Skip to content

Partial Wrist Fusion PDF Evidence

Illustration of the wrist bones showing the worn scaphoid removed and the small bones of the mid-wrist (capitate and lunate) fused together, while the joint between the lunate and the forearm bone (radius) is left free to keep some movement.
In a partial wrist fusion the worn scaphoid is removed and the capitate is fused to the lunate (a capitolunate fusion); the joint between the lunate and the radius is deliberately preserved, so the wrist keeps a useful, if reduced, range of movement. Kieran Hirpara 4.0

A protected recovery plan after a partial wrist fusion (capitolunate fusion, usually with removal of the scaphoid) for a worn-out wrist, immobilised until the bones knit at about six to eight weeks, then progressively restoring a useful but deliberately reduced arc of wrist movement and grip strength.

This protocol guides your recovery after a partial wrist fusion — an operation that removes the worn-out scaphoid bone and fuses the small bones in the middle of the wrist (most often the capitate to the lunate, a capitolunate fusion) — with Dr Kieran Hirpara at Mater Private Hospital Rockhampton. It begins with your home exercise program, followed by the structured clinical protocol written for your hand therapist — bring this page or its PDF to your first therapy visit so your rehabilitation stays coordinated. Your hand therapist may adjust the plan depending on how your recovery progresses.

If you have any concerns about your wound after surgery, get in touch with the rooms. It is often helpful to take a photo of the wound and email it for review.

What to expect

A partial wrist fusion treats a wrist that has worn out (arthritis) along the path that follows an old scaphoid problem — either a scapholunate ligament injury (a "SLAC" wrist) or an old scaphoid fracture that never healed (a "SNAC" wrist). The damaged scaphoid is removed, and the bones of the mid-wrist are fused together so they no longer rub. Dr Hirpara most often fuses the capitate to the lunate (a capitolunate fusion), sometimes including the neighbouring bones — when the lunate, capitate, triquetrum and hamate are all fused this is called a four-corner fusion, and it follows the same recovery principles.

The key idea behind this operation is that only part of the wrist is fused, not all of it. The joint between the lunate and the forearm bone (the radius) is deliberately left alone. That preserved joint is what allows the wrist to keep moving:

  • Fusing the worn surfaces takes the pain away — that is the main goal, and it is reliably achieved.
  • Keeping the radius–lunate joint means you keep useful movement. The trade-off is that the movement is reduced: most people end up with roughly half to two-thirds of their former bending range, and grip strength of about three-quarters of the other side. This is a normal, expected result — not a complication — and for a painful, worn wrist it is usually a very worthwhile exchange.

The fused bones need time to knit solidly together, just like a fracture. For about the first six to eight weeks the wrist is held still in a cast or splint while this happens. During that time the fingers, thumb and forearm are kept moving freely, but the wrist itself is rested. Once the surgeon confirms on X-ray that the bones have united, wrist movement and then strengthening are opened up in careful stages. Setting your expectations early — a comfortable, useful wrist rather than a fully mobile one — is an important part of the recovery.

Precautions and limitations

  • Keep your wrist still in its cast or splint until your surgeon confirms the fusion has healed (usually about six to eight weeks) — the bones must knit before the wrist is moved.
  • Keep your fingers, thumb and forearm moving from day one, but do NOT move the wrist itself until cleared.
  • Do NOT grip hard, lift, push, pull or bear weight through the wrist until the fusion is confirmed solid — this protects the healing bone and any plate, screws or staples.
  • Expect a reduced final range of movement — this is the planned result of fusing part of the wrist, not a sign anything has gone wrong.
  • Keep the cast or dressing clean and dry, and do NOT drive while you are in a cast or cannot safely control the wheel.

For wound, swelling and scar management, see the practice's wound care guidance.

Your exercises

Opening the hand fully then making a full fist, and touching the thumb to each fingertip, while the wrist stays still in the cast or splint.

Kieran Hirpara 4.0

Finger and thumb movement

From the day of surgery, keep your fingers and thumb moving while the wrist itself rests in the cast or splint. Fully straighten all your fingers, then make a complete fist, then touch your thumb to the tip of each finger in turn. This stops the hand stiffening and keeps the tendons gliding while the wrist bones knit together. Do not move the wrist itself.

