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Infected Flexor Sheath (Pyogenic Flexor Tenosynovitis)

38 citationsUpdated Oct 2026
Illustration: Infected Flexor Sheath (Pyogenic Flexor Tenosynovitis)

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Overview

Pyogenic flexor tenosynovitis is a closed-space infection of the finger or thumb flexor tendon sheath or the radial and ulnar bursae [9]. Although described as uncommon [3], it is a relatively common but often misdiagnosed hand infection [6]. The condition may present with uniform finger swelling, though this finding does not appear to distinguish pyogenic flexor tenosynovitis from other finger infections [10]. Ultrasound serves as a useful diagnostic tool for managing early cases due to its excellent negative predictive value and specificity [8].

The consequences of untreated or delayed management include destruction of the tendon sheath, scarring, inflammation causing oedema of the soft tissues of the finger with resultant finger stiffness, or occasionally compartment syndrome [13]. Even in otherwise healthy patients who receive aggressive and prompt antibiotic therapy and surgical intervention, some residual digital stiffness is expected following flexor tendon sheath infection [4]. The presence of pus within the flexor sheath is the only significant predictive factor for repeated flexor tendon washout [15].

Surgical decompression is the treatment of choice for nearly all cases of septic flexor tenosynovitis, with expediency potentially improving final motion and function [2]. Studies demonstrate benefits of early treatment and systemic antibiotic use [5]. Early diagnosis followed by drainage through small incisions and continuous postoperative irrigation appears to lead to the best functional outcome [18]. A single open debridement with irrigation and primary wound closure followed by 10 days of antibiotic therapy has resolved uncomplicated cases [1]. Limited flexor sheath incision and drainage in the emergency department provides a potential safe and effective way to manage patients with early flexor tenosynovitis [19]. No complications were experienced in managing pyogenic flexor tenosynovitis through closed continuous irrigation with lidocaine and immediate mobilization [11].

Anatomy & Pathophysiology

Anatomy

The flexor tendon sheath contains the flexor tendons and extends from the distal interphalangeal joint proximally to the A1 pulley [25]. The fibroosseous tunnel, or digital flexor sheath, extends distally to the proximal aspect of the distal phalanx [63]. The synovial sheath comprises a visceral and parietal component separated by a potential synovial cavity containing a very thin layer of synovial fluid [64]. This structure allows a considerable amplitude of movement for the flexor tendons [64]. The tenosynovium lining the fibroosseous tunnel supplies nutrition and lubrication to the poorly vascularized flexor tendons [63]. Within the sheath, tendon vascularity is supplied via the vincula system, specifically the vinculum longus and brevis [63]. The A2 and A4 pulleys are the most essential in maintaining the mechanical advantage of the flexor tendons [63].

The thumb flexor tendon sheath is contiguous with the radial bursa [25, 63]. The small finger sheath is contiguous with the ulnar bursa [25, 63]. The radial and ulnar bursae communicate via Parona's space [25]. In some patients, the radial and ulnar bursae communicate, allowing a horseshoe abscess to spread between the thumb and little finger [63]. The radial and ulnar bursae extend up to the carpal tunnel in up to 80% of people [25].

Pathophysiology

Pyogenic flexor tenosynovitis is a bacterial infection of the flexor tendon sheath between the visceral layer on the flexor tendon and the parietal layer [25]. It is a closed-space infection of the hand that can result in severe stiffness and other sequela [3]. The condition is most commonly associated with S. aureus after a penetrating trauma [25]. Local inoculation via lacerations, puncture wounds, and bites are more common causes than hematogenous spread [36]. Pyogenic flexor tenosynovitis can also be caused by hematogenous spread [36].

Pus in hand infections is a mixture of bacterial virulence factors, neutrophil-derived degranulation and netosis, dead and dying pathogens, defensive neutrophils, other immune cell types, and dead and dying host structural cells [47]. Infections can spread to the radial and ulnar bursa connections, resulting in a horseshoe abscess [25]. Proximal spread of infection into Parona's space can occur [25].

