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Hand Infections

Paronychia, deep-space and flexor sheath infections — recognition, antibiotics, drainage.

40 citationsUpdated Aug 2026

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Overview

Early identification and treatment of hand infections are essential to achieve optimal outcomes [1]. Delayed diagnosis can result in amputation or death [1]. Hand infections are associated with a high rate of complications that are often difficult to manage [2]. Prompt diagnosis, surgical debridement, and antibiotic coverage remain the standard of care [12].

Management principles for hand osteomyelitis include good surgical debridement and culture-guided antimicrobial therapy [3]. Antibiotic therapy typically lasts 4–6 weeks, though the optimal length and mode of administration remain under study [3]. Initial treatment of mycobacterial infections involves a combination of long-term antibiotics and surgical debridement, with reconstructive procedures aiding in restoring lost function [6]. Deep infection after hand surgery is uncommon but can lead to significant morbidity [7].

Challenges persist in managing hand infections in immunosuppressed patients and intravenous drug users [12]. Aggressive treatment is needed in immunosuppressed patients to prevent limb- and life-threatening complications from bone and soft-tissue infections [18]. The choice of empiric antibiotics for acute hand infections should be based on the severity of the infection, the comorbidities of the patient, and local prevalence of MRSA [13]. The incidence of virulent and MRSA infections is rising [18].

An initial debridement of dorsal hand infections at the bedside is at least as effective as formal debridement in the operating room [29]. Bedside debridement decreases the number of formal debridements and hospital days without increasing complications [29].

Anatomy & Pathophysiology

Prompt diagnosis and early treatment of hand infections are necessary to prevent complications such as hand stiffness, contractures, and amputation [17]. Hand and upper-extremity infections are usually a clinical diagnosis, but imaging and laboratory evaluation aid in diagnosis [4]. An excellent knowledge of hand anatomy and function allows for an accurate diagnosis and effective management of deep space infections [14].

Pyogenic Flexor Tenosynovitis: Early diagnosis and prompt treatment are required to preserve the digit and prevent morbidity and loss of hand function [22]. Despite timely and thorough treatment, severe pyogenic flexor tenosynovitis can lead to impaired function or amputation of the affected digit [31].

Pediatric Considerations: Pediatric hand infections involve unique environments and characteristics, including the frequency of fingers in mouths, open growth plates, and typically more robust circulation with fewer systemic comorbidities [25]. Chronic recurrent multifocal osteomyelitis of the hand is a rare pediatric condition that presents special functional and anatomical considerations [49].

Iatrogenic and Traumatic Etiologies: Complications of the fingers and hand after arthroscopic rotator cuff repair, such as carpal tunnel syndrome, flexor tenosynovitis, and complex regional pain syndrome, easily occurred in patients with a past history of carpal tunnel syndrome or tenosynovitis and in patients with edema [51]. Animal bite injuries of the hands should be treated immediately to avoid further complications [48].

Classification

Hand infections encompass a diverse array of entities with potential for serious morbidity [11]. Atypical hand infections are difficult to recognize and treat due to their indolent nature and nonspecific symptoms [5]. Chronic hand infections are uncommon and require a high index of suspicion for early diagnosis [9]. These chronic infections are grouped by microorganism into bacterial (mycobacterial and others), fungal, and viral types [9]. Fungal infections of the hand are most commonly cutaneous infections involving the skin and nails [23]. Renal disease and diabetes increase the risk of failed outpatient management of cellulitic hand infections [20].

Open Fracture Classification: The new classification system for open fractures of the hand divides patients into three groups based on a risk score to predict infection requiring re-debridement [34].

Necrotizing Soft Tissue Infection (NSTI) Classification: NSTIs can be classified based on anatomic location, depth of involvement, or microbial pathogen [37]. * Type II: Monomicrobial and comprise approximately 20% to 30% of cases [37]. These infections are caused by group A beta-hemolytic streptococci (GAS) either alone or in association with Staphylococcus aureus [37]. * Type IV: Fungal, rare, and primarily affect immunocompromised patients [37].

Clinical Presentation

Hand infections are primarily a clinical diagnosis [4]. Imaging and laboratory evaluations serve to aid in the diagnostic process [4]. Atypical hand infections present with an indolent nature and nonspecific symptoms, making them difficult to recognize [5]. Specific presentations and treatments are emphasized for each type of chronic hand infection [9]. Fingertip infections can mimic common infections, requiring awareness of obscure conditions and relevant anatomy [24].

