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Sagittal Band Rupture (Boxer's Knuckle)

Sagittal band injury with extensor subluxation: Rayan-Murray classification, relative-motion splinting vs repair/reconstruction, boxer's knuckle vs spontaneous.

37 citationsUpdated Sep 2026
Illustration: Sagittal Band Rupture (Boxer's Knuckle)

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

Overview

Sagittal band rupture, commonly known as boxer's knuckle, involves injury to the radial sagittal band or extensor hood, leading to volar subluxation of the metacarpophalangeal (MCP) joint. Even minimal damage results in measurable subluxation, though the presence of 10% intact fibers confers some stability [10]. Dislocation may occur with partial division of the radial band [5]. Untreated or inadequately managed injuries can progress to extensor quadriga dysfunction, swan neck deformity, and joint contractures [6]. Early diagnosis and repair of acute, displaced injuries are associated with good outcomes [4].

Non-operative management is a reasonable first-line treatment, including for chronic incompetence [13]. MP joint blocking orthoses and MCP extension orthoses yield mostly satisfactory results, with 71% of patients achieving good to excellent outcomes or resolution of symptomatic translocation [11, 15]. Acute closed injuries in non-rheumatoid patients can be successfully treated conservatively with a sagittal band bridge, producing results comparable to surgery without scar formation [35]. However, manual labor, longer symptom duration, and grade III injury increase the likelihood of treatment failure in nonsurgical cases [15].

Surgical intervention is recommended when non-operative measures fail or for chronic injuries [21]. The treatment of choice is centralization of the extensor tendon and sagittal band repair [1], often involving repair or reconstruction of the radial band with adjunctive techniques to prevent subluxation [7]. An anomalous extensor tendon slip may serve as a resource for reconstruction [14]. Precisely executed operative treatment allows the vast majority of boxers to return to competition with pain relief and restored function [2, 8]. Specific rehabilitation principles enable return to the highest level of competition [20], with documented cases of championship defense 10 months post-surgery [9]. Surgical repair of complete tears in the acute setting may improve results for subacute-to-chronic grade III injuries in lesser digits [90]. Relative motion splinting in lacerated extensor tendons permits 98% recovery of flexion and 96% recovery of total active motion [26].

Anatomy & Pathophysiology

Sagittal Band Anatomy and Function

The sagittal bands consist of transverse, sagittal, and oblique fibers [18]. These structures stabilize the extensor digitorum communis (EDC) tendon over the midline of the metacarpophalangeal (MCP) joint [39]. The fibers insert onto the volar proximal phalanx and the lateral borders of the volar plate [39]. By forming a sling, the sagittal bands transmit proximal extrinsic extensor tension to the proximal phalanx, permitting MCP joint extension without a direct tendinous insertion onto the bone [39]. This mechanism holds the extrinsic extensor tendon balanced over the metacarpal head prominence, keeping it as far as possible from the MCP joint center of rotation to maximize mechanical efficiency [39]. Anatomically, the deep fibers of the superficial palmar fascia continue dorsally to merge with sagittal interosseous fascia fibers. These fibers pierce the transverse deep intermetacarpal ligament to merge with the extensor mechanism’s sagittal bands [59]. The MCP joint is further stabilized by collateral ligaments and the thick volar articular capsule, or volar plate, which serves as the insertion site for the lateral accessory ligaments, sagittal bands, and the first annular segment of the flexor tendon pulley [52].

Mechanism of Injury

Boxer's knuckle specifically refers to an injury or tear of the MCP joint capsule, a term often associated with or confused for sagittal band injuries [16]. These injuries are most commonly attritional, resulting from repetitive trauma and progressive capsular attenuation [16]. Forceful hyperflexion of the MCP joint tensions the capsule and extensor hood over the narrow dorsal ridge of the metacarpal head, rendering the structure vulnerable to injury from a direct blow [16]. Athletes competing in boxing, martial arts, or other combat sports are at particular risk [16]. The sagittal bands can also be injured by blunt trauma over the MCP joint during a clenched fist impact [18]. Dislocation may occur when the radial sagittal band is only partially divided [5].

