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Flexor Sheath Ganglion

Flexor tendon sheath ganglia (palmar A1-pulley seed cysts).

37 citationsUpdated Oct 2026
Illustration: Flexor Sheath Ganglion

Overview

Flexor sheath ganglions are fibrous lesions of the digital flexor tendon sheath, with distribution patterns characterized in a cohort of 57 patients [2]. The nerve supply to the flexor tendon within the digital sheath enters alongside the transverse branch of the digital artery via the digital nerve [8]. Ultrasound serves as a useful diagnostic tool to assist in identification and to determine whether patients should undergo aspiration or surgical excision [3]. Decision tree and Markov modeling approaches have accurately recreated the management of these lesions, mirroring observed clinical experience [1].

Management options include both nonsurgical and surgical interventions. A nonsurgical approach is both cost-effective and successful [5], with percutaneous puncture offering a practical option given its low cost, lack of downtime, and low recurrence rate [7]. In the cohort assessed for percutaneous puncture, no recurrences were observed after a second puncture [7]. Aspiration-puncture followed by 3 weeks of immobilization is successful in approximately 50% of cases for patients with carpal ganglions who wish to avoid or delay operative treatment [10]. The mid-axial route is a dependable site for drug infiltration into the flexor sheath and is devoid of complications if meticulous care is given during the procedure [11].

Surgical excision is a simple, safe, and effective method for treating painful ganglions of the digital flexor tendon sheath [4]. Ultrasound-guided excision using a 2-mm portal under local anaesthesia has proven reliable and efficient, without specific morbidity [6]. Arthroscopic resection was an effective treatment method for well-selected volar wrist ganglion arising from the radiocarpal joint in the long run [17]. In a series of 12 fingers, 92% achieved excellent or good results using the International Federation of Societies for Surgery of the Hand evaluation system [29, 55]. The importance of sheath closure at the time of tendon suture is based in part on evidence that diffusion is a significant nutrient pathway to the flexor tendon [27, 28]. The study suggests a need for one standard method of measurement and recording if a comparison of results after flexor tendon repair is to be of value [115].

Anatomy & Pathophysiology

Flexor Tendon Sheath & Pulley System

The fibroosseous tunnel, or digital flexor sheath, extends distally to the proximal aspect of the distal phalanx [65]. This tendinous sheath comprises annular pulleys that provide mechanical stability and cruciate pulleys that provide flexibility [65]. The first, third, and fifth annular pulleys (A1, A3, and A5) are located over the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints, respectively [65]. Conversely, the second and fourth pulleys (A2 and A4) are situated over the middle portion of the proximal and middle phalanges [65]. The A2 and A4 pulleys are the most essential in maintaining the mechanical advantage of the flexor tendons [65]. Anatomical studies have identified two annular and one oblique pulley in the thumb [85]. Repair or reconstruction of either the A1 or oblique pulley after injury will restore normal thumb kinematics [79].

Biomechanical data indicate that the force required to fully flex the digit decreased with more extensive A1 pulley release, becoming significant when more than 50% of the pulley was released [93]. At half the total tendon excursion, the force required to flex the digit through half its range is always less than a third of the force required to flex the digit fully [22].

Vascularization & Nerve Supply

The tenosynovium that lines the fibroosseous tunnel supplies both nutrition and lubrication to the poorly vascularized flexor tendons [65]. Within the sheath, tendon vascularity is supplied via the vincula system: the vinculum longus and brevis [65].

Pathophysiology & Biomechanics

Following injury, flexor tendon healing occurs through both extrinsic and intrinsic mechanisms [65]. Extrinsic tendon healing occurs via cells brought to the site of repair by ingrowth of capillaries and fibroblasts, followed by the formation of adhesions at the repair site [65]. Intrinsic healing occurs from tenocytes within the tendon [65]. The goal of flexor tendon repair and postoperative care is to encourage both intrinsic and extrinsic healing without the formation of thick adhesions, which would limit tendon excursion and result in restricted motion of the finger [65].

Flexor tendon force is highly dependent on wrist position and less so on the number of fingers manipulated [77]. In its interposed position between the anterior row of tendons and the transverse carpal ligament, the median nerve is subject to shearing and compression as the fingers are flexed [9]. Hydrostatic pressure increases in the carpal canal when the wrist is held in either flexion or extension [9]. Repetitive wrist flexion and extension cause a sustained increase in intracarpal pressure [9]. In flexion, the finger flexor tendons are shifted anteriorly against the transverse carpal ligament, while in extension they are aligned more dorsally [9]. The extent to which shear forces result in tensile strain in the median nerve has not been investigated [9].