10 times each, several times a day, every day from the start

With the elbow tucked at the side and bent to a right angle, the forearm turns the palm up towards the ceiling then down towards the floor.

Kieran Hirpara 4.0

Forearm rotation (palm up / palm down)

With your elbow tucked in at your side and bent to a right angle, gently turn your palm up to face the ceiling, then down to face the floor. Keep the movement coming from the forearm, not the wrist. This keeps the forearm supple and does not disturb the healing fusion, so it can begin straight away.

10 times each direction, 2–3 times a day

Gently bending the wrist up and down and side to side within a comfortable, reduced range, once the bones have healed.

Kieran Hirpara 4.0

Wrist movement (after union)

A LATER exercise — only once the fusion has healed and your surgeon and hand therapist have cleared wrist movement (usually after about six to eight weeks). Gently bend the wrist up (back) and down (forwards), then tilt it towards the thumb and towards the little finger, moving only as far as is comfortable. Remember the fused part of the wrist will not move — you are restoring the movement that comes from the preserved joint, so the final range will be smaller than before, and that is expected.

10 times in each direction, 2–3 times a day, within comfort (after union)

Scar care

Once the wound is fully healed and dry, massage the scar with a little non-perfumed moisturiser, using small firm circles with the opposite thumb for a couple of minutes. This softens the scar and reduces sensitivity. Do not start until the wound has sealed and your therapist is happy.

2–3 minutes, twice a day, once the wound is healed

Squeezing a soft ball or putty in the palm to build hand and forearm strength.

Kieran Hirpara 4.0

Grip strengthening

A LATER exercise — begun only once the fusion is solid and strengthening has been cleared (usually from around eight to twelve weeks). Squeeze a soft ball or therapy putty in the palm, hold briefly, then release. Build the effort up gradually over several weeks. Heavy gripping, lifting and weight-bearing through the wrist are held back until your surgeon confirms the bones are fully united.

10–15 squeezes, 2–3 times a day, building gradually (later phase)

These are the exercises from your handout. Start them only as guided by Dr Hirpara and your hand therapist, staying within whatever range and limits you have been given. The early exercises keep the fingers, thumb and forearm moving without disturbing the healing fusion — the wrist itself stays still in its cast or splint. Wrist movement and grip strengthening belong to later phases and should not be started until your surgeon has confirmed the bones have united. Stop anything that causes sharp pain over the wrist.

Your clinical protocol

The rest of this page is the staged clinical protocol for rehabilitation after a partial wrist fusion (capitolunate ± scaphoid excision; the same principles apply to four-corner fusion). This section is to be provided to your hand therapist, and each phase opens with a plain-English explanation of what is happening. Unlike a tendon repair, the construct here is bony — progression is gated by radiographic union of the fusion, not by a fixed calendar. Until the surgeon confirms union, the wrist is immobilised and only the fingers, thumb and forearm are mobilised; thereafter wrist range and then load are restored, with a realistic ceiling of roughly 50–65% of contralateral flexion–extension and ~70–80% grip.

Prior to treatment, check the patient's operation report and confirm the fixation used (circular/dorsal plate, headless compression screws, staples or K-wires) and whether the scaphoid was excised. Do NOT initiate wrist motion until the treating surgeon confirms radiographic union — typically 6–8 weeks, sometimes longer with screw or staple fixation. Counsel the patient from the first visit that the goal is a pain-free, functional wrist with a deliberately reduced arc, not full mobility.

Phase I — protected immobilisation until union (weeks 0 to ~6–8)

The fusion is healing like a fracture, so the wrist is held still while the bones knit. The hand and forearm are kept fully mobile to prevent stiffness and tendon adhesion, but the wrist is not moved.

For your hand therapist:

Education and precautions - Wrist immobilised in a cast or splint until the surgeon confirms radiographic union (typically 6–8 weeks) - No active or passive wrist motion during this phase - No gripping, lifting, pushing, pulling or weight-bearing through the operated wrist - Set the expectation early: final motion will be reduced (the radiolunate joint is preserved; the midcarpal joint is fused)

Management - Wound: surgical dressings as directed; bulky dressing/splint for ~10–14 days, then short-arm cast or thermoplastic splint; monitor for infection - Oedema: elevation above heart level, gentle hand pumping, ice as needed - Exercises: full active finger, thumb and MCP/IP ROM; forearm pronation/supination; gentle shoulder and elbow ROM; no wrist motion

Criteria to progress - Radiographic union confirmed by the surgeon (do not progress on calendar alone); wound healed; swelling controlled

Phase II — restoring wrist motion (from union, ~weeks 6–8 to 12)

Once the surgeon confirms the fusion is solid, the wrist comes out of the cast and gentle wrist movement begins. Progress is gradual; the patient is reminded that the fused portion will not move and the achievable arc is smaller than before.