Pediatric hand infections occur in a unique environment characterized by the frequency of fingers in mouths, open growth plates, and typically more robust circulation with fewer systemic comorbidities [25].

The diagnosis of infectious flexor tenosynovitis has historically been made based on physical exam using Kanavel's signs [26]. The specificity of Kanavel's signs for diagnosing infectious flexor tenosynovitis has come into question [26]. A higher number of Kanavel signs were present in patients with confirmed flexor tenosynovitis compared to those with finger cellulitis without concomitant flexor tenosynovitis (2.9 vs. 0.5) [26].

Radiographic soft tissue swelling does not distinguish flexor tenosynovitis from other causes [26]. Magnetic resonance imaging has been described in aiding the diagnosis of flexor tenosynovitis, but its sensitivity and specificity have not been well studied [26]. Ultrasound has been briefly studied as a diagnostic tool for flexor tenosynovitis with high sensitivity but mediocre specificity [26]. Ultrasound assessment of flexor tenosynovitis comes with inherent user variability and limitations with access and equipment [26].

Diagnosis of septic arthritis of the wrist is made based mainly on a thorough patient history, physical examination, and joint aspiration [27]. No serum laboratory values have been shown to consistently confirm wrist joint infection [27].

Investigations

Early identification and treatment of hand infections are essential to achieve optimal outcomes, as delayed diagnosis can result in amputation or death [1]. Early identification of atypical hand infections through appropriate laboratory testing is imperative for eradication of the causative organism [5]. A high index of suspicion coupled with an excellent knowledge of hand anatomy and function allows for an accurate diagnosis and effective management of deep space infections [14].

Laboratory: Clinicians should be aware of obscure conditions that can mimic common fingertip infections [24]. The incidence of finger infections presenting to emergency departments is rising [19]. Patients aged 40 to 59 years are most at risk for finger infections presenting to emergency departments [19]. Diagnosis of upper-extremity nontuberculous mycobacterial infections is often delayed because of indolent presentation and lack of clinical suspicion [44].

MRI: Magnetic resonance imaging (MRI) has been described in aiding the diagnosis of flexor tenosynovitis, but its sensitivity and specificity have not been well studied [26]. MRI access and time spent obtaining MRI may delay diagnosis, with a negative impact on patient outcomes [26].

CT: Contrast-enhanced computed tomography (CT) has been evaluated to increase the successful diagnosis of acute pyogenic flexor tenosynovitis [26].

Ultrasound: Ultrasound diagnosis of flexor tenosynovitis comes with inherent user variability and limitations with access and equipment [26].

Other Considerations: The specificity of Kanavel's signs for the diagnosis of infectious flexor tenosynovitis has come into question [26].

Treatment

Non-Operative

The use of prophylactic antibiotics in small elective soft tissue procedures of the hand is debated and often not necessary [7]. There is no significant difference in infection rate in elective hand surgery whether antibiotics were administered preoperatively or not [28]. Outpatient management of diabetic hand infections provides a safe alternative to inpatient admission in selected patients [33].

Operative

Indications: Early identification through appropriate laboratory testing is imperative for the eradication of the causative organism in atypical hand infections [5]. Surgical treatment paired with medical management is imperative for the eradication of the causative organism in atypical hand infections [5]. Initial treatment for mycobacterial infections in the hand and wrist involves a combination of long-term antibiotics and surgical debridement to cure the infection [6]. Management of osteomyelitis of the hand and wrist should consist of a combined surgical and medical approach to achieve the most favorable outcome [30].

Surgical Approach / Technique: Prompt diagnosis and early treatment with broad-spectrum intravenous antibiotics and surgical irrigation and debridement are essential to avoid complications and preserve hand function in pyogenic flexor tenosynovitis [16]. Severe pyogenic flexor tenosynovitis can still lead to impaired function or amputation despite prompt treatment [16]. The rising incidence of virulent and MRSA infections emphasizes the need for aggressive treatment in immunosuppressed patients to prevent limb and life-threatening complications [18].

Empiric Antibiotic Selection: The choice of empiric antibiotics for acute infections of the hand should be based on the severity of the infection [13]. The choice of empiric antibiotics for acute infections of the hand should be based on the comorbidities of the patient [13]. The choice of empiric antibiotics for acute infections of the hand should be based on local prevalence of MRSA [13].

Complications

The complications associated with mycobacterial hand infections can be significant [10]. There is a rising incidence of virulent and MRSA infections in hand surgery [18]. Since 1961, the rates of both community-acquired MRSA and health care–associated MRSA hand infections have increased rapidly [38]. The incidence of finger infections presenting to emergency departments is rising, with 40- to 59-year-old patients most at risk [19].

