Skip to content

Clinicians › Hand

Infected Flexor Sheath (Pyogenic Flexor Tenosynovitis)

23 citationsUpdated Sep 2026

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

Overview

Pyogenic flexor tenosynovitis is a closed-space infection of the finger or thumb flexor tendon sheath or the radial and ulnar bursae [3]. While uniform finger swelling may occur, this finding does not appear to distinguish pyogenic flexor tenosynovitis from other finger infections [4]. Ultrasound serves as a useful diagnostic tool for managing early cases, owing to its excellent negative predictive value and specificity [10]. A three-tier clinical classification system based on preoperative clinical assessment has been proposed to aid in prognosis and guide treatment for upper extremity cases [2].

Surgical decompression is the treatment of choice for nearly all cases of septic flexor tenosynovitis [6]. Expediency in surgical decompression potentially improves final motion and function [6]. Studies have demonstrated the benefits of both early treatment and systemic antibiotic use for pyogenic flexor tenosynovitis [5]. In uncomplicated cases, a single open debridement with irrigation and primary wound closure followed by 10 days of antibiotic therapy has resolved the infection [1].

Despite aggressive and prompt antibiotic therapy and surgical intervention, even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection [8].

Anatomy & Pathophysiology

Anatomy

The flexor tendon sheath encloses the flexor tendons, extending from the distal interphalangeal joint proximally to the A1 pulley [18]. Anatomical continuity exists between the thumb flexor tendon sheath and the radial bursa, as well as between the small finger sheath and the ulnar bursa [18]. The radial and ulnar bursae communicate via Parona's space and extend into the carpal tunnel in up to 80% of individuals [18]. Infection can spread through these connections to the small finger flexor tendon sheaths, resulting in a horseshoe abscess, or proximally into Parona's space from the flexor tendon sheath [18].

Pathophysiology

Pyogenic flexor tenosynovitis is a bacterial infection located between the visceral layer on the flexor tendon and the parietal layer of the sheath [18]. Staphylococcus aureus following penetrating trauma is the most common etiology, though hematogenous spread is also a recognized cause [18, 21]. Local inoculation via lacerations, puncture wounds, and bites occurs more frequently than hematogenous spread [21]. This condition accounts for 2.5% to 9.4% of all hand infections, with one large series reporting a prevalence of 9.4% (13/138) [21, 11].

Clinical presentation may include uniform finger swelling, a finding that does not distinguish pyogenic flexor tenosynovitis from other finger infections [4]. Kanavel's four cardinal signs include: * Exquisite tenderness: Localized over the course of the sheath [18]. * Semiflexed position: The finger rests in a semiflexed posture [18]. * Pain on extension: Exquisite pain occurs upon extending the finger, most marked at the proximal end where definite swelling may be observed [18]. * Symmetrical swelling: The entire finger exhibits symmetrical swelling [18].

Not all of Kanavel's signs are necessarily present in every case [18]. If treatment is delayed, the infection can lead to tendon necrosis and adhesions, causing marked loss of motion, deformity, and potential loss of the limb [11].

Classification

Kanavel's Signs: The presence of all four classic signs is not required for diagnosis; however, when flexor tenosynovitis is suspected, immediate treatment must be instituted to prevent disastrous complications [18]. In a retrospective study of 40 patients, the number of Kanavel signs and the duration of symptoms were significantly greater in the surgical management group compared with the early antibiotics only group [40]. No statistical significance was found regarding age, smoking status, or specific individual Kanavel signs between these two groups [40]. Patients presenting with a shorter duration of symptoms and fewer Kanavel signs were treated successfully with antibiotics alone [40]. Conversely, operatively confirmed flexor tenosynovitis presented more acutely, characterized by fewer days of symptoms and a higher number of Kanavel signs [40].

Other Considerations: Patients with subacute presentations may represent inflammatory conditions rather than infection [40]. Computed tomography measurements, specifically the tendon sheath to tendon ratio, can differentiate flexor tenosynovitis from finger cellulitis with high sensitivity and specificity [15]. Pyogenic flexor tenosynovitis may result in uniform finger swelling, but this finding does not appear to distinguish pyogenic flexor tenosynovitis from other finger infections [4].

Clinical Presentation

Pyogenic flexor tenosynovitis is a relatively common but often misdiagnosed hand infection [9]. The condition is most commonly associated with S aureus following penetrating trauma [18]. While not all of Kanavel's signs will be present, the clinical suspicion of flexor tenosynovitis mandates immediate treatment to prevent disastrous complications, including tendon adhesions or even necrosis [18].