An intraosseous ganglion of the trapezium may originate from the scaphotrapezial joint rather than the tendon sheath itself, as the flexor carpi radialis tendon is closely applied to the capsule of the scaphotrapezial joint at the proximal edge of the trapezium [51]. Schajowicz et al. (1979) postulated two mechanisms of formation of intraosseous ganglion: the penetrating variety, where the ganglion penetrates the bone from surrounding soft tissue, and the idiopathic variety, where there is no evidence of penetration and the ganglion arises spontaneously within the bone [51]. The idiopathic ganglion is proposed to arise within bone by intramedullary mucoid degeneration, secondary to repeated minor trauma or avascular necrosis [51].

Classification

Physical Examination: A physical examination of the metacarpophalangeal region distinguishes a flexor sheath ganglion from a trigger digit and Dupuytren's nodule [20].

Imaging: Ultrasound imaging assists in the diagnosis of suspected flexor tendon sheath ganglions and helps determine whether a patient should undergo aspiration or surgical excision [3].

Other Considerations: A midpalmar ganglion can displace carpal tunnel contents, acting as a major factor in the development of carpal tunnel syndrome [14]. An intraarticular-intraosseous carpal ganglion can present as a dumbbell-like structure with both intraarticular and extraarticular components [30].

Clinical Presentation

A detailed physical examination of the metacarpophalangeal region of the affected digit distinguishes between a flexor sheath ganglion, trigger digit, and Dupuytren's disease [20]. Ultrasound imaging assists in diagnosing suspected flexor tendon sheath ganglions and determines whether patients should undergo aspiration or surgical excision [3]. Magnetic resonance imaging is helpful in identifying the origin of a complex ganglion and its relationship to the deep branch of the ulnar nerve [43].

The clinical presentation varies by anatomical location and associated pathology. A volar wrist ganglion can present as trigger finger by kinking the adjacent flexor tendons within the carpal tunnel [42]. A ganglion arising from a wrist joint can present as a painless mass in the center of the palm without signs or symptoms of median or ulnar nerve compression [15]. Conversely, a midpalmar ganglion can cause concomitant compressive neuropathy of the ulnar and median nerves [14]. The displacement of carpal tunnel contents by a ganglion can be a major factor in the development of carpal tunnel syndrome [14].

Investigations

Clinical Examination: A careful physical examination is essential to direct care and future testing if indicated [37]. The flexor tendon sheath in the fingers is a synovial-lined, fibroosseous tunnel with segmental condensations of fibrous tissue [34]. This structure is seen to be a contained bursal environment with specialized anatomy to provide for flexion and extension [32].

Ultrasonography: Ultrasonography facilitates dynamic, real-time evaluation of bones, joints, tendons, nerves, and vessels [41]. The architecture and relationship of the FDS to FDP within the flexor sheath is accurately defined using a non-invasive imaging technique [33]. Additionally, the pulley system can be clearly imaged in cross-section using a non-invasive imaging technique [33].

MRI: MRI may be helpful in providing a quantitative noninvasive measure of cellularity of affected areas, which is an index of biologic activity [71].

Treatment

Non-Operative

Aspiration treatment of ganglion cysts of the wrist and hand can safely remove 85% of these tumors if one, two, or three separate treatments are administered [46]. Patients with carpal ganglions who wish to avoid or delay operative treatment should be advised that aspiration-puncture followed by 3 weeks of immobilization will be successful in approximately 50% of cases [10].

Operative

Surgical Approach / Technique: Ultrasound-guided excision of flexor tendon sheath ganglion using a 2-mm portal under local anaesthesia was reliable and efficient [6]. This procedure was performed without specific morbidity [6].

Complications

Nerve palsy: Wrist joint ganglions can present as painless masses in the center of the palm without signs or symptoms of median or ulnar nerve compression [15].

Other Considerations: Mid-axial injection of steroid into the flexor sheath is devoid of complications if meticulous care is given during the procedure [11]. Ultrasound-guided excision of flexor tendon sheath ganglion using a 2-mm portal under local anaesthesia was performed without specific morbidity [6]. Surgical excision of a painful ganglion of the digital flexor tendon sheath is a safe method [4].