Infection: HIV infection increases the risk of developing a hand infection but does not lead to an increased risk of revision surgery or ablation [35]. Immunosuppressed patients require aggressive treatment to prevent limb and life-threatening complications [18].

Other Considerations: The demographic shift toward 40- to 59-year-old patients represents a key risk profile for emergency department presentations of finger infections [19].

Recovery

Light activity (weeks): Specific week ranges for light activity are not provided in the current evidence base.

Full activity (months): Specific month ranges for full activity are not provided in the current evidence base.

Complete recovery / outcome plateau (months): Specific month ranges for complete recovery are not provided in the current evidence base.

Rehabilitation protocol: Management of hand osteomyelitis requires good surgical debridement and culture-guided antimicrobial therapy [3]. For atypical hand infections, early identification through appropriate laboratory testing and surgical treatment paired with medical management is imperative for eradication of the causative organism [5]. Initial treatment of mycobacterial infections in the hand and wrist involves a combination of long-term antibiotics and surgical debridement to cure the infection [6]. Prophylactic antibiotics are indicated for hand procedures lasting longer than 2 hours, contaminated wounds, and open fractures [7].

Functional milestones: Severe pyogenic flexor tenosynovitis can lead to impaired function or amputation despite timely and thorough treatment [16, 31]. Complications associated with mycobacterial hand infections can be significant [10].

Other Considerations: The incidence of finger infections presenting to emergency departments in the United States was rising from 2012 to 2016, with patients aged 40 to 59 years being most at risk [19]. Factors including time to antibiotics, time to operative debridement, smoking status, and chronic disease comorbidities were not predictive of infection or nonunion in open hand fractures [45]. Early amputation to maximize disease-free survival may be appropriate for patients with hand osteomyelitis and arterial calcification [47]. Regarding pin site care in adult hand and wrist surgery, a protocol from Ilizarov confirms a very high wire survival rate (99.5%) and a very low rate of pin site infection (4.5%) [15]. There were no cases of bony infection requiring further surgery in the study supporting this protocol [15]. The study supports the recommendation to leave wires exposed in adult hand and wrist surgery when the specific Ilizarov protocol is adopted [15].