Diagnostic Evaluation

Hand and upper-extremity infections are usually a clinical diagnosis, but imaging and laboratory evaluation aid in diagnosis [19]. CT measurements, specifically the tendon sheath to tendon ratio, can differentiate FTS from finger cellulitis with high sensitivity and specificity [15]. The presence of pus within the flexor sheath is the only significant predictive factor for repeated flexor tendon washout [13].

Prognosis and Outcomes

A three-tier clinical classification system based on preoperative clinical assessment is proposed to aid in prognosis and guidance in the treatment of pyogenic flexor tenosynovitis of the upper extremity [2].

Investigations

Clinical Examination

Kanavel described three cardinal signs of pyogenic flexor tenosynovitis: exquisite tenderness over the course of the sheath limited to the sheath, flexion of the finger, and exquisite pain on extending the finger most marked at the proximal end [11]. Kanavel also noted that the whole of the involved finger is uniformly swollen, although this was not initially described as a cardinal sign [11]. A three-tier clinical classification system based on preoperative clinical assessment has been proposed to aid in prognosis and treatment guidance for pyogenic flexor tenosynovitis [2]. A careful physical examination is essential to direct care and future testing if indicated, as diagnostic tests can be expensive, time consuming, and often nonspecific [20].

Imaging

Ultrasound: Ultrasound is useful as a diagnostic tool for managing early pyogenic flexor tenosynovitis due to its excellent negative predictive value and specificity [10]. Point-of-care ultrasound has been utilized in the emergency department for the diagnosis of pyogenic flexor tenosynovitis [22].

CT: Contrast-enhanced computed tomography measurements, specifically the tendon sheath to tendon ratio, can differentiate flexor tenosynovitis from finger cellulitis with high sensitivity and specificity [15].

MRI: MRI may aid in the preoperative diagnosis of vascular malformations in tendon sheaths that present as tenosynovitis [44].

Other Considerations: Pyogenic flexor tenosynovitis may result in uniform finger swelling, but this finding does not appear to distinguish pyogenic flexor tenosynovitis from other finger infections [4]. Preoperative imaging was useful in assessing the condition of flexor tendons in cases of chronic or severe tenosynovitis [46].

Treatment

Non-Operative

No patients with suspicion for pyogenic flexor tenosynovitis based on specific criteria were managed with antibiotics alone [16].

Operative

Indications: Expediency in surgical treatment potentially improves final motion and function [6]. Early diagnosis of purulent flexor tenosynovitis followed by drainage through small incisions and continuous postoperative irrigation appear to lead to the best functional outcome [12]. Patients with frank purulence on clinical examination are taken immediately to the operating room for irrigation and debridement and flexor sheath washout [16]. Frank purulence is defined as draining purulence from a wound or the presence of a diffuse subcutaneous and/or palpable abscess [16]. Patients with pyogenic flexor tenosynovitis but without frank findings of purulence on examination may undergo a limited bedside flexor sheath irrigation and debridement in the emergency department [16].

Surgical Approach / Technique: A designation of purulence after irrigation and debridement is defined by the clinical provider as an overt thick, white, odorous fluid expressed from the hand [16]. Fluid types including dark, cloudy, bloody, or clear fluid are deemed as nonpurulent and as a possible manifestation of early flexor tenosynovitis [16]. If purulence is encountered during limited bedside irrigation and debridement, patients are taken to the operating room [16]. For limited bedside procedures, an oblique Bruner incision is made over the area(s) of concern [16], and a longitudinal incision is made along the most volar aspect of the flexor sheath [16]. Abnormal fluid expressed either subcutaneously or from within the flexor sheath is cultured during limited bedside irrigation and debridement [16]. The wound is irrigated with sterile saline fluid and a bulky soft dressing is applied during limited bedside irrigation and debridement [16].

Adjuncts: Management of pyogenic flexor tenosynovitis includes prompt administration of empirical intravenous antibiotics [21]. Systemic antibiotic use shows benefits in the management of acute pyogenic flexor tenosynovitis [5].

Prognosis and Outcomes: Early treatment of pyogenic flexor tenosynovitis shows benefits [5]. Complication rates can be high, leading to impaired function and even amputation of the affected digit, despite prompt treatment and regardless of the protocol used [21].

Complications

Stiffness / Arthrofibrosis: Even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection despite aggressive and prompt antibiotic therapy and surgical intervention [8]. This outcome persists even when management includes early diagnosis, drainage through small incisions, and continuous postoperative irrigation, which are associated with the best functional outcomes [12].

