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Pilon fracture

48 citationsUpdated Sep 2026

Overview

High-energy pilon fractures present a significant clinical challenge, with no level I evidence currently defining optimal management [1]. These injuries are technically demanding to treat and require thoughtful planning to avoid complications associated with the soft-tissue envelope [16]. Historically plagued by wound and infectious issues, staged operative care is emphasized to mitigate these risks [2]. Complications can be minimized through preoperative planning, meticulous operative technique, and delaying surgery 5 to 14 days until swelling subsides [5]. Despite these strategies, the consequences of pilon fractures can be persistent and devastating to patients' health and well-being at more than three years after the injury [6].

The most important factor affecting outcome in surgically treated tibia pilon fractures is the quality of reduction [21]. There is no 'one-size-fits-all' approach to complex pilon fractures; surgeons must weigh the advantages and disadvantages of all techniques and select the method based on soft tissue status, comorbidities, and specific injury patterns [18]. In patients with a pilon fracture, the use of computer-assisted preoperative planning yielded better functional and radiographic outcomes and a lower rate of soft-tissue complications compared with the use of conventional planning methods [11].

Anatomy & Pathophysiology

Bony Anatomy

The ankle mortise is formed by the tibial plafond, medial malleolus, and lateral malleolus, which articulates with the dome of the talar body [49]. During motion from plantar flexion to dorsiflexion, the ankle mortise widens 1 to 1.5 mm [49]. Consequently, medial and superior clear spaces appear wider with the foot in plantar flexion [49]. The distal fibula features a convex medial surface that articulates with the concave incisura fibularis of the distal lateral tibia [49]. The fibula rotates approximately 2 degrees within the incisura during ankle motion and ambulation [49]. Ankle dorsiflexion results in external rotation and proximal translation of the fibula [49]. The distal tibiofibular joint and fibula provide stability against lateral talar translation [49].

Ligamentous Anatomy

The lateral ankle ligaments function as restraints to varus and inversion forces at the ankle [49]. The anterior talofibular ligament originates from the anteroinferior aspect of the lateral malleolus, 1 cm proximal to its tip, and extends to the lateral aspect of the talar neck [49]. The calcaneofibular ligament extends from the tip of the lateral malleolus to the lateral aspect of the calcaneus [49]. The posterior talofibular ligament extends from the posterior lateral malleolus to the posterolateral talus [49]. Among these, the anterior talofibular ligament is the weakest ankle ligament, while the posterior talofibular ligament is the strongest [49].

The deltoid ligament complex is the primary ankle stabilizer during stance [49]. The deep deltoid ligament extends from the apex of the medial malleolus to the medial talar body and functions primarily to resist lateral talar translation and external rotation [49]. The posterior deep deltoid ligament is the most important component of the deltoid complex [49]. The superficial deltoid ligament extends from the distal medial malleolus to the navicular bone, sustentaculum tali of calcaneus, medial talus, and spring ligament [49]. This superficial component functions primarily to resist valgus and eversion ankle forces [49]. Biomechanical testing demonstrates that the deep deltoid ligament has the highest load to failure at 713.8 N ± 69.3 compared with the lateral collateral ligaments [54]. The dominant mode of failure for the deep deltoid ligament is an intrasubstance rupture near its talar insertion [54]. In contrast, the dominant mode of failure for the superficial deltoid ligament is at its insertion on the anterior malleolus [54]. The deltoid ligament has a rich vascular supply from the medial tarsal artery, posterior tibial artery, and tibialis anterior artery [54].

Biomechanics & Motion

The ankle joint is responsible for most sagittal plane motion of the foot and ankle [49]. Ankle plantar flexion ranges from 23 to 48 degrees [49]. Ankle dorsiflexion ranges from 10 to 23 degrees [49]. The ankle joint also contributes to inversion, eversion, and rotation [49]. A simplified model of the ankle joint has a horizontal axis from anteromedial to posterolateral and a coronal axis from superomedial directed distally and laterally to the tip of the fibula [49].

Pathophysiology & Injury Mechanisms

A high-energy axial impulse on a fixed ankle specimen in light dorsiflexion and supination can successfully simulate realistic pilon fractures in cadaveric specimens with an intact soft tissue envelope [71]. The fibular lesion is part of a single biomechanical entity of distal tibial fractures [87].

Achieving a reduced ankle requires that the fibula be restored to its full length [53]. The talus must sit squarely in the mortise with no tilt [53]. The medial joint space must be restored to its normal width [53]. There must be no tibiofibular diastasis [53]. Swelling can be severe and may preclude surgery until it improves enough that the surgeon is confident they can close primarily [53]. Persistent swelling that does not settle may be due to persistent subluxation or instability that needs to be addressed [53].

Injury patterns vary by Danis–Weber classification. Undisplaced Danis–Weber type C fractures are often accompanied by disruption of medial structures as well as the tibiofibular syndesmosis and interosseous membrane [53]. Displaced Danis–Weber type A fractures are usually accompanied by a nearly vertical medial malleolar fracture that tends to displace proximally [53]. Displaced Danis–Weber type B fractures are typically spiral and accompanied by an oblique medial malleolar fracture [53]. Abduction injuries lead to a more transverse fibula fracture line and tend to be more unstable and more likely to require fixation [53]. Displaced Danis–Weber type C fractures occur above the syndesmosis and frequently have associated medial and posterior malleolar fragments [53].