Key Evidence

  • [L5] Early identification and treatment of hand infections are essential to achieve optimal outcomes, as delayed diagnosis can result in amputation or death. [1] (10.1016/j.jhsa.2018.05.027)
  • [L5] Hand infections are associated with a high rate of complications that are often difficult to manage. [2] (10.1016/j.hcl.2020.03.010)
  • [L5] Management principles include good surgical debridement and culture-guided antimicrobial therapy, with antibiotic therapy typically lasting 4–6 weeks, though the optimal length and mode of administration in the hand remain under study. [3] (10.1177/1753193415612373)
  • [L5] Hand and upper-extremity infections are usually a clinical diagnosis, but imaging and laboratory evaluation aid in diagnosis. [4] (10.1016/j.hcl.2020.03.002)
  • [L4] Atypical hand infections are difficult to recognize and treat due to their indolent nature and nonspecific symptoms; early identification through appropriate laboratory testing and surgical treatment paired with medical management is imperative for eradication of the causative organism. [5] (10.1016/j.jhsa.2025.09.023)
  • [L5] Initial treatment involves a combination of long-term antibiotics and surgical debridement to cure the infection, with reconstructive procedures aiding in restoring hand function lost secondary to the disease process. [6] (10.1016/j.hcl.2020.03.013)
  • [Paper] Deep infection after hand surgery is uncommon but can lead to significant morbidity; prophylactic antibiotics are indicated for procedures lasting longer than 2 hours, contaminated wounds, and open fractures, while their use in small elective soft tissue procedures is debated and often not necessary. [7] (10.1016/j.hcl.2014.12.007)
  • [L5] Chronic hand infections are uncommon and require a high index of suspicion for early diagnosis; they are grouped by microorganism into bacterial (mycobacterial and others), fungal, and viral types, with specific presentations and treatments emphasized for each. [9] (10.1016/j.jhsa.2014.04.003)
  • [L4] The complications associated with mycobacterial hand infections can be significant. [10] (10.1177/1558944720940064)
  • [L5] Hand infections include a diverse array of entities with potential for serious morbidity. [11] (10.1016/j.jhsa.2011.05.035)
  • [L5] Prompt diagnosis, surgical debridement, and antibiotic coverage remain the standard of care for hand infections, though challenges persist with immunosuppressed patients and intravenous drug use. [12] (10.1016/j.hcl.2020.03.001)
  • [L5] The choice of empiric antibiotics for acute infections of the hand should be based on the severity of the infection, the comorbidities of the patient, and local prevalence of MRSA. [13] (10.1016/j.jhsa.2009.10.024)
  • [L5] A high index of suspicion coupled with an excellent knowledge of hand anatomy and function allows for an accurate diagnosis and effective management of deep space infections. [14] (10.1016/j.hcl.2020.03.014)
  • [L4] The study confirms a very high wire survival rate (99.5%) and a very low rate of pin site infection (4.5%) with no cases of bony infection requiring further surgery, supporting the recommendation to leave wires exposed in adult hand and wrist surgery when this specific protocol is adopted. [15] (10.1177/1753193421991318)
  • [L5] Prompt diagnosis and early treatment with broad-spectrum intravenous antibiotics and surgical irrigation and debridement are essential to avoid complications and preserve hand function, though severe infection can still lead to impaired function or amputation. [16] (10.1016/j.jhsa.2019.04.011)
  • [L5] Prompt diagnosis and early treatment are necessary to prevent complications such as hand stiffness, contractures, and amputation. [17] (10.1016/j.jhsa.2014.03.031)
  • [L3] The study demonstrated a rising incidence of finger infections presenting to EDs, with 40- to 59-year-old patients most at risk. [19] (10.1177/1558944720915614)
  • [L3] [20] (10.1186/s13018-023-03911-5)
  • [L5] Early diagnosis and prompt treatment are required to preserve the digit and prevent morbidity and loss of hand function. [22] (10.1016/j.hcl.2020.03.005)
  • [L5] Fungal infections of the hand are most commonly cutaneous infections involving the skin and nails and can be treated with topical or local therapy. [23] (10.1016/j.hcl.2020.03.009)
  • [Paper] This review seeks to direct clinicians in an evidence-based manner, to make them aware of more obscure conditions that can mimic common infections, and to provide an understanding of the relevant anatomy of the fingertip. [24] (10.1016/j.hcl.2020.03.004)
  • [L5] Although many management principles are the same in pediatric and adult patients, physicians should bear in mind the unique environments and characteristics of the pediatric hand, including the frequency of fingers in mouths, open growth plates, and typically more robust circulation with fewer systemic comorbidities. [25] (10.1016/j.hcl.2020.03.012)
  • [L3] [26] (10.1177/15589447221092058)
  • [L5] Diagnosis is made based mainly on a thorough patient history, physical examination, and joint aspiration, as no serum laboratory values have been shown to consistently confirm wrist joint infection. [27] (10.5435/jaaos-d-16-00414)
  • [L2] Our prospective multicenter trial showed no significant difference in infection rate in elective hand surgery whether antibiotics were administered preoperatively or not. [28] (10.1177/1558944719842238)
  • [L3] An initial debridement of dorsal hand infections at the bedside is at least as effective as formal debridement in the operating room, decreasing the number of formal debridements and hospital days without increasing complications. [29] (10.1177/1558944719836234)
  • [L5] Management of osteomyelitis of the hand and wrist should consist of a combined surgical and medical approach to achieve the most favorable outcome. [30] (10.1016/j.jhsa.2009.03.020)
  • [Paper] Despite timely and thorough treatment, severe infection can nevertheless lead to impaired function or even amputation of the affected digit. [31] (10.1055/s-0039-1700370)
  • [L4] Outpatient management of diabetic hand infections provides a safe alternative to inpatient admission in selected patients. [33] (10.1177/17531934231196026)
  • [L3] The new classification system divides patients into three groups based on a risk score to predict infection requiring re-debridement. [34] (10.1177/17531934231187553)
  • [L3] HIV infection increased the risk of developing a hand infection but did not lead to an increased risk of revision surgery or ablation. [35] (10.1177/1753193420977791)
  • [L4] [37] (10.5435/jaaos-d-17-00716)
  • [L5] Since 1961, the rates of both community-acquired MRSA and health care–associated MRSA hand infections have increased rapidly. [38] (10.1016/j.hcl.2020.03.003)
  • [L4] Diagnosis of upper-extremity NTMI is often delayed because of indolent presentation and lack of clinical suspicion. [44] (10.1016/j.jhsa.2017.10.030)
  • [Paper] Factors including time to antibiotics, time to operative debridement, smoking status, and chronic disease comorbidities were not predictive of either infection or nonunion in open hand fractures. [45] (10.1055/s-0039-3399488)
  • [L4] Early amputation to maximize disease-free survival may be appropriate for patients with hand osteomyelitis and arterial calcification. [47] (10.1177/1753193420981871)
  • [L3] Hence, animal bite injuries of the hands should be treated immediately to avoid further complications. [48] (10.1007/s00402-020-03443-1)
  • [L4] The cases educate key stakeholders, raise awareness of the diagnosis, and illustrate challenging aspects of managing these patients, including special functional and anatomical considerations essential in managing cases involving the hand. [49] (10.1177/1558944719846599)
  • [L2] Complications of the fingers and hand after arthroscopic rotator cuff repair easily occurred in patients with a past history of carpal tunnel syndrome or tenosynovitis and in patients with edema as per a subjective assessment. [51] (10.1016/j.jseint.2021.07.001)