For your hand therapist:

Assessments - Wrist active and passive ROM (flexion/extension, radial/ulnar deviation), forearm rotation, grip baseline, pain and swelling, wound/scar review

Education and precautions - Begin active and active-assisted wrist ROM within comfort; transition to a removable wrist splint for comfort/protection between sessions - Continue to avoid heavy gripping, loaded lifting and weight-bearing through the wrist until cleared for strengthening - Reinforce the reduced-motion expectation (target ~50–65% of the contralateral flexion–extension arc)

Management - Exercises: active/active-assisted wrist flexion, extension, radial and ulnar deviation; commence scar massage and desensitisation once the wound is fully healed; continue full finger/thumb ROM and forearm rotation; oedema management as needed

Criteria to progress - Comfortable, controlled wrist arc within the expected reduced range; pain settling; surgeon's clearance for strengthening

Phase III — strengthening and return to function (from ~12 weeks)

With the fusion solid and motion restored to its useful ceiling, strengthening and graded loading begin and are built up over weeks. Return to manual work and sport is criterion-based.

For your hand therapist:

Assessments - Grip and pinch strength versus the other side; pain/swelling response to loading; task- and job-specific functional testing

Education and precautions - Begin progressive grip and wrist strengthening (putty, ball, then graded resistance) once cleared - Introduce loaded and weight-bearing tasks gradually; build up over several weeks rather than all at once - Expected end-point: grip recovering toward ~70–80% of the other side and a useful, pain-free, reduced arc

Management - Exercises: progressive gripping and forearm/wrist strengthening; graded functional and work simulation; ongoing scar management and ROM maintenance - Watch for and refer back to the surgeon if there is persistent dorsal wrist pain on extension (possible dorsal impingement), suspected nonunion, or a recovery plateau - Consider discharge once strength and function are adequate for the patient's daily and occupational needs

Criteria for return to load / work - Solid united fusion, pain-free within the restored arc, grip adequate for task; heavy manual demands deferred until ~4–6 months and graded up

Getting back to work and activity

Light everyday hand use — eating, writing, light self-care — is encouraged from the start, within comfort, as long as it does not load or twist the wrist. Because you must not drive while your wrist is in a cast or unable to safely control the wheel, plan for help with transport in the early weeks; driving resumes once you are out of the cast and can confidently control the car, as confirmed at your review.

Gripping, lifting and weight-bearing through the wrist wait until the fusion is confirmed solid (usually after about six to eight weeks) and are then built up gradually. People with desk-based or light work often return at around three months; heavier manual work is usually closer to four to six months and is reintroduced in stages. Throughout, remember that the planned result is a comfortable, useful wrist with a reduced range of movement — judged by how the wrist feels and functions, with Dr Hirpara and your hand therapist guiding the pace, not the calendar alone.

After your protocol

This protocol works alongside the practice's general recovery advice — see managing post-operative pain, wound care and scar management. The phased plan above reflects published rehabilitation guidance after partial wrist fusion, and your ongoing recovery is guided individually by Dr Hirpara and your hand therapist according to how your wrist heals and progresses.

Reviewed by Dr Kieran Hirpara · 2026-06-21 02:56:25.798536+00:00.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

Partial Wrist Fusion — Procedure Outcomes & Post-operative Rehabilitation (Capitolunate / Four-Corner Arthrodesis with Scaphoid Excision)

Topic scope: post-operative rehabilitation after midcarpal partial wrist arthrodesis for scapholunate advanced collapse (SLAC) or scaphoid nonunion advanced collapse (SNAC). The index procedure here is a capitolunate fusion (the capitate fused to the lunate, usually with excision of the worn scaphoid); the closely related four-corner fusion (lunate–capitate– triquetrum–hamate) follows the same rehabilitation principles. This is a bony arthrodesis, so the rehabilitation is a union-gated pathway: the mid-wrist is immobilised until the fusion consolidates, after which a deliberately reduced wrist arc and grip are restored.

