Skip to content

Ankle & Tibial Fractures

Ankle & tibial fractures: classification, stable vs unstable injury patterns, ORIF indications, and pilon fracture management.

Overview

Ankle fractures are common injuries that may result in tibiotalar instability [2]. When appropriately managed either surgically or nonsurgically, these fractures typically yield good outcomes [2]. Non-surgical treatment of stable ankle fractures does not lead to an increase in reoperations caused by non-union [5]. However, a wide variety of outcome measures are used in interventional trials, with no consensus on a core set of primary outcomes [3].

Current evidence is insufficient to strongly recommend concurrent ankle arthroscopy in the routine management of ankle fractures, as it is not routinely performed by most orthopedic surgeons [10]. High-quality studies are needed to solidify the role of this technique [10]. For unstable tibial fractures, a composite technique is useful for a subset of patients who are unwilling or unable to undergo surgery [11]. In Finland, findings on complications after ankle fracture surgery allow for the identification of patients prone to complications or reoperations following operative treatment [19].

Regarding operative management, patients should be offered spinal anesthesia unless there is a specific contraindication [20]. Where medically or socially appropriate, surgery should be provided in an outpatient surgical facility to provide the greatest value to the patient and society [23]. Future studies must continue to investigate the mechanism of injury, fracture patterns, and optimal treatments [1]. Recent research topics include indications for operative treatment of isolated lateral malleolus fractures, the need for fixation of the posterior malleolus, utilization of the posterolateral approach, treatment of the syndesmosis, and the potential role of fibular nailing [25]. Authors recommend defining a core outcome set for use following tibial fracture to standardise outcome reporting [43].

Anatomy & Pathophysiology

Ankle fractures represent common injuries, with rotational variants among the most frequent requiring orthopaedic care [2, 6]. These injuries span a spectrum from simple cases with minimal long-term effects to complex fractures with severe sequelae [6]. Demographic analysis reveals substantial differences between men and women regarding age, lifestyle factors, comorbidities, accident mechanisms, and fracture types [8].

Diagnostic Imaging: While standard protocols may suffice, the inclusion of computed tomography (CT) can detect a higher volume of injuries in larger cohorts [26]. Pre-operative CT scans of both the injured and uninjured ankles provide surgeons with more accurate information for reduction and facilitate correct intraoperative maneuvers [30].

Surgical Approaches and Fixation: The posterolateral surgical approach offers adequate access to the posterior malleolus, enabling anatomical reduction and stable fixation with few complications [57]. For unstable ankle fractures in exceptional situations, vertical transarticular-pin fixation provides efficient and reliable stabilization but should be limited to emergencies or cases where conventional methods are inadvisable [12]. In elderly patients, clinical emphasis should prioritize a congruent ankle joint with axial alignment and stability over achieving anatomic articular reduction [54].

Biomechanics and Specialized Indications: External fixation is recommended exclusively for ankle joint fractures caused by axial compression due to its biomechanical superiority and lower complication rate [51]. In congenital pseudarthrosis of the tibia treated by intramedullary nailing, the essential mechanical feature involves converting angulatory strains into longitudinal compression forces [48]. The biphasic plate concept aims to improve the biomechanics of locked plating [46]. While biomechanical data regarding the safe distance between humerus shaft fractures and distal locking screws in antegrade nailing exists, these results require confirmation via clinical studies [39]. Furthermore, the biomechanical effects of tensioned wires versus half-pins on Ilizarov ring fixators are critical for determining weight-bearing protocols in patients lacking bone apposition [56]. Although fixation patterns significantly affect pelvic mechanics, biomechanical studies remain essential for understanding the efficacy of different stabilization techniques regarding mechanical stability and early mobilization [59].

Classification

DAFC: The Distal Ankle Fracture Classification (DAFC) system provides a reliable and comprehensive framework for ankle fracture classification, offering prognostic insights specifically regarding dislocation and posterior malleolus involvement [35].

Other Considerations: Ankle fractures are common injuries that may result in tibiotalar instability and typically have good outcomes when appropriately managed either surgically or nonsurgically [2]. Rotational fractures of the ankle are among the most common injuries requiring orthopaedic care, ranging from simple injuries with minimal long-term effects to complex injuries with severe sequelae [6]. Management of ankle fractures depends on stability; stable fractures are managed nonsurgically while unstable fractures require open reduction and internal fixation [16]. Men and women differ substantially in age, lifestyle factors, comorbidities, accident type, and type of ankle fracture [8]. A wide variety of outcome measures are used in interventional trials for ankle fractures, with no consensus on a core set of primary outcomes [3]. Future studies must continue to investigate the mechanism of injury, fracture patterns, and optimal treatments for ankle fractures [1]. In resource-limited settings, adult ankle fractures in Malawi were predominantly treated nonoperatively despite often meeting evidence-based criteria for surgery due to resource limitations, knowledge deficits, and lack of treatment standardization [4]. The Ottawa ankle rule is highly sensitive and can correctly predict the likelihood of ankle fractures when present, however, lower specificity rates increase the likelihood of false positives [7].