Recovery

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

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

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

Rehabilitation protocol: Aspiration-puncture followed by 3 weeks of immobilization is successful in approximately 50% of cases for patients with carpal ganglions who wish to avoid or delay operative treatment [10].

Functional milestones: The evidence does not provide validated patient-reported outcome measure trajectories or specific outcome-measure benchmarks.

Other Considerations: Surgical excision of a painful ganglion of the digital flexor tendon sheath is a simple, safe, and effective method [4]. Ultrasound-guided excision of a flexor tendon sheath ganglion using a 2-mm portal under local anaesthesia was reliable and efficient, without specific morbidity [6]. Percutaneous puncture for managing flexor tendon sheath ganglions has a low recurrence rate, with no recurrences observed after a second puncture in the studied cohort [7].

Key Evidence

  • [L5] Both decision tree and Markov modeling approaches accurately recreated the management of flexor sheath ganglia and mirrored the observed clinical experience reported in the literature. [1] (10.1007/s11552-007-9060-4)
  • [L4] The distribution of fibrous flexor sheath ganglions was studied in 57 patients. [2] (10.1016/s0266-7681(97)80068-x)
  • [L4] Ultrasound is useful for assisting in diagnosis and determining whether patients should undergo aspiration or surgical excision for suspected flexor tendon sheath ganglions. [3] (10.1016/s0363-5023(97)80043-3)
  • [L4] Surgical excision is a simple, safe, and effective method for treating a painful ganglion of the digital flexor tendon sheath. [4] (10.1007/s11552-007-9028-4)
  • [L4] A nonsurgical approach to flexor tendon sheath ganglions is both cost-effective and successful. [5] (10.1053/jhsu.2002.34318)
  • [L4] The ultrasound-guided excision of flexor tendon sheath ganglion, using a 2-mm portal, under local anaesthesia was reliable and efficient, without specific morbidity. [6] (10.1016/j.hansur.2018.10.116)
  • [L4] Percutaneous puncture is a practical option for managing flexor tendon sheath ganglions given its low cost, lack of downtime, and low recurrence rate, with no recurrences observed after a second puncture in this cohort. [7] (10.1177/17531934221115983)
  • [L5] This study provides the gross anatomical evidence that the nerve supply of the flexor tendon in the digital sheath comes via the digital nerve, entering the sheath alongside the transverse branch of the digital artery. [8] (10.1016/0266-7681(91)90138-e)
  • [Paper] [9] (10.1016/0363-5023(94)90087-6)
  • [L2] Patients with carpal ganglions who wish to avoid or delay operative treatment should be advised that aspiration-puncture followed by 3 weeks of immobilization will be successful in approximately 50% of cases. [10] (10.1016/s0363-5023(87)80108-9)
  • [Paper] The mid-axial route is a dependable site for infiltration of the drug into the flexor sheath and is devoid of complications if meticulous care is given during the procedure. [11] (10.1007/s12593-014-0120-z)
  • [L4] The ganglion's displacement of carpal tunnel contents strongly suggests it was a major factor in the patient's developing carpal tunnel syndrome. [14] (10.1007/s11552-012-9416-2)
  • [L4] We report 2 cases of ganglions arising from wrist joints that presented as painless masses in the center of the palm without signs or symptoms of median or ulnar nerve compression. [15] (10.1016/j.jhsa.2003.11.006)
  • [L4] Arthroscopic resection was an effective treatment method for well-selected volar wrist ganglion arising from the radiocarpal joint in long run. [17] (10.1016/j.main.2006.07.028)
  • [L4] Distinguishing between a flexor sheath ganglion, trigger digit, and Dupuytren's may be accomplished with a detailed physical examination of the MCP region of the affected digit. [20] (10.1177/15589447221109644)
  • [L5] At half the total tendon excursion, the force required to flex the digit through half its range is always less than a third of the force required to flex the digit fully. [22] (10.1016/0266-7681(90)90086-j)
  • [L5] The importance of sheath closure at the time of tendon suture is based in part on the evidence that diffusion is a significant nutrient pathway to the flexor tendon. [27] (10.1016/0266-7681(88)90077-0)
  • [L5] The importance of sheath closure at the time of tendon suture is based in part on the evidence that diffusion is a significant nutrient pathway to the flexor tendon. [28] (10.1016/0266-7681_88_90077-0)
  • [L4] In this series of 12 fingers, 92% achieved excellent or good results using the International Federation of Societies for Surgery of the Hand evaluation system. [29] (10.1016/0266-7681_88_90084-8)
  • [L5] The ganglion in this case represents both intraarticular and extraarticular components—in essence, a dumbbell-like ganglion with the primary pathological process in the volar carpometacarpal joint capsule. [30] (10.1016/s0363-5023(79)80079-9)
  • [L5] The flexor sheath is seen to be a contained bursal environment with specialized anatomy to provide for flexion and extension. [32] (10.1016/s0363-5023(85)80152-0)
  • [L5] The architecture and relationship of the FDS to FDP within the flexor sheath is accurately defined using a non-invasive imaging technique and the pulley system can be clearly imaged in cross-section. [33] (10.1016/j.jhsb.2005.08.001)
  • [Paper] The flexor tendon sheath in the fingers is a synovial-lined, fibroosseous tunnel with segmental condensations of fibrous tissue. [34] (10.1016/0363-5023(89)90110-x)
  • [L5] Ultrasonography facilitates dynamic, real-time evaluation of bones, joints, tendons, nerves, and vessels, making it an ideal imaging modality for hand and wrist conditions. [41] (10.5435/jaaos-d-15-00170)
  • [L4] [42] (10.1177/1753193412453699)
  • [L4] Magnetic resonance imaging is helpful in identifying the origin of a complex ganglion and its relationship to the deep branch of the ulnar nerve, facilitating surgical planning and excision. [43] (10.1007/s11552-006-9008-0)
  • [L2] Aspiration treatment of ganglion cysts of the wrist and hand can safely remove 85% of these tumors if one, two or three separate treatments are administered. [46] (10.1016/s0363-5023(87)80221-6)
  • [L4] [51] (10.1054/jhsb.1999.0159)
  • [L4] In a series of 12 fingers, 92% achieved excellent or good results using the International Federation of Societies for Surgery of the Hand evaluation system. [55] (10.1016/0266-7681(88)90084-8)
  • [Paper] The main finding of this study is that flexor tendon force is highly dependent on wrist position and less so on the number of fingers manipulated. [77] (10.1016/s0363-5023(96)80299-1)
  • [Paper] These findings indicate that repair or reconstruction of either the A1 or oblique pulley after injury will restore normal thumb kinematics. [79] (10.1016/0363-5023(94)90066-3)
  • [L5] Anatomical studies have identified two annular and one oblique pulley in the thumb. [85] (10.1016/s0363-5023(77)80101-9)
  • [L5] The force required to fully flex the digit decreased with more extensive A1 pulley release, becoming significant when more than 50% of the pulley was released. [93] (10.1016/s0266-7681(98)80217-9)
  • [L4] The study suggests a need for one standard method of measurement and recording, if a comparison of results after flexor tendon repair is to be of value. [115] (10.1016/s0266-7681(85)80018-8)