Pathophysiology and Clinical Presentation

Rupture or attenuation of the sagittal band fibers allows the extrinsic extensor tendon to sublux to the ulnar side of the metacarpal head, causing ulnar deviation of the finger [39]. This painful EDC tendon subluxation results in an inability to achieve active extension of the finger at the MCP joint [18]. Patients with EDC tendon subluxation cannot obtain but can maintain extension at the MCP joint [18]. The central rays are more often affected due to more prominent bony structure, thinner superficial tissue, longer radial fibers, and single extensor tendons [18].

Clinical Examination Findings: * Weakness of MCP joint extension in the affected digit [18]. * Painful tendon subluxation, usually in an ulnar direction [18]. * Tenderness over the injured sagittal band [18]. * A subtle but detectable defect in the dorsal joint capsule, often palpable radial, ulnar, or deep to the extensor tendon, which is the hallmark examination finding [16].

Athletes can present with an acute or chronic injury [18]. They often delay presentation until the injury affects performance, such as after recurrent injuries and worsening symptoms [16]. Chronic injuries may exhibit thickening of the extensor mechanism on examination due to scar tissue formation [16]. An extensor tendon and/or sagittal band injury may lead to volar subluxation of the MCP joints [6], extensor quadriga [6], swan neck deformity [6], or subsequent joint contractures [6].

Classification

2022 Review Modification: A 2022 review describes a modification to the most prevalent classification system for sagittal band injuries to guide treatment and allow standardization in documenting and describing injuries [3].

1957 Classification: The 1957 paper presents a classification of injuries to boxers' knuckles based on limited observations, ranging from soft tissue thickening to tears extending into the joint space [19].

Other Considerations: The term "boxer's knuckle" reflects injury specifically to the MCP joint capsule, which is important because surgery is typically recommended for symptomatic capsular tears [16]. Boxer's knuckle refers to an injury or tear of the MCP joint capsule, which is often associated with or confused for sagittal band injuries [16]. A boxer's knuckle also refers to an injury of the sagittal band, which is the structure that normally keeps the extensor digitorum communis (EDC) tendon centralized over the metacarpal head at the level of the MCP joint [18]. Injuries are most commonly attritional because of repetitive trauma and progressive capsular attenuation [16]. Athletes competing in boxing, martial arts, or other combat sports are at particular risk for these injuries [16]. Grade III injury is associated with a higher likelihood of treatment failure in nonsurgically treated sagittal band injuries [15].

Clinical Presentation

Mechanism and Risk Factors

Boxer's knuckle refers to an injury or tear of the MCP joint capsule, a term often associated with or confused for sagittal band injuries [16]. These injuries are most commonly attritional, resulting from repetitive trauma and progressive capsular attenuation [16]. Forceful hyperflexion of the MCP joint, such as from a thrown punch, tensions the capsule and extensor hood over the narrow dorsal ridge of the metacarpal head, rendering the structure vulnerable to injury from a direct blow [16]. Athletes competing in boxing, martial arts, or other combat sports are at particular risk [16]. The rate of hand and wrist injuries is higher in competition than in training [22]. Six cases within the same family suggest a possible familial predisposition to extensor tendon dislocation, potentially due to a genetic weakness in the sagittal bands or common environmental factors, though the condition is not proven to be truly genetic [24].

Clinical Findings and Examination

Examination reveals weakness of MCP joint extension in the affected digit [18]. Painful EDC tendon subluxation can ensue, causing an inability to achieve active extension of the finger at the MCP joint, characterized by the inability to obtain but ability to maintain extension [18]. Painful tendon subluxation, usually in an ulnar direction, is evident on examination [18]. Tenderness over the injured sagittal band is also evident on examination [18].

Classification

A classification of injuries to boxers' knuckles based on limited observations ranges from soft tissue thickening to tears extending into the joint space [19]. A contemporary perspective on sagittal band injuries describes a modification to the most prevalent classification system to guide treatment and allow standardization in documenting and describing injuries [3].