Clinical Presentation

Ankle fractures are among the most common injuries requiring orthopaedic care, ranging from simple injuries with minimal long-term effects to complex injuries with severe sequelae [6]. These injuries may result in tibiotalar instability [2], yet typically yield good outcomes when appropriately managed either surgically or nonsurgically [2]. Adult ankle fractures in Malawi were predominantly treated nonoperatively despite often meeting evidence-based criteria for surgery [4].

Demographics: Men and women differ substantially in age, lifestyle factors, comorbidities, accident type, and type of ankle fracture [8]. Evaluation: The application of the Ottawa ankle rule is highly sensitive and can correctly predict the likelihood of ankle fractures when present, though lower specificity rates increase the likelihood of false positives [7]. Pediatric Considerations: A knowledge of common pediatric ankle fracture patterns and the pitfalls associated with their evaluation and treatment will aid the clinician in the effective management of these injuries [14].

Management Strategy: Management of ankle fractures depends on stability, where stable fractures are managed nonsurgically while unstable fractures require open reduction and internal fixation [16]. Non-surgical treatment of stable ankle fractures does not lead to an increase in reoperations caused by non-union [5]. For bimalleolar ankle fractures in older adults, treatment requires rigorous analysis starting by evaluating the cutaneous status and viability of the soft tissues upon admission [9].

Post-Operative Monitoring: The greatest incidence of ED visits after ankle fracture ORIF occurs within the first 2 weeks, with 11.5% of patients visiting the ED within 90 days [15]. Prognostic Tools: The Ganga Hospital Score can be used to predict the outcome of patients who present with an open fracture of the tibia [34].

Investigations

Plain radiography: The Ottawa ankle rule is highly sensitive for excluding fractures in acute ankle injuries in adults, though it exhibits lower specificity rates that increase the likelihood of false positives [7]. Serial roentgenographic studies are necessary to demonstrate the evolution of multiple stress fractures in rheumatoid arthritis [63]. Current evidence is insufficient to strongly recommend concurrent ankle arthroscopy for acute fracture fixation in the routine management of ankle fractures, and such procedures are not routinely performed by most orthopedic surgeons [10].

CT: Preoperative use of computed tomography may be justified due to the great variation in posterior malleolar fracture configurations [60]. A protocol including computed tomography of the ankle may detect more injuries in patients with spiral distal tibial fractures due to a high association with posterior malleolus fractures [26]. Use of a pre-operative CT scan of the injured and uninjured ankle gives surgeons more accurate information for reduction and helps in correct intraoperative maneuvers for Weber B and C type fractures [30]. CT scan is better than X-rays for analyzing and classifying tibial plateau fractures, although the addition of 3DCT reconstructions did not improve the reliability of CT-based evaluation of these fractures [61, 62]. Analysis of imaging features and evaluation of the diagnostic value of various methods can provide imaging basics for developing accurate treatment options for tibial shaft fractures with concomitant posterior malleolar fractures [17]. Implementation of a reduced-imaging protocol following an ankle fracture has no measurable negative effects on functional outcome, pain, and complication rates during the first year of follow-up [24].

Other Considerations: Ankle fractures may result in tibiotalar instability [2]. Future studies must continue to investigate the mechanism of injury, fracture patterns, and optimal treatments for ankle fractures [1]. There is no consensus on a core set of primary outcome measures for interventional trials in ankle fractures [3]. Recent research topics in ankle fractures include indications for operative treatment of isolated lateral malleolus fractures, the need for fixation of the posterior malleolus, utilization of the posterolateral approach, treatment of the syndesmosis, and the potential role of fibular nailing [25]. Adult ankle fractures in Malawi were predominantly treated nonoperatively despite often meeting evidence-based criteria for surgery [4]. A composite technique is useful for a subset of patients with unstable tibial fractures who are unwilling or unable to undergo surgery [11]. Vertical transarticular-pin fixation provides efficient and reliable stabilization for unstable ankle fractures in exceptional situations but should be limited to emergencies or cases where conventional methods are inadvisable [12]. Management of tibial shaft nonunions requires a multidisciplinary effort and an understanding of fundamental concepts, etiology, and risk factors [13]. Knowledge of common pediatric ankle fracture patterns and the pitfalls associated with their evaluation and treatment aids in effective management [14]. Removal of a syndesmotic screw after surgical treatment of an ankle fracture in adult patients produces no significant functional, clinical, or radiological benefit [64].