Pyogenic flexor tenosynovitis can result in tendon necrosis and adhesions leading to marked loss of motion, deformity, and loss of limb, particularly if treatment is delayed [16]. The most common adverse sequelae of acute pyogenic flexor tenosynovitis are loss of digital range of motion and persistent infection [41]. Loss of motion occurs in 10% to 25% of patients with acute pyogenic flexor tenosynovitis [41]. Persistent infection is reported in up to 9% of cases of acute pyogenic flexor tenosynovitis [41]. Persistent infection is more common in patients with purulent exudate discovered intraoperatively, with a 20% incidence [41]. Other reported complications of acute pyogenic flexor tenosynovitis include tendon necrosis with rupture, skin and soft tissue loss necessitating flap coverage, and amputation [41]. Despite aggressive and prompt antibiotic therapy and surgical intervention, otherwise healthy patients can expect some residual digital stiffness following flexor tendon sheath infection [4].

Classification

Three-Tier Clinical Classification: 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 of the upper extremity [7].

Kanavel’s Cardinal Signs: Kanavel’s 4 cardinal symptoms and signs of pyogenic flexor tenosynovitis include exquisite tenderness over the course of the sheath, limited to the sheath [25]. The signs also include a semiflexed position of the finger [25]. Exquisite pain on extending the finger, most marked at the proximal end where definite swelling often may be seen, is a third cardinal sign [25]. The fourth sign is symmetrical swelling of the entire finger [25]. Not all of Kanavel's signs will be present, but when flexor tenosynovitis is suspected, treatment should be instituted immediately to prevent disastrous complications [25].

Other Considerations: The flexor tendon sheath runs from the distal interphalangeal joint proximally to the A1 pulley [25]. The thumb flexor tendon sheath and the radial bursa are contiguous [25]. The small finger sheath and ulna bursa are contiguous [25]. The radial and ulna bursae communicate via Parona's space [25]. The radial and ulna bursae extend up to the carpal tunnel in up to 80% of people [25]. Infections can spread to the radial and ulna bursae connections, with spread to small finger flexor tendon sheaths, resulting in a horseshoe abscess [25]. Proximal spread into Parona's space can occur [25]. In one large series, pyogenic flexor tenosynovitis was reported to represent 9.4% (13/138) of hand infections [16]. CT measurements, specifically the tendon sheath to tendon ratio, can differentiate FTS from finger cellulitis with high sensitivity and specificity [24].

Clinical Presentation

Definition and Epidemiology

Pyogenic flexor tenosynovitis is an infection of the flexor tendon sheath of the finger [16]. If treatment is delayed, the condition can result in tendon necrosis and adhesions, leading to marked loss of motion, deformity, and loss of limb [16].

Clinical Signs and Symptoms

The diagnosis relies on identifying specific clinical signs. Kanavel described three cardinal signs: 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 [16]. Kanavel further noted that the whole of the involved finger is uniformly swollen [16]. These observations are consolidated into four cardinal symptoms and signs: exquisite tenderness over the course of the sheath limited to the sheath, a semiflexed position of the finger, exquisite pain on extending the finger most marked at the proximal end where definite swelling often may be seen, and symmetrical swelling of the entire finger [25]. Not all of Kanavel's signs will be present when flexor tenosynovitis is suspected [25].

Diagnostic Evaluation

Hand and upper-extremity infections are usually a clinical diagnosis, but imaging and laboratory evaluation aid in diagnosis [28]. Commonly used inflammatory blood markers, including WBC, ESR, and CRP, may be helpful in diagnosing purulent flexor tenosynovitis; if elevated, the likelihood of infection is extremely high [87]. CT measurements, specifically the tendon sheath to tendon ratio, can differentiate flexor tenosynovitis from finger cellulitis with high sensitivity and specificity [24].

Investigations

Clinical Examination

A careful physical examination is essential to direct care and future testing if indicated [33]. Early recognition and clinical suspicion remain paramount to minimizing potentially devastating consequences from delayed treatment of these infections [16]. Dr Allen B. Kanavel initially described three cardinal signs of pyogenic flexor tenosynovitis in 1912: 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 [16]. Kanavel explained that "the whole of the involved finger is uniformally swollen," although this was not noted in his initial description as a cardinal sign [16].