Investigations

Clinical Examination

A careful physical examination is essential to direct care and determine the need for future testing [37]. The hallmark finding is a subtle but detectable defect in the dorsal joint capsule, which is often palpable radial, ulnar, or deep to the extensor tendon [16]. Patients present with an inability to achieve active extension of the finger at the MCP joint, characterized by the inability to obtain but ability to maintain extension [18]. Weakness of MCPJ extension in the affected digit is evident on exam [18].

Imaging

Ultrasound: Ultrasound is a valuable adjunct to clinical examination in a specialist clinic, particularly for differentiating displaced from undisplaced tears, provided it is performed soon after presentation [44].

Plain radiography: The presence of a second small bone fragment, known as the 'two fleck sign', on X-ray may indicate a Stener lesion requiring surgical repair, which can be missed on initial evaluation [28]. Stress radiography should be performed cautiously in thumbs with a prominent radial condyle, as it may cause locking due to entrapment of the avulsed ligament or volar plate [84].

Treatment

Non-Operative

Sagittal band injuries without subluxation or dislocation are managed with MCPJ extension splinting while leaving the PIP joint free [18]. In cases of chronic sagittal band incompetence, splintage remains a reasonable first-line treatment before advising surgical intervention [13]. Conservative management may be attempted for frank EDC subluxation or dislocation, although reported results in the literature are mixed [18]. This feasibility is particularly relevant for the middle and ring fingers, where dislocation may occur even when the radial sagittal band is only partially divided [5]. Biomechanical data indicate that even minimal sagittal band damage results in measurable subluxation, but the presence of even 10% intact fibers confers some stability against subluxation [10].

Operative

Indications: Centralization of the extensor tendon and sagittal band repair is the recommended treatment of choice for this injury [1]. Surgical intervention is also indicated in chronic cases where residual ligament retraction or significant attenuation limits primary repair [17].

Surgical Approach / Technique: A reproducible technique for treating these injuries is described, allowing patients to return to boxing with little risk of complications [8]. Precisely executed operative treatment of both injuries has resulted in expectant favorable outcomes, with the vast majority of boxers experiencing relief of pain, restoration of function, and an unrestricted return to competition [2].

Other Considerations: Clinical outcomes demonstrate that patients can successfully return to high-level competition following repair; one patient returned to boxing at 4 months postsurgery and defended his third national championship 10 months after surgery [9].

Post-Operative Care and Rehabilitation

MCPJ immobilization is required after repair or reconstruction to allow adequate healing, after which aggressive range of motion exercises can be initiated [18]. Athletes must be cautioned against returning to sports too quickly to prevent wound complications and recurrence [18]. The hand therapist’s role in this process remains a critical component contributing to satisfactory outcomes [42].

Complications

Patellar / Extensor-mechanism: Chronic sagittal band injuries may exhibit thickening of the extensor mechanism on examination due to scar tissue formation [16].

Wound complications: Athletes returning to sports too quickly after surgical repair or reconstruction are at risk for wound complications and recurrence [18].

Recovery

Operative Outcomes: A reproducible surgical technique for treating extensor hood injuries in elite boxers allows patients to return to boxing with little risk of complications [8]. In a case study of traumatic extensor tendon dislocation in a boxer, the patient successfully returned to boxing at 4 months postsurgery and defended his third national championship 10 months after surgery [9]. In a series of 180 patients with lacerated extensor tendons, relative motion splinting permitted 98% recovery of flexion and 96% recovery of total active motion compared with the normal uninjured side [26]. When a ligament is determined to be repairable based on intraoperative findings, reinsertion on bone provides satisfactory and long-lasting stabilization of the MCP joint even if the procedure is not done immediately after the injury occurs [47]. After a 40-month follow-up for 35 acute, subacute, and chronic cases, direct and suture-anchor repairs are feasible, painless treatments associated with good finger function [85]. All collateral ligament avulsion fractures of the base of the proximal phalanx treated with Kirschner wire stabilization healed with no instability observed at final follow-up [87].