Treatment

Ankle fractures are common injuries that may result in tibiotalar instability and typically have good outcomes when appropriately managed either surgically or nonsurgically [2]. Management of ankle fractures depends on stability; stable fractures are managed nonsurgically while unstable fractures require open reduction and internal fixation [16]. The non-surgical treatment of stable ankle fractures does not lead to an increase in reoperations caused by non-union [5].

Non-Operative

Nondisplaced pediatric tibial eminence fractures are amenable to nonsurgical management, while displaced fractures are managed with arthroscopic reduction and fixation [49]. The composite technique for managing unstable tibial fractures is useful for a subset of patients with unstable tibial fractures who are unwilling or unable to undergo surgery [11]. In resource-limited settings, adult ankle fractures in Malawi were predominantly treated nonoperatively despite often meeting evidence-based criteria for surgery due to resource limitations, knowledge deficits, and lack of treatment standardization [4].

Operative

Indications: The treatment of bimalleolar ankle fractures in older adults requires rigorous analysis starting by evaluating the cutaneous status and viability of the soft tissues upon admission [9]. Patients with untypical high-energy transsyndesmotic ankle fracture dislocation ("Logsplitter" injury) had better fracture reduction, range of motion, and a low incidence rate of posttraumatic ankle arthritis than those with typical injuries [47].

Surgical Approach / Technique: Arthroscopically assisted reduction internal fixation (ARIF) and open reduction internal fixation (ORIF) are comparable in terms of providing pain relief and improving function for patients with ankle fractures [38]. Concurrent ankle arthroscopy for acute fracture fixation is not routinely performed by most orthopedic surgeons and current evidence is insufficient to strongly recommend it in the routine management of ankle fractures [10]. Vertical transarticular-pin fixation provides efficient and reliable stabilization for unstable ankle fractures in exceptional situations but should be limited to emergencies or cases where conventional methods are inadvisable [12].

Implant Selection: Retrograde tibial intramedullary nailing (RTN) is an effective and reliable option for the treatment of distal tibial fractures, demonstrating favorable clinical outcomes and a low complication rate [37]. Alignment can be well maintained despite the short distal tibial segment, and a simple articular fracture or fracture extension is not a contraindication to intramedullary fixation [44]. A systematic review suggests that fibular intramedullary nail fixation (FINF) exhibits comparable effectiveness in the management of ankle fractures among adults as compared to plate fixation (PF) [18].

Pain Management: A multimodal surgical-site injection as an adjunct to postoperative pain management in patients with operatively treated ankle fractures resulted in slightly lower mean VAS scores compared with the control group over the first 48 hours postoperatively [45]. Unless there is a specific contraindication, patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture [20].

Setting of Care: Where medically or socially appropriate, ankle fracture surgery should be provided in an outpatient surgical facility to provide the greatest value to the patient and society [23].

Other Considerations: The mean time for a tibial fracture to heal is 18 weeks, with 13.8% of patients requiring longer than 25 weeks to achieve healing [22]. Low-intensity pulsed ultrasound is a non-invasive procedure that seems to promote consolidation in case of non-union [50]. Non-union often results from a combination of adverse situations, and its prevention depends to a great extent on the application of well-established sound principles of fracture management [52]. Future studies must continue to investigate mechanism of injury, fracture patterns, and optimal treatments for ankle fractures [1]. There is no consensus on a core set of primary outcomes for interventional trials for ankle fractures, with a wide variety of outcome measures currently used [3].

Complications

Instability: Ankle fractures may result in tibiotalar instability [2]. Rotational fractures of the ankle range from simple injuries with minimal long-term effects to complex injuries with severe sequelae [6]. Long-term outcomes for distal tibial pilon fractures are related to the severity of the bone and soft-tissue injury and the quality of the reduction, with more severe injuries having a poorer outcome [21].

Infection (PJI): A low incidence of infection following open reduction and internal fixation of fractures of the ankle was observed in a large UK trauma unit [58]. Insulin-dependent diabetes mellitus was associated with an increased rate of adverse events after ankle fracture ORIF, whereas noninsulin-dependent diabetes mellitus was not [42]. At a mean of 4 years after injury, fracture-related infection and nonunion became chronic conditions in nearly a quarter of participants who experienced these complications, regardless of reintervention [31].

Wound complications: Surgical site complications account for almost half of reported readmissions after ORIF for ankle fractures [41]. The letter raises critical questions regarding the vascular supply in medial open ankle fractures, the exclusion of closed fracture dislocations, and the diagnostic criteria for osteonecrosis at early time points [28].

Other Considerations: Non-surgical treatment of stable ankle fractures does not lead to an increase in reoperations caused by non-union [5]. 11.5% of patients visited the emergency department within 90 days after ankle fracture open reduction and internal fixation (ORIF), with the greatest incidence occurring within the first 2 weeks [15]. 2% of patients required unplanned readmission after ORIF for ankle fractures [41]. Implementation of a reduced-imaging protocol following an ankle fracture has no measurable negative effects on functional outcome, pain, and complication rates during the first year of follow-up [24]. Adult ankle fractures in Malawi were predominantly treated nonoperatively despite often meeting evidence-based criteria for surgery due to resource limitations, knowledge deficits, and lack of treatment standardization [4].