See Also

References

[1] Modeling the Management of a Flexor Sheath Ganglion. HAND. 2007. DOI: 10.1007/s11552-007-9060-4

[2] The Distribution of Fibrous Flexor Sheath Ganglions. Journal of Hand Surgery. 1997. DOI: 10.1016/s0266-7681(97)80068-x

[3] Treatment of flexor tendon sheath ganglions using ultrasound imaging. The Journal of Hand Surgery. 1997. DOI: 10.1016/s0363-5023(97)80043-3

[4] Flexor Tendon Sheath Ganglions: Results of Surgical Excision. HAND. 2007. DOI: 10.1007/s11552-007-9028-4

[5] Management of flexor tendon sheath ganglions: A cost analysis. The Journal of Hand Surgery. 2002. DOI: 10.1053/jhsu.2002.34318

[6] Flexor tendon sheath ganglions — A new procedure to perform excision under ultrasound-guidance. Hand Surgery and Rehabilitation. 2018. DOI: 10.1016/j.hansur.2018.10.116

[7] Percutaneous puncture of flexor sheath ganglions: an assessment of recurrence. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221115983

[8] Anatomical Demonstration of the Nerve-Supply to the Flexor Tendon. Journal of Hand Surgery. 1991. DOI: 10.1016/0266-7681(91)90138-e

[9] Median nerve displacement through the carpal canal. The Journal of Hand Surgery. 1994. DOI: 10.1016/0363-5023(94)90087-6