Infection (PJI): Severe infection can lead to impaired function or even amputation of the affected digit despite timely and thorough treatment [24].

Other Considerations: A three-tier clinical classification system based on preoperative clinical assessment has been proposed to aid in prognosis and guidance in the treatment of pyogenic flexor tenosynovitis [2]. Surgical decompression is the treatment of choice for nearly all cases of septic flexor tenosynovitis, with expediency potentially improving final motion and function [6]. Studies have shown benefits of early treatment of pyogenic flexor tenosynovitis and of systemic antibiotic use [5].

Key Evidence

  • [L4] A single open debridement with irrigation and primary wound closure followed by 10 days of antibiotic therapy resolved uncomplicated pyogenic flexor tenosynovitis. [1] (10.1007/s00402-016-2587-5)
  • [L2] The authors propose a three-tier clinical classification system based on preoperative clinical assessment to aid in prognosis and guidance in the treatment of pyogenic flexor tenosynovitis of the upper extremity. [2] (10.2106/jbjs.f.01356)
  • [L5] Pyogenic flexor tenosynovitis is a closed-space infection of the finger or thumb flexor tendon sheath or the radial and ulnar bursae. [3] (10.1016/s0749-0712(21)00418-2)
  • [L4] Pyogenic flexor tenosynovitis may result in uniform finger swelling, but this does not appear to distinguish PFT from other finger infections. [4] (10.1016/j.jhsa.2019.01.013)
  • [L3] The studies showed benefits of early treatment of pyogenic flexor tenosynovitis and of systemic antibiotic use. [5] (10.1177/1753193415570248)
  • [L5] Surgical decompression is the treatment of choice for nearly all cases of septic flexor tenosynovitis, with expediency potentially improving final motion and function. [6] (10.1016/j.jhsa.2010.11.033)
  • [L5] Despite aggressive and prompt antibiotic therapy and surgical intervention, even otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection. [8] (10.5435/jaaos-20-06-373)
  • [L5] Pyogenic flexor tenosynovitis is a relatively common but often misdiagnosed hand infection. [9] (10.1136/bcr-2012-006778)
  • [L2] Ultrasound is useful as a diagnostic tool for managing early pyogenic flexor tenosynovitis thanks to its excellent negative predictive value and specificity. [10] (10.1016/j.hansur.2017.12.004)
  • [L5] [11] (10.1007/s11999-015-4367-x)
  • [L4] Early diagnosis of purulent flexor tenosynovitis followed by drainage through small incisions and continuous postoperative irrigation appear to lead to the best functional outcome. [12] (10.1177/1753193408087071)
  • [Paper] The presence of pus within the flexor sheath is the only significant predictive factor for repeated flexor tendon washout. [13] (10.1055/s-0040-1715556)
  • [L3] The study demonstrates that CT measurements, specifically the tendon sheath to tendon ratio, can differentiate FTS from finger cellulitis with high sensitivity and specificity. [15] (10.1177/15589447221092058)
  • [L4] [16] (10.1177/1558944721999729)
  • [L5] [18] (10.1016/j.jhsa.2011.05.035)
  • [L5] Hand and upper-extremity infections are usually a clinical diagnosis, but imaging and laboratory evaluation aid in diagnosis. [19] (10.1016/j.hcl.2020.03.002)
  • [L5] [21] (10.1016/j.jhsa.2019.04.011)
  • [L4] [22] (10.5811/cpcem.2018.3.37415)
  • [Paper] Despite timely and thorough treatment, severe infection can nevertheless lead to impaired function or even amputation of the affected digit. [24] (10.1055/s-0039-1700370)
  • [L4] [40] (10.1177/15589447211043187)
  • [L4] Vascular malformations in tendon sheaths can present as tenosynovitis, creating a diagnostic challenge; early diagnosis and treatment are necessary to prevent complications, and MRI may aid in preoperative diagnosis. [44] (10.1007/s11552-011-9384-y)
  • [L4] Preoperative imaging was useful in a case of chronic or severe tenosynovitis to assess the condition of flexor tendons, and wide-awake surgery was the appropriate procedure for the treatment of this case. [46] (10.1055/s-0038-1645951)

See Also

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[40] Antibiotics Versus Surgery in Treatment of Early Flexor Tenosynovitis. HAND. 2022. DOI: 10.1177/15589447211043187

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

[46] Flexor Tendon Entrapment Caused by Intratendinous Tumor-Like Chronic Proliferative Tenosynovitis. Journal of Hand and Microsurgery. 2019. DOI: 10.1055/s-0038-1645951

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.