Recovery

Light activity (weeks): Patients with stable ankle fractures managed non-surgically do not experience increased reoperation rates due to non-union [5]. Functional below-the-knee casting holds reduction well and permits healing of tibial fractures in a relatively short period [65]. The mean time for a tibial fracture to heal is 18 weeks, though 13.8% of patients require longer than 25 weeks to achieve healing [22]. Emergency department visits within 90 days post-ORIF for ankle fractures occur in 11.5% of patients, with the highest incidence in the first two weeks [15].

Full activity (months): In adults under 65 with unstable ankle fractures, fibular nailing yields functional outcomes at 1 year comparable to open reduction and internal fixation (ORIF) [36]. For medial malleolar fractures, single-screw and double-screw fixation show no difference in functional outcome or ankle health at 3 months [53]. Intramedullary nailing of tibial shaft fractures produces results comparable to a reference population at the 5-year follow-up [66]. Immediate internal fixation or conversion from external to internal fixation does not alter the clinical course for acute compartment syndrome associated with tibial fractures [67].

Complete recovery / outcome plateau (months): Ankle fracture outcomes are generally good with appropriate management, whether surgical or non-surgical [2]. Rotational ankle fractures range from simple injuries with minimal long-term effects to complex injuries with severe sequelae [6]. Long-term outcomes for distal tibial pilon fractures depend on the severity of bone and soft-tissue injury and reduction quality, with more severe injuries correlating to poorer outcomes [21]. At a mean of 4 years post-injury, fracture-related infection and nonunion become chronic conditions in nearly a quarter of participants, regardless of reintervention [31].

Rehabilitation protocol: Stress lesions of the distal tibial physis present with a history, examination, radiographic appearance, and recovery consistent with athletic activity [27].

Functional milestones: No specific validated PROM trajectories or outcome-measure benchmarks (e.g., Constant, ASES, WOMAC) are provided in the current evidence base for this section.

Other Considerations: The history, examination results, radiographic appearance, and recovery of a patient with a stress lesion of the distal tibial physis are consistent with a stress lesion secondary to athletic activity [27].