Imaging

MRI: MRI may aid in preoperative diagnosis of vascular malformations in tendon sheaths that present as tenosynovitis [93]. Preoperative imaging was useful in a case of chronic or severe tenosynovitis to assess the condition of flexor tendons [101].

Laboratory and Pathology

Laboratory: Three patients presented with classic signs and symptoms of acute bacterial tenosynovitis, but the inflammatory condition was found to be sterile in each instance [17].

Treatment

Non-Operative

While early recognition and clinical suspicion are paramount to minimizing potentially devastating consequences from delayed treatment [16], and systemic antibiotic use shows benefits [5], surgical decompression remains the treatment of choice for nearly all cases of septic flexor tenosynovitis [2]. There is no standardized treatment algorithm regarding the need for, timing, or type of surgical treatment [36].

Operative

Indications: Management of pyogenic flexor tenosynovitis includes prompt administration of empirical intravenous antibiotics and often surgical treatment [36]. When flexor tenosynovitis is suspected, treatment should be instituted immediately to prevent disastrous complications including tendon adhesions or necrosis [25]. Expediency in treatment potentially improves final motion and function [2].

Surgical Approach / Technique: Early diagnosis followed by drainage through small incisions and continuous postoperative irrigation appears to lead to the best functional outcome [18]. Limited flexor sheath incision and drainage in the emergency department provides a potential safe and effective way to manage patients with early flexor tenosynovitis [19]. For mycobacterial flexor tenosynovitis, immediate operative debridement and flexor sheath irrigation, followed by a full course of antimycobacterial antibiotic therapy managed by an infectious disease specialist, optimize chances of acceptable functional outcome and infection eradication [14]. Successful management of Mycobacterium asiaticum flexor tenosynovitis included radical flexor tenosynovectomy and therapy with oral minocycline and clarithromycin [32]. Treatment of Candida albicans tenosynovitis was successful after radical synovectomy of both the flexor and extensor aspects of the hand after failure to respond to combined amphotericin B and 5-fluorouracil therapy [53]. Standard two-stage flexor tendon reconstruction is a reasonable option once tuberculous infection has been adequately treated and is not associated with recurrence of that infection [23]. The disease will respond to a combined treatment of tendon sheath drainage, irrigation, and antibiotics, whereas antibiotics alone may be insufficient for acute gonococcal flexor tenosynovitis [98].

Postoperative Care: Continuous postoperative catheter irrigation is not necessary for the treatment of suppurative flexor tenosynovitis, as there were no statistically significant differences in outcomes between patients receiving intraoperative irrigation only and those receiving both intraoperative and continuous postoperative irrigation [72].

Outcomes: The advent of antibiotics and appropriate surgical treatment has decreased the risk of serious sequelae secondary to pyogenic flexor tenosynovitis [16]. Complication rates for pyogenic flexor tenosynovitis can be high, leading to impaired function and even amputation of the affected digit, despite prompt treatment [36]. Flexor tenosynovitis along with proper antibiotic treatment resulted in complete resolution in a patient with chronic tenosynovitis caused by Actinobacillus actinomycetemcomitans [21].

Complications

Stiffness / Arthrofibrosis: Pyogenic flexor tenosynovitis frequently results in severe stiffness and other sequelae [3]. Even in otherwise healthy patients, residual digital stiffness is expected following flexor tendon sheath infection, despite aggressive and prompt antibiotic therapy and surgical intervention [4]. This stiffness arises from scarring and inflammation causing oedema of the soft tissues of the finger [13].

Tissue Destruction: The consequences of pyogenic flexor tenosynovitis can include destruction of the tendon sheath [13]. In severe cases, despite timely and thorough treatment, infection can lead to impaired function or even amputation of the affected digit [37]. Pyogenic flexor tenosynovitis can also lead to digital ischaemic necrosis and amputation [13, 6].

Compartment Syndrome: Pyogenic flexor tenosynovitis can result in compartment syndrome [13].

Other Considerations: A rare complication of acute pyogenic flexor tenosynovitis is the isolation of Nocardia nova from the affected digit approximately 6 weeks after surgical treatment [46].

Recovery

Other Considerations: The consequences of pyogenic flexor tenosynovitis can include destruction of the tendon sheath, scarring and inflammation causing oedema of the soft tissues of the finger with resultant finger stiffness or, occasionally, compartment syndrome [13]. Expediency in surgical decompression potentially improves final motion and function [2].