References

[1] Hand Infections. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.05.027

[2] Complications of Hand Infections. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.010

[3] Osteomyelitis of the hand. Journal of Hand Surgery (European Volume). 2015. DOI: 10.1177/1753193415612373

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

[5] Atypical Hand Infections. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2025.09.023

[6] Mycobacterial Infections in the Hand and Wrist. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.013

[7] Infection After Hand Surgery. Hand Clinics. 2015. DOI: 10.1016/j.hcl.2014.12.007

[9] Chronic Hand Infections. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.04.003

[10] Mycobacterial Infections of the Hand. HAND. 2020. DOI: 10.1177/1558944720940064

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

[12] Hand Infections. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.001

[13] Empiric Antibiotics for Acute Infections of the Hand. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2009.10.024

[14] Hand Abscesses. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.014

[15] Reducing the incidence of pin site infection in hand surgery with the use of a protocol from Ilizarov. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/1753193421991318

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

[17] Acute Hand Infections. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.03.031

[18] Chapter 30 Bone and Soft-­Tissue Infections of the Hand and Wrist. 2020.

[19] A Nationwide Epidemiological Analysis of Finger Infections Presenting to Emergency Departments in the United States From 2012 to 2016. HAND. 2020. DOI: 10.1177/1558944720915614

[20] Renal disease and diabetes increase the risk of failed outpatient management of cellulitic hand infections: a retrospective cohort study. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03911-5

[22] Pyogenic Flexor Tenosynovitis: Evaluation and Management. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.005

[23] Fungal Infections of the Hand. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.009

[24] Fingertip Infections. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.004

[25] Pediatric Hand Infections. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.012

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

[27] Septic Arthritis of the Wrist. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-16-00414

[28] Prospective Analysis of Hand Infection Rates in Elective Soft Tissue Procedures of the Hand: The Role of Preoperative Antibiotics. HAND. 2019. DOI: 10.1177/1558944719842238

[29] Initial Debridement of Dorsal Hand Abscesses in the Operating Room Does Not Improve Outcomes. HAND. 2019. DOI: 10.1177/1558944719836234

[30] Current Recommendations in the Management of Osteomyelitis of the Hand and Wrist. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.03.020

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

[33] The incidence and severity of diabetic hand infection presentations during the COVID-19 pandemic. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231196026

[34] Open fractures of the hand: a new classification based on risk score to predict infection requiring re-debridement. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231187553

[35] Factors affecting suboptimal outcomes in hand infections. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420977791

[37] Necrotizing Infections of the Hand and Wrist: Diagnosis and Treatment Options. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-17-00716

[38] Antibiotic Management and Antibiotic Resistance in Hand Infections. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.03.003

[44] Nontuberculous Mycobacterial Infections of the Upper Extremity: 15-Year Experience at a Tertiary Care Medical Center. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2017.10.030

[45] Factors Influencing Infection Rates after Open Hand Fractures. Journal of Hand and Microsurgery. 2020. DOI: 10.1055/s-0039-3399488

[47] Hand osteomyelitis in arterial calcification, diabetes mellitus and end-stage renal failure: a comparison of 210 cases over 12 years. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/1753193420981871

[48] “Cat and dog bite injuries of the hand: early versus late treatment”. Archives of Orthopaedic and Trauma Surgery. 2020. DOI: 10.1007/s00402-020-03443-1

[49] Chronic Recurrent Multifocal Osteomyelitis of the Hand: A Rare Pediatric Condition. HAND. 2019. DOI: 10.1177/1558944719846599

[51] Risk factors related to complications of the fingers and hand after arthroscopic rotator cuff repair – carpal tunnel syndrome, flexor tenosynovitis, and complex regional pain syndrome. JSES International. 2021. DOI: 10.1016/j.jseint.2021.07.001

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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.