Key Evidence

  • [L5] It is essential that future studies continue to investigate mechanism of injury, fracture patterns, and optimal treatments for ankle fractures. (10.1007/s11999-015-4306-x)
  • [L2] The review identified a wide variety of outcome measures used in interventional trials for ankle fractures, with no consensus on a core set of primary outcomes. (10.1186/s12891-019-2770-2)
  • [L4] Adult ankle fractures in Malawi were predominantly treated nonoperatively despite often meeting evidence-based criteria for surgery due to resource limitations, knowledge deficits, and lack of treatment standardization. (10.2106/jbjs.20.00660)
  • [L3] The non-surgical treatment of stable ankle fractures does not lead to an increase in reoperations caused by non-union. (10.1186/s12891-024-07924-x)
  • [L1] Application of the OAR is highly sensitive and can correctly predict the likelihood of ankle fractures when present, however, lower specificity rates increase the likelihood of false positives. (10.1186/s12891-022-05831-7)
  • [L3] Men and women differed substantially in age, lifestyle factors, comorbidities, accident type, and type of ankle fracture. (10.1186/s12891-021-04144-5)
  • [L5] The treatment of bimalleolar ankle fractures in older adults requires rigorous analysis starting by evaluating the cutaneous status and viability of the soft tissues upon admission. (10.1016/j.otsr.2021.103137)
  • [Commentary] The author concludes that concurrent ankle arthroscopy for acute fracture fixation is not routinely performed by most orthopedic surgeons and that current evidence is insufficient to strongly recommend it in the routine management of ankle fractures, though high-quality studies are needed to solidify its role. (10.1016/j.arthro.2020.03.022)
  • [Paper] The technique is useful for a subset of patients with unstable tibial fractures who are unwilling or unable to undergo surgery. (10.1016/j.injury.2007.10.010)
  • [L4] The procedure provides efficient and reliable stabilization for unstable ankle fractures in exceptional situations but should be limited to emergencies or cases where conventional methods are inadvisable. (10.2106/00004623-196547070-00004)
  • [L5] This article provides guidance based on the most recent literature to aid the treating provider in the diagnosis, workup, and management of tibial shaft nonunions, emphasizing the need for a multidisciplinary effort and understanding of fundamental concepts, etiology, and risk factors. (10.5435/jaaos-d-23-00453)
  • [L5] A knowledge of common pediatric ankle fracture patterns and the pitfalls associated with their evaluation and treatment will aid the clinician in the effective management of these injuries. (10.5435/00124635-200107000-00007)
  • [L3] 11.5% of patients visited the ED within 90 days after ankle fracture ORIF, with the greatest incidence occurring within the first 2 weeks. (10.5435/jaaos-d-22-00484)
  • [L5] Management of ankle fractures depends on stability; stable fractures are managed nonsurgically while unstable fractures require open reduction and internal fixation. (10.5435/00124635-200311000-00004)
  • [L3] An analysis of the imaging features of such fractures and evaluation of the diagnostic value of various methods can provide imaging basics for the development of accurate and appropriate treatment options. (10.1186/s12891-018-1982-1)
  • [L1] This systematic review suggests that FINF exhibits comparable effectiveness in the management of ankle fractures among adults, as compared to PF. (10.1186/s13018-024-05032-z)
  • [L3] The findings of this study allow us to identify patients who are prone to complications or reoperations after undergoing operative treatment for ankle fracture. (10.2106/jbjs.23.00745)
  • [L2] We recommend that, unless there is a specific contraindication, patients should be offered spinal anesthesia when undergoing operative fixation of an ankle fracture. (10.2106/jbjs.h.01852)
  • [Paper] The mean time for a tibial fracture to heal is 18 weeks, with 13.8% of patients requiring longer than 25 weeks to achieve healing. (10.1016/j.otsr.2019.10.010)
  • [L3] Where medically or socially appropriate, ankle fracture surgery should be provided in an outpatient surgical facility to provide the greatest value to the patient and society. (10.5435/jaaos-d-16-00897)
  • [L1] Implementation of a reduced-imaging protocol following an ankle fracture has no measurable negative effects on functional outcome, pain, and complication rates during the first year of follow-up. (10.2106/jbjs.19.01381)
  • [L5] Recent research topics in ankle fractures include indications for operative treatment of isolated lateral malleolus fractures, the need for fixation of the posterior malleolus, utilization of the posterolateral approach, treatment of the syndesmosis, and the potential role of fibular nailing. (10.1016/j.injury.2017.08.016)
  • [L2] A protocol including computed tomography of the ankle may detect more injuries in a larger study. (10.1007/s11999-008-0224-5)
  • [L4] The history, examination results, radiographic appearance, and recovery of this patient are all consistent with a stress lesion of the distal tibial physis secondary to athletic activity. (10.1177/0363546513485938)
  • [Letter] The letter raises critical questions regarding the vascular supply in medial open ankle fractures, the exclusion of closed fracture dislocations, and the diagnostic criteria for osteonecrosis at early time points in the original study. (10.1016/j.injury.2014.11.029)
  • [L2] Use of the pre-operative CT scan of the injured and uninjured ankle gives surgeons more accurate information for reduction and helps in correct intraoperative maneuvers. (10.1016/j.injury.2018.10.005)
  • [L4] At a mean of 4 years after injury, fracture-related infection and nonunion became chronic conditions in nearly a quarter of the participants who experienced these complications, regardless of reintervention. (10.2106/jbjs.22.00016)
  • [L3] The GHS can be used to predict the outcome of patients who present with an open fracture of the tibia. (10.1302/0301-620x.102b1.bjj-2019-0853.r2)
  • [L4] The DAFC system offers a reliable and comprehensive framework for ankle fracture classification, with the added benefit of prognostic insights, particularly regarding dislocation and posterior malleolus involvement. (10.1186/s13018-025-05539-z)
