer to Restore Intrinsic Muscle Function in Combined Proximal Median and Ulnar Nerve Injury: Case Report and Surgical Technique. J Hand Surg Am. 2014;39(7):1358–1362. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.07.058

[31] Pseudoaneurysm of the Superficial Palmar Arch. A Case Report. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199607000-00014

[33] Targeted Muscle Reinnervation in the Hand: An Anatomical Feasibility Study for Neuroma Treatment and Prevention. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2020.04.019

[36] Ischemic Monomelic Neuropathy. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2009.08.014

[37] Innervation Patterns of Thumb Trapeziometacarpal Joint Ligaments. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2011.12.038

[38] Digital artery intravascular myopericytoma – a rare cause of a painful finger. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414534380

[39] Harnessing the uninjured hemisphere for treatment of the stroke or brain-injured patient – evolution of the contralateral C7 transfer. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251314640

[41] A Multicenter Matched Cohort Study of Processed Nerve Allograft and Conduit in Digital Nerve Reconstruction. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2020.07.016

[43] The Role of Microsurgery in Nerve Repair and Nerve Grafting. Hand Clinics. 2007. DOI: 10.1016/j.hcl.2007.02.003

[45] Spontaneous intraneural haematoma causing acute neuropathy of the median nerve. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193408100959

[46] Hypothenar Hammer Syndrome in a Golf Player. The American Journal of Sports Medicine. 2000. DOI: 10.1177/03635465000280052101

[47] Evaluation of Protective Sensation after Hemi-contralateral C7 Nerve Root Transfer to Median Nerve in Total Root Avulsion Brachial Plexus Injury. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.07.035

[48] High Division of the Median Nerve with Unusually High Origin of the 3rd Space Common Digital Nerve. Injury. 2020. DOI: 10.1016/j.injury.2020.03.024

[51] Circulation of the Hand, Injection-Corrosion Studies. The Journal of Bone & Joint Surgery. 1959. DOI: 10.2106/00004623-195941040-00010

[52] Median Nerve Injury and Repair. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.01.025

[54] Penetration of the Digital Nerves by the Common Palmar Digital Arteries in Human Cadavers. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.08.025

[55] Pathological Findings of Hourglass-Like Constriction in Spontaneous Posterior Interosseous Nerve Palsy. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2019.12.011

[56] More Than Epineurium Deep: Characterizing Peripheral Nerve Damage Using High-Resolution Micro-Computed Tomography for Simulated Peripheral Nerve Lacerations. Journal of Hand Surgery Global Online. 2025. DOI: 10.1016/j.jhsg.2025.100833

[57] Ulnar Nerve Anatomy. Hand Clinics. 2007. DOI: 10.1016/j.hcl.2007.05.001

[58] Nerve Physiology. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2013.04.002

[59] Persistent Median Artery in a Pediatric Trauma Patient: Case Report. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.01.020

[60] Commentary on Enhanced early sensory outcome after nerve repair as a result of immediate post-operative re-learning: a randomized controlled trial. B. Rosén, P. Vikström, S. Turner, D. A. McGrouther, R. W. Selles, T. A. R. Schreuders and A. Björkman. J Hand Surg Eur. 2015, 40: 598–606. Journal of Hand Surgery (European Volume). 2015. DOI: 10.1177/1753193414567826

[61] Acute Hand Ischemia Following Elective Venous Sclerotherapy for Dorsal Hand Varicose Veins. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.03.018

[62] Long-term patient-reported outcome measures of fingertip coverage with a homodigital unipedicle neurovascular island flap. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231172081

[63] Thoracic Outlet Syndrome in the Pediatric and Young Adult Population. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2023.12.013

[64] Fingertip replantation at the eponychial level with venous anastomosis: an anatomic study and clinical application. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413490653

[65] Chapter 33 Evaluation and Management of Acetabular Fractures. 2021.

[66] Neonatal Magnetic Resonance Imaging Without Sedation Correlates With Injury Severity in Brachial Plexus Birth Palsy. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.01.032

[67] Timing of surgery in peripheral nerve injury of the upper extremity. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241240867

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

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

Creative Commons Attribution-NonCommercial 4.0 International Public License

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

Section 1 -- Definitions.

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

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

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

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

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

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

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

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

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

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

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

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

Section 2 -- Scope.

a. License grant.

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

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

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

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

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

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

5. Downstream recipients.

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

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

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

b. Other rights.

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

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

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

Section 3 -- License Conditions.

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

a. Attribution.

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

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

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

ii. a copyright notice;

iii. a notice that refers to this Public License;

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

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

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

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

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

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

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

Section 4 -- Sui Generis Database Rights.

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

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

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

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

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

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

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

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

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

Section 6 -- Term and Termination.

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

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

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

2. upon express reinstatement by the Licensor.

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

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

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

Section 7 -- Other Terms and Conditions.

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

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

Section 8 -- Interpretation.

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

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

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

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

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

Creative Commons may be contacted at creativecommons.org.