Prognostic Factors and Complications: Six cases of extensor tendon dislocation in the same family suggest a possible familial predisposition, potentially due to a genetic weakness in the sagittal bands or common environmental factors, though the condition is not proven to be truly genetic [24]. Delay in primary repair does not necessarily result in poor patient-reported outcomes [93].

Key Evidence

  • [L4] The authors recommend centralization of the extensor tendon and sagittal band repair as the treatment of choice for this injury. [1] (10.1177/03635465000280061701)
  • [L4] Precisely executed operative treatment of both injuries has resulted in an expectant favorable outcome, as in the vast majority of cases the boxers have experienced relief of pain, restoration of function, and an unrestricted return to competition. [2] (10.1016/j.csm.2009.06.004)
  • [L4] This review provides a contemporary perspective on sagittal band injuries and describes a modification to the most prevalent classification system to guide treatment and allow standardization in documenting and describing injuries. [3] (10.1016/j.jhsa.2021.09.011)
  • [L4] Early diagnosis and repair of an acute, displaced, complete radial collateral ligament avulsion with injury to the sagittal band of the small finger MCP joint is associated with good outcome. [4] (10.1007/s11552-008-9087-1)
  • [L5] Dislocation may occur when the radial sagittal band is only partially divided, which may explain why conservative treatment of tendon dislocation in the middle and ring fingers is feasible. [5] (10.1177/1753193420963257)
  • [Paper] An extensor tendon and/or sagittal band injury may lead to a number of complications including volar subluxation of the MCP joints, extensor quadriga, swan neck deformity, and subsequent joint contractures. [6] (10.1007/s12593-015-0172-8)
  • [L5] Surgical management consists of repair or reconstruction of the radial sagittal band, with numerous adjunctive techniques described to prevent subluxation. [7] (10.5435/jaaos-d-13-00203)
  • [L4] A reproducible technique for treating these injuries is described, with patients able to return to boxing with little risk of complications. [8] (10.1177/17531934221123139)
  • [L5] The patient successfully returned to boxing at 4 months postsurgery and defended his third national championship 10 months after surgery. [9] (10.1249/01.mss.0000089340.89660.eb)
  • [L5] Even minimal sagittal band damage results in measurable subluxation, but the presence of even 10% intact fibers confers some stability against subluxation. [10] (10.1016/j.jhsa.2025.04.026)
  • [L4] MP joint blocking orthosis for sagittal band injury led to mostly satisfactory results, with 71% of patients achieving good to excellent outcomes. [11] (10.1016/j.jhsa.2018.06.113)
  • [L4] Even in patients with chronic sagittal band incompetence, splintage is a reasonable first line of treatment before advising surgical intervention. [13] (10.1177/1753193414530591)
  • [L4] An anomalous slip of the extensor tendon to the middle finger can be a resource for surgical reconstruction that adds stability to primary sagittal band repair. [14] (10.1016/j.jhsa.2012.05.029)
  • [L4] An MCP extension orthosis for sagittal band injury led to mostly satisfactory results with 71% of patients achieving resolution of symptomatic tendon translocation, but manual labor, longer symptom duration, and grade III injury were associated with a higher likelihood of treatment failure. [15] (10.1016/j.jhsa.2018.11.011)
  • [L5] [16] (10.5435/jaaos-d-21-01031)
  • [L5] This technique may be especially useful in chronic cases where the residual ligament may have retracted or attenuated significantly, limiting primary repair. [17] (10.1016/j.jhsg.2026.101050)
  • [L5] [18] (10.1186/s13018-016-0432-8)
  • [L4] The paper presents a classification of injuries to boxers' knuckles based on limited observations, ranging from soft tissue thickening to tears extending into the joint space. [19] (10.1016/0002-9610(57)90828-0)
  • [L4] Our case demonstrates that if certain surgical and rehabilitation principles are applied, boxers can return to the highest level of competition following extensor hood rupture. [20] (10.1007/s11552-008-9154-7)
  • [L4] Patients with chronic injuries or those failing nonoperative management may benefit from surgical exploration. [21] (10.1177/1558944719895622)
  • [L3] The rate of hand and wrist injuries was higher in competition than in training. [22] (10.1177/1558944716642756)
  • [L4] Six cases in the same family suggest a possible familial predisposition to extensor tendon dislocation, potentially due to a genetic weakness in the sagittal bands or common environmental factors, though the condition is not proven to be truly genetic. [24] (10.1177/1753193413489083)
  • [L4] In a series of 180 patients with 1 to 3 lacerated extensor tendons studied over a 10-year interval, relative motion splinting permitted 98% recovery of flexion and 96% recovery of total active motion compared with the normal uninjured side. [26] (10.1053/oa.2000.5972)
  • [L5] The presence of a second small bone fragment ('two fleck sign') on X-ray may indicate a Stener lesion requiring surgical repair, which can be missed on initial evaluation. [28] (10.1177/1753193408087106)
  • [L4] The study supported the hypothesis that acute closed sagittal band injuries in non-rheumatoid patients can be successfully treated with conservative management using a sagittal band bridge, producing results comparable to surgical reconstruction without associated scar formation. [35] (10.1197/j.jht.2006.11.007)
  • [L5] The hand therapist's role in this process remains a critical component contributing to satisfactory outcomes. [42] (10.1016/j.jht.2011.10.004)
  • [L2] Ultrasound is a valuable adjunct to clinical examination in a specialist clinic, particularly for differentiating displaced from undisplaced tears, provided it is performed soon after presentation. [44] (10.1054/jhsb.1999.0283)
  • [Paper] When a ligament is determined to be repairable based on intraoperative findings, reinsertion on bone provides satisfactory and long-lasting stabilization of the MCP joint even if the procedure is not done immediately after the injury occurs. [47] (10.1016/j.otsr.2021.102969)
  • [L4] The case suggests that stress radiography should be performed cautiously in thumbs with a prominent radial condyle, as it may cause locking due to entrapment of the avulsed ligament or volar plate. [84] (10.1007/s00402-009-0933-6)
  • [L4] After a 40-month follow-up for 35 acute, subacute, and chronic cases, the results suggest that direct and suture-anchor repairs are feasible, painless treatments associated with good finger function. [85] (10.1186/s12891-022-05605-1)
  • [L4] All fractures healed with no instability observed at final follow-up. [87] (10.1177/1753193410381676)
  • [L4] Surgical repair of complete tears in the acute setting may be more appropriate to improve results. [90] (10.1016/j.jhsa.2013.08.039)
  • [L2] Delay in primary repair does not necessarily result in poor patient-reported outcomes. [93] (10.1016/j.jhsa.2023.05.003)