  • [L1] In adults aged <65 years with unstable ankle fractures, fibular nailing did not differ from ORIF for functional outcome at 1 year. (10.2106/jbjs.22.00486)
  • [L4] RTN is an effective and reliable option for the treatment of distal tibial fractures, demonstrating favorable clinical outcomes and a low complication rate. (10.1186/s13018-025-05995-7)
  • [L1] ARIF and ORIF are comparable in terms of providing pain relief and improving function for patients with ankle fractures. (10.1186/s13018-023-03597-9)
  • [L5] These biomechanical results, although very promising, should be confirmed with clinical studies. (10.1186/s12891-025-08711-y)
  • [Letter] The authors clarify their 'four-column and nine-segment' classification system for tibial plateau fractures, addressing comments on segment injury classification, the Tibia Plateau Injury Index (TPII), rare fracture lines extending to cortices, and the exclusion of complex multi-dimensional displacement parameters. (10.1016/j.injury.2019.11.010)
  • [L3] Despite a low adverse event rate, 2% of patients required unplanned readmission after ORIF for ankle fractures, with surgical site complications accounting for almost half of reported readmissions. (10.1186/s13018-024-04895-6)
  • [L3] Insulin-dependent diabetes mellitus was associated with an increased rate of adverse events after ankle fracture ORIF, whereas noninsulin-dependent diabetes mellitus was not. (10.1007/s11999-014-4005-z)
  • [L2] The authors recommend the definition of a core outcome set for use following tibial fracture to standardise outcome reporting. (10.1016/j.injury.2018.11.025)
  • [L4] Alignment can be well maintained despite the short distal tibial segment, and a simple articular fracture or fracture extension is not a contraindication to intramedullary fixation. (10.2106/jbjs.c.01135)
  • [L1] The study evaluated the efficacy of a multimodal surgical-site injection as an adjunct to postoperative pain management in patients with operatively treated ankle fractures, finding slightly lower mean VAS scores in the injection group compared with the control group over the first 48 hours postoperatively. (10.2106/jbjs.19.00293)
  • [L5] The biphasic plate concept is aimed at improving the biomechanics of locked plating. (10.1016/j.injury.2020.04.032)
  • [L3] Patients with untypical injury had better fracture reduction, range of motion, and low incidence rate of posttraumatic ankle arthritis than those typical ones, and the postoperative outcome was affected by the injury and treatment characteristics. (10.1186/s13018-016-0502-y)
  • [L4] The essential feature of the method is mechanical, converting angulatory strains into longitudinal compression forces. (10.2106/00004623-195638020-00004)
  • [L5] Nondisplaced fractures are amenable to nonsurgical management, while displaced fractures are managed with arthroscopic reduction and fixation. (10.5435/00124635-201007000-00002)
  • [L3] Low-intensity pulsed ultrasound is a non-invasive procedure that seems to promote consolidation in case of non-union. (10.1016/j.otsr.2010.09.016)
  • [L4] External fixation is recommended only for fractures of the ankle joint caused by axial compression because it is biomechanically superior and has a lower complication rate. (10.1186/1749-799x-4-35)
  • [L5] Non-union often results from a combination of adverse situations, and its prevention depends to a great extent on the application of well-established sound principles of fracture management. (10.2106/00004623-196547010-00015)
  • [L1] In patients with a medial malleolar fracture, single-screw and double-screw surgical fixation did not differ for functional outcome or ankle health at 3 months. (10.2106/jbjs.19.00178)
  • [L5] In elderly patients, a congruent ankle joint with axial alignment and stability should be emphasized over achieving anatomic articular reduction. (10.2106/jbjs.17.01658)
  • [L5] These biomechanical effects are important for determining weight-bearing protocols in patients without bone apposition. (10.1186/1749-799x-6-61)
  • [L4] The posterolateral surgical approach to the ankle gives adequate access to the posterior malleolus, allowing its anatomical reduction and stable fixation with few complications. (10.1302/0301-620x.98b6.36497)
  • [L3] A low incidence of infection following open reduction and internal fixation of fractures of the ankle was observed. (10.1302/0301-620x.96b5.33143)
  • [Paper] The authors emphasize that fixation patterns significantly affect pelvic mechanics and that biomechanical studies provide essential knowledge regarding the efficacy of different stabilization techniques for mechanical stability and early mobilization. (10.1016/j.injury.2010.10.001)
  • [L4] Because of the great variation in fracture configurations, preoperative use of computed tomography may be justified. (10.2106/jbjs.e.00856)
  • [L3] CT scan is better than X-rays for analyzing and classifying tibial plateau fractures. (10.1016/j.otsr.2013.06.007)
  • [L3] Furthermore, the addition of 3DCT reconstructions did not improve the reliability of CT-based evaluation of tibial plateau fractures. (10.1016/j.injury.2015.12.022)
  • [L5] A heightened awareness and serial roentgenographic studies are necessary to demonstrate the evolution of these fractures. (10.2106/00004623-196749070-00017)
  • [L1] Removal of a syndesmotic screw produces no significant functional, clinical or radiological benefit in adult patients who are treated surgically for a fracture of the ankle. (10.1302/0301-620x.96b12.34258)
  • [L4] The results indicate that this type of cast holds reduction well and permits healing of tibial fractures in a relatively short period of time. (10.2106/00004623-196749050-00003)
  • [L3] Results are comparable to those of a reference population at the 5-year follow-up, highlighting that patients can expect a satisfactory outcome years after fracture and treatment. (10.1007/s00402-020-03608-y)
  • [L3] Immediate internal fixation and changing from external fixation to internal fixation did not affect the clinical course for the treatment of ACS with tibial fractures. (10.1016/j.injury.2017.11.018)