Defining principle of the rehab here: a partial wrist fusion is a motion-preserving salvage. The arthritic midcarpal surfaces are fused to abolish pain, while the radiolunate joint is intentionally preserved to retain movement. The construct that needs protecting is healing bone (plate, headless screws, staples or K-wires across the fusion), not a soft-tissue repair — so progression is gated by radiographic union, not a calendar. Counselling the patient that the planned end-point is a pain-free, functional wrist with a reduced arc (~50–65% of normal flexion–extension, ~70–80% grip) is itself part of the treatment: the reduced motion is the intended trade-off, not a failure. The two principal branch points are the fixation method (which sets the immobilisation window and union risk) and whether scaphoid excision was performed (standard in the SLAC/SNAC setting).

A. PROCEDURE OUTCOMES (capitolunate / four-corner fusion for SLAC–SNAC)

Partial wrist fusion is a well-established, durable salvage for the SLAC/SNAC wrist. The dominant debate is which motion-preserving salvage (four-corner / capitolunate fusion vs proximal row carpectomy), not whether to operate; both reliably relieve pain at the cost of some motion.

  • Reliable pain relief with a useful but reduced arc. Across series, midcarpal fusion abolishes the painful midcarpal arthritis while preserving radiolunate motion. Typical results are roughly 50–65% of contralateral flexion–extension and ~70–80% of contralateral grip strength, with high rates of pain relief and return to work — the expected, planned trade-off of a partial fusion [Enna Hand Clin 2005; Strauch J Hand Surg Am 2011; Merrell J Hand Surg Am 2008; long-term series J Wrist Surg 2015]. Moderate (cohort/consensus).
  • Capitolunate fusion (± scaphoid excision) performs comparably to full four-corner fusion while fusing fewer joints, simplifying the construct. A systematic review of capitolunate arthrodesis and comparative work report comparable motion, grip and union to four-corner fusion, supporting it as a sound index choice [Dunn J Hand Surg Am 2020 (systematic review); lunocapitate series J Hand Surg Eur 2009; J Chin Med Assoc 2017]. Moderate.
  • A meta-analysis of two-, three- and four-corner constructs finds the number of fused columns does not materially change motion, grip, union or complications — biomechanically consistent with the radiolunate joint being the motion-determining segment [Hundepool J Hand Surg Am 2025 (SR/meta-analysis); Hernandez-Soria J Hand Surg Am 2016 (capitate-position biomechanics)]. Moderate (SR) + mechanistic.
  • Modern fixation is forgiving but union is not guaranteed. Circular dorsal plates, headless compression screws and nitinol staples all achieve consolidation in the great majority, with nonunion and dorsal impingement the characteristic failures to watch for [Merrell J Hand Surg Am 2008 (circular plate); Ahmady J Hand Surg Glob Online 2025 (nitinol staples)]. Moderate.

B. REHABILITATION / THERAPY EVIDENCE

The rehab questions are (1) how long to immobilise, (2) what gates the start of wrist motion, and (3) how to set the patient's expectation of reduced motion. The evidence and published surgeon protocols converge on a union-gated sequence: immobilise the wrist (mobilise the hand and forearm) for ~6–8 weeks, then restore a reduced arc, then strengthen.

  • Immobilise until radiographic union, not by the calendar. Because the construct is bony, wrist motion is withheld until the surgeon confirms consolidation — typically 6–8 weeks, longer with some screw/staple fixations. Published institutional protocols use a bulky dressing/splint for ~10–14 days, a short-arm cast to ~4–6 weeks, then a removable splint as motion begins. Moderate (consensus protocols).
  • Keep the hand and forearm fully mobile from day one. Immediate active finger, thumb and forearm rotation prevents stiffness and tendon adhesion without disturbing the fusion — the same glide-preserving logic used across hand rehab. Consensus.
  • Restore motion gradually after union, against a realistic ceiling. Once united, active and active-assisted wrist ROM is introduced; patients should be counselled that the fused midcarpal segment will not move and the achievable arc is smaller than pre-operatively (the radiolunate joint alone supplies wrist motion). Consensus + mechanistic (capitate-position biomechanics, Hernandez-Soria 2016).
  • Strengthen and load only once the fusion is solid. Grip and loaded/weight-bearing work begins after union and is built up gradually; heavy manual demands are deferred to ~4–6 months. Consensus.