References

[1] Boxer's Knuckle in the Professional Athlete. The American Journal of Sports Medicine. 2000. DOI: 10.1177/03635465000280061701

[2] Disabling Hand Injuries in Boxing: Boxer's Knuckle and Traumatic Carpal Boss. Clinics in Sports Medicine. 2009. DOI: 10.1016/j.csm.2009.06.004

[3] Sagittal Band Injuries: A Review and Modification of the Classification System. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2021.09.011

[4] A Complete Radial Collateral Ligament Avulsion of the Small Finger Metacarpophalangeal Joint with Displacement through the Radial Sagittal Band. HAND. 2008. DOI: 10.1007/s11552-008-9087-1

[5] Functional anatomy of the sagittal bands and mechanisms of extensor tendon dislocation: a cadaveric study. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420963257

[6] Relationship Between Juncturae Tendinum and Sagittal Bands. Journal of Hand and Microsurgery. 2015. DOI: 10.1007/s12593-015-0172-8

[7] Closed Sagittal Band Injury of the Metacarpophalangeal Joint. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-d-13-00203

[8] Extensor hood injuries in elite boxers: injury characteristics, surgical technique and outcomes. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221123139

[9] Traumatic Extensor Tendon Dislocation in a Boxer: A Case Study. Medicine & Science in Sports & Exercise. 2003. DOI: 10.1249/01.mss.0000089340.89660.eb