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)
  • [L5] Surgical decompression is the treatment of choice for nearly all cases of septic flexor tenosynovitis, with expediency potentially improving final motion and function. [2] (10.1016/j.jhsa.2010.11.033)
  • [L5] Pyogenic flexor tenosynovitis (PFT) is an uncommon closed-space infection of the hand that can result in severe stiffness and other sequela. [3] (10.2106/jbjs.rvw.26.00015)
  • [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. [4] (10.5435/jaaos-20-06-373)
  • [L3] The studies showed benefits of early treatment of pyogenic flexor tenosynovitis and of systemic antibiotic use. [5] (10.1177/1753193415570248)
  • [L5] Pyogenic flexor tenosynovitis is a relatively common but often misdiagnosed hand infection. [6] (10.1136/bcr-2012-006778)
  • [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. [7] (10.2106/jbjs.f.01356)
  • [L2] Ultrasound is useful as a diagnostic tool for managing early pyogenic flexor tenosynovitis thanks to its excellent negative predictive value and specificity. [8] (10.1016/j.hansur.2017.12.004)
  • [L5] Pyogenic flexor tenosynovitis is a closed-space infection of the finger or thumb flexor tendon sheath or the radial and ulnar bursae. [9] (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. [10] (10.1016/j.jhsa.2019.01.013)
  • [L4] No complications were experienced in managing pyogenic flexor tenosynovitis through this approach. [11] (10.1097/bth.0000000000000164)
  • [L5] The consequences of pyogenic flexor tenosynovitis can be destruction of the tendon sheath, scarring and inflammation causing oedema of the soft tissues of the finger with resultant finger stiffness or, occasionally, compartment syndrome. [13] (10.1016/j.jhsb.2006.02.019)
  • [Case_report] Immediate operative debridement and flexor sheath irrigation, followed by a full course of antimycobacterial antibiotic therapy managed by an infectious disease specialist, optimize chances of acceptable functional outcome and infection eradication. [14] (10.1016/j.jhsa.2012.11.011)
  • [Paper] The presence of pus within the flexor sheath is the only significant predictive factor for repeated flexor tendon washout. [15] (10.1055/s-0040-1715556)
  • [L5] [16] (10.1007/s11999-015-4367-x)
  • [L4] Three patients presented with classic signs and symptoms of acute bacterial tenosynovitis, but the inflammatory condition was found to be sterile in each instance. [17] (10.1016/s0363-5023(86)80122-8)
  • [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. [18] (10.1177/1753193408087071)
  • [L4] Limited flexor sheath I&D in the ED provides a potential safe and effective way to manage patients with early flexor tenosynovitis. [19] (10.1177/1558944721999729)
  • [L5] Flexor tenosynovitis along with proper antibiotic treatment resulted in complete resolution in this patient. [21] (10.1016/s0363-5023(87)80294-0)
  • [L4] Standard two-stage flexor tendon reconstruction is a reasonable option once the tuberculous infection has been adequately treated and is not associated with recurrence of that infection. [23] (10.1177/1753193409360604)
  • [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. [24] (10.1177/15589447221092058)
  • [L5] [25] (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. [28] (10.1016/j.hcl.2020.03.002)
  • [L5] Successful management included radical flexor tenosynovectomy and therapy with oral minocycline and clarithromycin. [32] (10.1016/s0363-5023(98)80066-x)
  • [L5] [36] (10.1016/j.jhsa.2019.04.011)
  • [Paper] [37] (10.1055/s-0039-1700370)
  • [L4] [41] (10.1097/bth.0b013e3181bef5a3)
  • [L4] This case is unique in that the patient experienced a rare complication of acute pyogenic flexor tenosynovitis with a previously unreported organism isolate of Nocardia nova cultured from the affected digit approximately 6 weeks after surgical treatment. [46] (10.1016/j.jhsa.2017.11.016)
  • [L5] [47] (10.1177/17531934231174819)
  • [L5] Treatment was successful after radical synovectomy of both the flexor and extensor aspects of the hand after he failed to respond to combined amphotericin B and 5-fluorouracil therapy. [53] (10.1016/s0363-5023(85)80217-3)
  • [L3] [72] (10.1054/jhsb.2000.0400)
  • [L3] Commonly used inflammatory blood markers (WBC, ESR, and CRP) may be helpful in diagnosing purulent flexor tenosynovitis; if elevated, the likelihood of infection is extremely high. [87] (10.1016/j.jhsa.2013.08.094)
  • [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. [93] (10.1007/s11552-011-9384-y)
  • [L5] The disease will respond to a combined treatment of tendon sheath drainage, irrigation, and antibiotics, where as antibiotics alone may be insufficient. [98] (10.1016/s0363-5023(81)80106-2)
  • [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. [101] (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] Septic Flexor Tenosynovitis. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2010.11.033