See Also

References

[1] Classifications in Brief: Lauge-Hansen Classification of Ankle Fractures. Clinical Orthopaedics and Related Research®. 2015. DOI: 10.1007/s11999-015-4306-x

[2] Chapter 43 Ankle Fractures. 2021.

[3] Primary outcome measures used in interventional trials for ankle fractures: a systematic review. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2770-2

[4] Improving Management of Adult Ankle Fractures in Malawi. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.20.00660

[5] Non-surgical treatment of lateral malleolar fractures is safe: long-term follow-up of a comprehensive treatment algorithm. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07924-x

[6] Chapter 103 Fractures of the Ankle and Tibial Plafond. 2019.

[7] Diagnostic accuracy of the Ottawa ankle rule to exclude fractures in acute ankle injuries in adults: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05831-7

[8] Operatively treated ankle fractures in Switzerland, 2002–2012: epidemiology and associations between baseline characteristics and fracture types. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04144-5

[9] Treatment of bimalleolar fractures in elderly. Orthopaedics & Traumatology: Surgery & Research. 2022. DOI: 10.1016/j.otsr.2021.103137

[10] Editorial Commentary: Optimizing Surgical Management of Ankle Fractures: Is Arthroscopy the Answer?. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2020. DOI: 10.1016/j.arthro.2020.03.022

[11] Management of unstable tibial fractures by a composite technique. Injury. 2008. DOI: 10.1016/j.injury.2007.10.010

[12] Vertical Transarticular-Pin Fixation for Unstable Ankle Fractures. The Journal of Bone & Joint Surgery. 1965. DOI: 10.2106/00004623-196547070-00004

[13] Approach to Tibial Shaft Nonunions: Diagnosis and Management. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-00453

[14] Pediatric Ankle Fractures: Evaluation and Treatment. Journal of the American Academy of Orthopaedic Surgeons. 2001. DOI: 10.5435/00124635-200107000-00007

[15] Ninety-Day Emergency Department Visits After Ankle Fracture Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-22-00484

[16] Ankle Fractures Resulting From Rotational Injuries. Journal of the American Academy of Orthopaedic Surgeons. 2003. DOI: 10.5435/00124635-200311000-00004

[17] Pre-operative radiographic findings predicting concomitant posterior malleolar fractures in tibial shaft fractures: a comparative retrospective study. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-1982-1

[18] The fibular intramedullary nail versus plate fixation for ankle fractures in adults: a systematic review and meta-analysis of randomized controlled trials. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05032-z

[19] Complications After Ankle Fracture Surgery in Finland Between 1998 and 2020. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.23.00745

[20] Spinal Anesthesia Mediates Improved Early Function and Pain Relief Following Surgical Repair of Ankle Fractures. The Journal of Bone & Joint Surgery. 2010. DOI: 10.2106/jbjs.h.01852

[21] Chapter 44 Distal Tibial Pilon Fractures. 2021.

[22] Application of the Radiographic Union Scale for Tibial fractures (RUST): Assessment of healing rate and time of tibial fractures managed with intramedullary nailing. Orthopaedics & Traumatology: Surgery & Research. 2020. DOI: 10.1016/j.otsr.2019.10.010

[23] Cost Comparison of Surgically Treated Ankle Fractures Managed in an Inpatient Versus Outpatient Setting. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-16-00897

[24] Omitting Routine Radiography of Traumatic Ankle Fractures After Initial 2-Week Follow-up Does Not Affect Outcomes. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.19.01381

[25] What’s new in ankle fractures. Injury. 2017. DOI: 10.1016/j.injury.2017.08.016

[26] High Association of Posterior Malleolus Fractures with Spiral Distal Tibial Fractures. Clinical Orthopaedics & Related Research. 2008. DOI: 10.1007/s11999-008-0224-5

[27] Stress Fracture of the Distal Tibial Physis in an Adolescent Recreational Dancer. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513485938

[28] Letter to the Editor for the article “Osteonecrosis of distal tibia in open dislocation fractures of the ankle”. Injury. 2015. DOI: 10.1016/j.injury.2014.11.029

[30] Beyond the pillars of the ankle: A prospective randomized CT analysis of syndesmosis' injuries in Weber B and C type fractures. Injury. 2018. DOI: 10.1016/j.injury.2018.10.005

[31] Outcomes of Intramedullary Nailing and External Fixation of Open Tibial Fractures. Journal of Bone and Joint Surgery. 2022. DOI: 10.2106/jbjs.22.00016

[34] The use of the Ganga Hospital Score to predict the treatment and outcome of open fractures of the tibia. The Bone & Joint Journal. 2020. DOI: 10.1302/0301-620x.102b1.bjj-2019-0853.r2

[35] A novel alphanumeric classification system for ankle fractures: clinical applications and evaluation. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05539-z

[36] In Adults Aged <65 Years with Unstable Ankle Fractures, Fibular Nailing Did Not Differ from Open Reduction and Internal Fixation for Functional Outcome at 1 Year. Journal of Bone and Joint Surgery. 2022. DOI: 10.2106/jbjs.22.00486

[37] Retrograde tibial intramedullary nailing for distal tibial fractures: outcomes and complications. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05995-7

[38] Arthroscopically assisted versus open reduction internal fixation for ankle fractures: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-03597-9

[39] Mechanical study of the safe distance between humerus shaft fracture and distal locking screws in antegrade nailing. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08711-y