[10] The Association Between the Extent of Sagittal Band Disruption and Extensor Tendon Subluxation in Different Flexion Angles: A Cadaveric Study. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2025.04.026

[11] Prognostic Factors for Conservatively Treated Sagittal Band Injuries of the Metacarpophalangeal Joint. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.06.113

[13] Splintage in the treatment of sagittal band incompetence and extensor tendon subluxation. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414530591

[14] Anomalous Tendon to the Middle Finger for Sagittal Band Reconstruction: Report of 2 Cases. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.05.029

[15] Prognostic Factors for Nonsurgically Treated Sagittal Band Injuries of the Metacarpophalangeal Joint. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.11.011

[16] Finger Metacarpophalangeal Joint Injuries in Athletes: Evaluation, Diagnosis, Treatment, and Return to Play. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-21-01031

[17] Use of Internal Brace for the Surgical Management of the “Baby Stener” Lesion of the Radial Collateral Ligament to the Small Finger. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2026.101050

[18] Sports-related wrist and hand injuries: a review. Journal of Orthopaedic Surgery and Research. 2016. DOI: 10.1186/s13018-016-0432-8

[19] Boxer's knuckle. The American Journal of Surgery. 1957. DOI: 10.1016/0002-9610(57)90828-0

[20] Traumatic Extensor Hood Rupture. HAND. 2008. DOI: 10.1007/s11552-008-9154-7

[21] Treatment of Sagittal Band Injuries and Extensor Tendon Subluxation: A Systematic Review. HAND. 2020. DOI: 10.1177/1558944719895622

[22] Hand and Wrist Injuries in Elite Boxing. HAND. 2016. DOI: 10.1177/1558944716642756

[24] Extensor tendon dislocation of the hand: six cases in a family. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413489083

[26] Achieving immediate active motion by using relative motion splinting after long extensor repair and sagittal band ruptures with tendon subluxation. Operative Techniques in Plastic and Reconstructive Surgery. 2000. DOI: 10.1053/oa.2000.5972

[28] The ‘‘Two Fleck Sign’’ for an Occult Stener Lesion. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408087106

[35] Closed Treatment of Nonrheumatoid Extensor Tendon Dislocations at the Metacarpal Joint. Journal of Hand Therapy. 2007. DOI: 10.1197/j.jht.2006.11.007

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

[39] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > Image DISORDERS OF THE MUSCULATURE OF THE HAND.

[42] Managing the Injured Tendon: Current Concepts. Journal of Hand Therapy. 2012. DOI: 10.1016/j.jht.2011.10.004

[44] The Use of Ultrasound in the Diagnosis of Injuries of the Ulnar Collateral Ligament of the Thumb. Journal of Hand Surgery. 2000. DOI: 10.1054/jhsb.1999.0283

[47] Surgical treatment of chronic instability of the metacarpophalangeal finger joint based on the intraoperative condition of the collateral ligament: Results of a single-center study with 7 years’ follow-up. Orthopaedics & Traumatology: Surgery & Research. 2021. DOI: 10.1016/j.otsr.2021.102969

[52] Exam Of The Hand Wrist 2Ed. The arches of the hand > The metacarpal arch.

[59] Green S Operative Hand Surgery. PERTINENT ANATOMY.

[84] Locking of the metacarpophalangeal joint of the thumb with the radial collateral ligament rupture after stress radiography. Archives of Orthopaedic and Trauma Surgery. 2009. DOI: 10.1007/s00402-009-0933-6

[85] Midterm clinical outcomes of collateral ligament repair of the thumb and lesser digits: a retrospective analysis of 35 cases. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05605-1

[87] Kirschner wire stabilization of collateral ligament avulsion fractures of the base of the proximal phalanx. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193410381676

[90] Outcomes After Repair of Subacute-to-Chronic Grade III Metacarpophalangeal Joint Collateral Ligament Injuries in the Lesser Digits Are Poor. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.08.039

[93] Patient-Reported Outcomes and Function After Surgical Repair of the Ulnar Collateral Ligament of the Thumb. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2023.05.003

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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.