Recovery trajectory (expected, evidence-anchored)

Phase Window Restraint Hand use / therapy focus Strength / load Notes
I — Immobilisation (union) Week 0 to ~6–8 Wrist immobilised (cast/splint) Full active finger, thumb & forearm motion; oedema control, elevation; no wrist motion None through the wrist Fusion knits like a fracture; progress is gated by radiographic union, not the calendar
II — Restoring wrist motion From union (~wk 6–8) to 12 Heavy-load avoidance; removable splint Begin active/active-assisted wrist flexion/extension & deviation; scar massage once healed No loaded grip yet Counsel the reduced-arc expectation (~50–65% of normal flexion–extension)
III — Strengthening & return From ~12 weeks (post-union) Restrictions lifted progressively Progressive grip/wrist strengthening; graded job simulation Grip recovers toward ~70–80% of the other side Desk work ~3 months; heavy manual ~4–6 months. Watch for dorsal impingement / nonunion

(Phase windows mirror the precautions in the patient protocol and published surgeon protocols; they are typical guides anchored to union, not trial-derived deadlines.)

C. KEY CONTROVERSIES / EVIDENCE QUALITY

  1. Capitolunate vs four-corner vs proximal row carpectomy (PRC). All three are accepted motion-preserving salvages for SLAC/SNAC. PRC tends to give a slightly larger arc and avoids fusion-specific complications (nonunion, dorsal impingement, hardware), while fusion may give marginally better grip and is preferred where capitate-head or proximal-capitate cartilage is compromised. Systematic reviews and a meta-analysis find no consistent superiority of one over the other; choice is individualised [Mulford J Hand Surg Eur 2009; J Hand Surg Am 2024 meta-analysis; Strauch J Hand Surg Am 2011]. Moderate (SR/meta-analysis of mostly observational data).
  2. Capitolunate vs full four-corner construct. Fusing fewer columns (capitolunate) simplifies the construct without clearly compromising motion, grip or union versus four-corner — consistent with the radiolunate joint being the motion-determining segment [Dunn 2020 SR; Hundepool 2025 meta-analysis; Hernandez-Soria 2016]. Moderate.
  3. When can wrist motion safely start? Union timing varies with fixation, and protocols differ on exact cast duration. The defensible position is surgeon-confirmed radiographic union gates wrist ROM rather than a fixed week number. Weak–moderate (consensus; protocol variation).
  4. Reduced motion is the plan, not a complication. The preserved radiolunate joint supplies a smaller arc by design; mislabelling the expected ~50–65% range as a poor result drives unnecessary dissatisfaction. Strong mechanistically; cohort-supported.
  5. Characteristic failures: nonunion and dorsal impingement. Both are recognised, fixation-related complications; persistent dorsal wrist pain on extension or a non-progressing fusion warrants surgical review rather than more therapy [Merrell 2008; Ahmady 2025; long-term series 2015]. Moderate.

D. EVIDENCE STRENGTH FLAGS (summary)

  • STRONG (mechanistic / well-supported): the reduced final arc is the planned consequence of preserving the radiolunate joint while fusing the midcarpal segment (capitate-position biomechanics); reliable pain relief from the fusion.
  • MODERATE: typical outcome envelope (~50–65% flexion–extension, ~70–80% grip); equivalence of capitolunate and four-corner constructs; no consistent superiority of fusion vs PRC (SR/meta-analysis of largely observational data); modern fixation achieves high union with defined nonunion / dorsal impingement risk.
  • WEAK / CONSENSUS: the specific union-gated immobilise → restore-motion → strengthen therapy sequence and exact phase timings (institutional/surgeon protocols, anchored to radiographic union rather than trial-derived).