[3] Management of Pyogenic Flexor Tenosynovitis. JBJS Reviews. 2026. DOI: 10.2106/jbjs.rvw.26.00015

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

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

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

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

[8] 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

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

[10] 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

[11] Closed Continuous Irrigation With Lidocaine and Immediate Mobilization for Treatment of Pyogenic Tenosynovitis. Techniques in Hand & Upper Extremity Surgery. 2017. DOI: 10.1097/bth.0000000000000164

[13] MRSA Pyogenic Flexor Tenosynovitis Leading to Digital Ischaemic Necrosis and Amputation. Journal of Hand Surgery. 2006. DOI: 10.1016/j.jhsb.2006.02.019

[14] Acute Mycobacterial Flexor Tenosynovitis Following Accidental Bacillus Calmette-Guérin Inoculation in a Health Care Worker: Case Report. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.11.011

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

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

[17] Sterile flexor tenosynovitis of the hand: A report of three cases. The Journal of Hand Surgery. 1986. DOI: 10.1016/s0363-5023(86)80122-8

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

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

[21] Chronic tenosynovitis caused by Actinobacillus actinomycetemcomitans. The Journal of Hand Surgery. 1987. DOI: 10.1016/s0363-5023(87)80294-0

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

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

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

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

[32] Flexor tenosynovitis due to Mycobacterium asiaticum. The Journal of Hand Surgery. 1998. DOI: 10.1016/s0363-5023(98)80066-x

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

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

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

[41] Use of Continuous Marcaine Irrigation in the Management of Suppurative Flexor Tenosynovitis. Techniques in Hand & Upper Extremity Surgery. 2009. DOI: 10.1097/bth.0b013e3181bef5a3

[46] A Rare Cause of Pyogenic Flexor Tenosynovitis: Nocardia nova. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2017.11.016

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

[53] Candida albicans tenosynovitis of the hand. The Journal of Hand Surgery. 1985. DOI: 10.1016/s0363-5023(85)80217-3

[63] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > FLEXOR TENDON INJURY.

[64] Exam Of The Hand Wrist 2Ed. 1.3 MOVEMENTS OF THE HAND AND WRIST > Gliding mechanisms.

[72] Continuous Postoperative Catheter Irrigation is not Necessary for the Treatment of Suppurative Flexor Tenosynovitis. Journal of Hand Surgery. 2000. DOI: 10.1054/jhsb.2000.0400

[87] The Diagnostic Accuracy of Inflammatory Blood Markers for Purulent Flexor Tenosynovitis. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.08.094

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

[98] Acute gonococcal flexor tenosynovitis-Case report and literature review. The Journal of Hand Surgery. 1981. DOI: 10.1016/s0363-5023(81)80106-2

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

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

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

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

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

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

5. Downstream recipients.

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

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

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

b. Other rights.

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

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

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

Section 3 -- License Conditions.

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

a. Attribution.

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

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

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

ii. a copyright notice;

iii. a notice that refers to this Public License;

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

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

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

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

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

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

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

Section 4 -- Sui Generis Database Rights.

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

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

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

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

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

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

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

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

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

Section 6 -- Term and Termination.

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

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

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

2. upon express reinstatement by the Licensor.

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

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

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

Section 7 -- Other Terms and Conditions.

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

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

Section 8 -- Interpretation.

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

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

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

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

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

Creative Commons may be contacted at creativecommons.org.