[40] Response to “Comments on: Classification of tibial plateau fracture according to the ‘four-column and nine-segment”. Injury. 2020. DOI: 10.1016/j.injury.2019.11.010

[41] Readmission within 30-days of open reduction and internal fixation for ankle fractures: NSQIP analysis of 29,905 patients. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04895-6

[42] Morbidity and Readmission After Open Reduction and Internal Fixation of Ankle Fractures Are Associated With Preoperative Patient Characteristics. Clinical Orthopaedics & Related Research. 2015. DOI: 10.1007/s11999-014-4005-z

[43] Measuring outcomes following tibial fracture. Injury. 2019. DOI: 10.1016/j.injury.2018.11.025

[44] Intramedullary Nailing of Distal Metaphyseal Tibial Fractures. The Journal of Bone and Joint Surgery (American). 2005. DOI: 10.2106/jbjs.c.01135

[45] Efficacy of Multimodal Analgesic Injections in Operatively Treated Ankle Fractures. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.19.00293

[46] Biphasic Plating – In vivo study of a novel fixation concept to enhance mechanobiological fracture healing. Injury. 2020. DOI: 10.1016/j.injury.2020.04.032

[47] Treatment and outcome prognosis of patients with high-energy transsyndesmotic ankle fracture dislocation—the “Logsplitter” injury. Journal of Orthopaedic Surgery and Research. 2017. DOI: 10.1186/s13018-016-0502-y

[48] Congenital Pseudarthrosis of the Tibia Treated by the Intramedullary Nail. The Journal of Bone & Joint Surgery. 1956. DOI: 10.2106/00004623-195638020-00004

[49] Pediatric Tibial Eminence Fractures: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 2010. DOI: 10.5435/00124635-201007000-00002

[50] Low-intensity pulsed ultrasound for non-union treatment: A 14-case series evaluation. Orthopaedics & Traumatology: Surgery & Research. 2011. DOI: 10.1016/j.otsr.2010.09.016

[51] Advantages of the Ilizarov external fixation in the management of intra-articular fractures of the distal tibia. Journal of Orthopaedic Surgery and Research. 2009. DOI: 10.1186/1749-799x-4-35

[52] Diagnosis and Prevention of Non-Union. The Journal of Bone & Joint Surgery. 1965. DOI: 10.2106/00004623-196547010-00015

[53] In Medial Malleolar Fractures, Single-Screw and Double-Screw Surgical Fixation Did Not Differ for Functional Outcome at 3 Months. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.19.00178

[54] Techniques and Considerations for the Operative Treatment of Ankle Fractures in the Elderly. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.17.01658

[56] The influence of a weight-bearing platform on the mechanical behavior of two Ilizarov ring fixators: tensioned wires vs. half-pins. Journal of Orthopaedic Surgery and Research. 2011. DOI: 10.1186/1749-799x-6-61

[57] Open reduction and internal fixation of posterior malleolar fractures using the posterolateral approach. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b6.36497

[58] A case–control study of surgical site infection following operative fixation of fractures of the ankle in a large UK trauma unit. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b5.33143

[59] Biomechanical aspects of pelvic ring reconstruction techniques: Evidence today. Injury. 2010. DOI: 10.1016/j.injury.2010.10.001

[60] Pathoanatomy of Posterior Malleolar Fractures of the Ankle. The Journal of Bone & Joint Surgery. 2006. DOI: 10.2106/jbjs.e.00856

[61] Tibial plateau fractures: Reproducibility of three classifications (Schatzker, AO, Duparc) and a revised Duparc classification. Orthopaedics & Traumatology: Surgery & Research. 2013. DOI: 10.1016/j.otsr.2013.06.007

[62] Interobserver reliability of the Schatzker and Luo classification systems for tibial plateau fractures. Injury. 2016. DOI: 10.1016/j.injury.2015.12.022

[63] Multiple Stress Fractures in Rheumatoid Arthritis. The Journal of Bone & Joint Surgery. 1967. DOI: 10.2106/00004623-196749070-00017

[64] Removal of the syndesmotic screw after the surgical treatment of a fracture of the ankle in adult patients does not affect one-year outcomes. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b12.34258

[65] A Functional Below-the-Knee Cast for Tibial Fractures. The Journal of Bone & Joint Surgery. 1967. DOI: 10.2106/00004623-196749050-00003

[66] Results following prolonged recovery show satisfactory functional and patient-reported outcome after intramedullary nailing of a tibial shaft fracture: a prospective 5-year follow-up cohort study. Archives of Orthopaedic and Trauma Surgery. 2020. DOI: 10.1007/s00402-020-03608-y

[67] Is external fixation needed for the treatment of tibial fractures with acute compartment syndrome?. Injury. 2018. DOI: 10.1016/j.injury.2017.11.018

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.