CITATIONS

RAG corpus (180,000+ Orthopaedic articles)

  • Enna M, Hoepfner P, Weiss AC. Scaphoid excision with four-corner fusion. Hand Clin. 2005. DOI: 10.1016/j.hcl.2005.08.012
  • Dunn JC, Polmear MM, Scanaliato JP, et al. Capitolunate arthrodesis: a systematic review. J Hand Surg Am. 2020. DOI: 10.1016/j.jhsa.2019.10.007
  • Hundepool CA, Duraku LS, Quanjel TJ, et al. Two-, three-, or four-corner arthrodesis for midcarpal osteoarthritis: a systematic review and meta-analysis. J Hand Surg Am. 2025. DOI: 10.1016/j.jhsa.2023.04.018
  • Strauch RJ. Scapholunate advanced collapse and scaphoid nonunion advanced collapse arthritis — update on evaluation and treatment. J Hand Surg Am. 2011. DOI: 10.1016/j.jhsa.2011.01.018
  • Merrell GA, McDermott EM, Weiss AC. Four-corner arthrodesis using a circular plate and distal radius bone grafting: a consecutive case series. J Hand Surg Am. 2008. DOI: 10.1016/j.jhsa.2008.02.001
  • Hernandez-Soria A, Das De S, Model Z, et al. The effect of capitate position on coronal plane wrist motion after simulated 4-corner arthrodesis. J Hand Surg Am. 2016. DOI: 10.1016/j.jhsa.2016.07.101
  • Ahmady AA, Zalzaleh M, Riedel BB. Midterm outcomes of four-corner fusion surgery using nitinol staples. J Hand Surg Glob Online. 2025. DOI: 10.1016/j.jhsg.2025.100805
  • Mulford JS, Ceulemans LJ, Nam D, Axelrod TS. Proximal row carpectomy vs four corner fusion for scapholunate (SLAC) or scaphoid nonunion advanced collapse (SNAC) wrists: a systematic review of outcomes. J Hand Surg Eur Vol. 2009. DOI: 10.1177/1753193408100954
  • Four-corner fusion versus proximal row carpectomy for scapholunate advanced collapse and scaphoid nonunion advanced collapse wrist: a systematic review and meta-analysis. J Hand Surg Am. 2024. DOI: 10.1016/j.jhsa.2024.01.011
  • Long-term results of lunocapitate arthrodesis with scaphoid excision for SLAC and SNAC wrists. J Hand Surg Eur Vol. 2009. DOI: 10.1177/1753193409105683
  • Lunocapitate fusion with scaphoid excision for the treatment of scaphoid nonunion advanced collapse or scapholunate advanced collapse wrist. J Chin Med Assoc. 2017. DOI: 10.1016/j.jcma.2016.10.001
  • The long-term outcome of four-corner fusion. J Wrist Surg. 2015. DOI: 10.1055/s-0035-1549277

Partial wrist fusion rehabilitation literature (protocols & guidance — basis for the union-gated phase structure)

  • University of Virginia Department of Orthopaedic Surgery. Wrist Partial Fusion (4-Corner) Rehabilitation Guidelines. https://med.virginia.edu/orthopaedic-surgery/wp-content/uploads/sites/242/2024/09/Wrist-Partial-Fusion-4-corner.pdf
  • Oregon Health & Science University (OHSU). Four-Corner Partial Wrist Fusion — Surgery Guide. https://www.ohsu.edu/sites/default/files/2020-12/Four-Corner%20Partial%20Wrist%20Fusion.pdf
  • Alaska Orthopedic Specialists. Four-Corner Fusion with Scaphoid Excision — Post-operative Protocol. https://www.akortho.com/wp-content/uploads/Four-Corner-Fusion-with-Scaphoid-Excision-1.pdf
  • Twin Cities Orthopedics (Olson). Scaphoid Excision 4-Corner Fusion Post-operative Protocol. https://www.toportho.com/wp-content/uploads/2024/10/olson-_4-Corner-Fusion-Protocol.pdf
  • The long-term outcome of four-corner fusion (open-access full text). PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC4408128/

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

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

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

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

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

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

5. Downstream recipients.

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

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

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

b. Other rights.

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

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

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

Section 3 -- License Conditions.

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

a. Attribution.

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

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

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

ii. a copyright notice;

iii. a notice that refers to this Public License;

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

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

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

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

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

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

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

Section 4 -- Sui Generis Database Rights.

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

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

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

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

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

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

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

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

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

Section 6 -- Term and Termination.

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

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

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

2. upon express reinstatement by the Licensor.

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

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

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

Section 7 -- Other Terms and Conditions.

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

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

Section 8 -- Interpretation.

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

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

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

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

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

Creative Commons may be contacted at creativecommons.org.