[10] Ganglions of the wrist and digits: Results of treatment by aspiration and cyst wall puncture. The Journal of Hand Surgery. 1987. DOI: 10.1016/s0363-5023(87)80108-9

[11] Mid-Axial Injection of Steroid into the Flexor Sheath for Trigger Fingers. Journal of Hand and Microsurgery. 2014. DOI: 10.1007/s12593-014-0120-z

[14] Concomitant compressive neuropathy of the ulnar and median nerves in the hand by midpalmar ganglion. HAND. 2012. DOI: 10.1007/s11552-012-9416-2

[15] Wrist joint ganglion presenting as a painless mass in the palm: report of 2 cases. The Journal of Hand Surgery. 2004. DOI: 10.1016/j.jhsa.2003.11.006

[17] Résection des kystes synoviaux palmaires par arthroscopie. Chirurgie de la Main. 2006. DOI: 10.1016/j.main.2006.07.028

[20] A Simple Physical Exam Maneuver to Distinguish Trigger Digit, Dupuytren’s Nodule, and Flexor Sheath Ganglion. HAND. 2022. DOI: 10.1177/15589447221109644

[22] The Mechanical Effect of Partial Resection of the Digital Fibrous Flexor Sheath. Journal of Hand Surgery. 1990. DOI: 10.1016/0266-7681(90)90086-j

[27] Flexor tendon healing. The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand. 1988. DOI: 10.1016/0266-7681(88)90077-0

[28] Flexor Tendon Healing. Journal of Hand Surgery. 1988. DOI: 10.1016/0266-7681_88_90077-0

[29] The Modified Kleinert Splint in Zone II Flexor Tendon Injuries. Journal of Hand Surgery. 1988. DOI: 10.1016/0266-7681_88_90084-8

[30] An intraarticular-intraosseous carpal ganglion. The Journal of Hand Surgery. 1979. DOI: 10.1016/s0363-5023(79)80079-9

[32] Digital flexor tendon sheath: An anatomic study. The Journal of Hand Surgery. 1985. DOI: 10.1016/s0363-5023(85)80152-0

[33] Mri ‘Magic Angle’ Imaging of Finger Tendons. Journal of Hand Surgery. 2006. DOI: 10.1016/j.jhsb.2005.08.001

[34] Anatomy of the flexor tendon sheath and pulley system: A current review. The Journal of Hand Surgery. 1989. DOI: 10.1016/0363-5023(89)90110-x

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

[41] Ultrasonography for Hand and Wrist Conditions. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-15-00170

[42] Volar wrist ganglion presenting as trigger finger. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193412453699

[43] Compression of the Deep Palmar Branch of the Ulnar Nerve by a Ganglion. HAND. 2006. DOI: 10.1007/s11552-006-9008-0

[46] Management of ganglion cysts of the hand by simple aspiration. The Journal of Hand Surgery. 1987. DOI: 10.1016/s0363-5023(87)80221-6

[51] Intraosseous Ganglion of the Trapezium in Communication with the Flexor Carpi Radialis Tendon Sheath. Journal of Hand Surgery. 1999. DOI: 10.1054/jhsb.1999.0159

[55] The modified kleinert splint in zone II flexor tendon injuries. The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand. 1988. DOI: 10.1016/0266-7681(88)90084-8

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

[71] Dupuytren S Disease And Related Hyperproliferative Disorders. 54. The Future of Dupuytren’s Research and Treatment > 54.4 Mechanical Measurements and Procedures > 54.4.4 Imaging.

[77] Relationship between joint motion and flexor tendon force in the canine forelimb. The Journal of Hand Surgery. 1996. DOI: 10.1016/s0363-5023(96)80299-1

[79] Biomechanics of the thumb flexor pulley system. The Journal of Hand Surgery. 1994. DOI: 10.1016/0363-5023(94)90066-3

[85] Anatomy of the flexor tendon sheath and pulleys of the thumb. The Journal of Hand Surgery. 1977. DOI: 10.1016/s0363-5023(77)80101-9

[93] The Effect of the Extent of A1 Pulley Release on the Force Required to Flex the Digits. Journal of Hand Surgery. 1998. DOI: 10.1016/s0266-7681(98)80217-9

[115] Methods of Evaluation of the Functional Results of Flexor Tendon Repair of the Fingers. Journal of Hand Surgery. 1985. DOI: 10.1016/s0266-7681(85)80018-8

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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.