Malreduction of the posterior malleolus leads to syndesmotic malreduction [93]. Syndesmotic malreduction risk is associated with incisura anatomy, where deep incisuras with the fibula not engaged into the tibial incisura are at risk of overcompression [57]. Anteverted incisuras are at risk of anterior fibular translation [57]. Retroverted incisuras are at risk of posterior fibular translation [57].

Classification

AO/OTA: The inter-observer reliability of the AO classification for tibial pilon fractures was poor (κ = 0.331) when assessed using 2D CT scans [43]. This reliability improved significantly to moderate (κ = 0.467, P = 0.03) when assessed using 3D-SR-CT reconstruction [43]. The intra-observer reliability of the AO classification was moderate (κ = 0.494) when assessed using 2D CT scans [43]. This intra-observer reliability improved to good (κ = 0.602) when assessed using 3D-SR-CT reconstruction, though the improvement was not significant (P = 0.167) [43].

Other Considerations: Using 3D CT images did not improve the intraobserver and interobserver reliabilities of the classification and treatment recommendations for pilon fractures [29]. Conversely, using 2D CT images improved the intraobserver and interobserver reliabilities of the fracture classifications and interobserver agreement for treatment recommendations for pilon fractures [29]. A nomogram model based on age, preoperative blood sugar, operative time, Tscherne classification, and fracture classification demonstrated good discrimination and calibration power for predicting surgical site infection risk in patients with pilon fractures [41].

Clinical Presentation

Pilon fractures carry a long-term burden, with persistent and devastating consequences on patients' health and well-being documented more than three years after the initial injury [6]. The clinical picture is further complicated by systemic factors; comorbid mental health conditions are associated with higher postoperative complication, readmission, and revision surgery rates for treated pilon fractures [35].

Functional recovery is assessed against specific range-of-motion benchmarks. Satisfactory ankle motion after pilon fracture treatment is defined as dorsal flexion of at least 15 degrees and plantar flexion of at least 30 degrees [65]. While clinical examination guides immediate management, molecular markers also inform prognosis. Diminished miR-122-5p is a potential prognostic indicator for nonunion in pilon fractures [74].

Investigations

CT: Computed tomography is the primary modality for characterizing the fracture pattern in pilon injuries. It is specifically helpful in identifying the fracture pattern when concurrent ipsilateral Tillaux fractures or medial malleolar fractures are present [100]. Axial CT scans provide the necessary data to accurately reconstruct the articular surface and guide surgical approach strategies for complex tibial Pilon fractures, facilitating solid internal fixation of assembled locking plates [48]. A simple, standardized, and reliable technique has been developed to quantify tibiotalar joint space following tibial pilon fracture on weight-bearing CT [95].

Other Considerations: Computer-assisted preoperative planning yields better functional and radiographic outcomes and a lower rate of soft-tissue complications compared with conventional planning methods in patients with a pilon fracture [11]. Early postoperative functional exercises contribute to the functional recovery of affected limbs and reduce related complications in surgically treated complex tibial Pilon fractures [48].

Treatment

Non-Operative

The provided evidence base does not support specific conservative management protocols such as weight loss, physical therapy, NSAIDs, or injections for pilon fractures.

Operative

Indications: Open reduction and internal fixation is indicated in types II and III pilon fractures [17]. For Ruedi type I pilon fractures, open reduction with plating is a reasonably effective procedure [20]. In cases of severely comminuted, non-reconstructable pilon fractures, blade plate ankle fusion using a posterior approach serves as a reliable salvage method for a small subset of patients [25].

Surgical Approach / Technique: Delayed internal fixation with interval temporizing external fixation represents the preferred technique for managing most high-energy pilon fractures presenting with characteristically substantial soft-tissue trauma [23]. Surgical approach strategies for complex tibial Pilon fractures based on axial CT scans accurately reconstruct the articular surface and achieve solid internal fixation of assembled locking plates, while early postoperative functional exercises contribute to the functional recovery of affected limbs and reduce related complications [48]. The sagittal plane alignment does not appear to be affected by the surgical approach [28]. Specific incisions include a modified posteromedial approach for posterior pilon variant fractures, which appear less common than previously reported [3], and the postero-medio-anterior approach, recommended as a simple and reliable incision for open reduction [4]. A novel anterior curved incision combined with MIPO achieves high functional recovery with a low complication rate [10]. For specific types of posterior pilon fractures, the trans-fibular fracture approach provides a better surgical option with a high rate of anatomic repositioning and a good near-term outcome [26].

Implant Selection: Pilon fractures treated with a single plate had more callus formation six months after surgery compared to those treated with dual plate fixation, and there was no difference in reoperation rates [7]. The Scallop Plate is effective for the treatment of pilon fractures and should be used in conjunction with a staged procedure in the acute trauma setting [8]. Hybrid external fixation is an effective method of stabilising tibial pilon fractures, particularly those with marked comminution [22]. External fixation is a satisfactory method of treatment for fractures of the tibial plafond and is associated with fewer complications than internal fixation [83].

Open Fracture Management: The use of staged wound debridement including relatively aggressive bone debridement in conjunction with systemic and local antibiotics, external fixators and patient tailored conversion from spanning external fixator to fine wire frame achieves low rates of wound infection and complications for patients with open pilon fractures [15]. Open reduction and internal fixation of open pilon fractures was accomplished with an acceptable outcome and a low prevalence of soft-tissue complications [13].

Alternative and Salvage Procedures: Acute hindfoot nailing as an index treatment option for pilon fractures may have fewer clinical implications than has been anticipated [14]. Calcaneo-tibial nail and immediate weight bearing is a viable treatment strategy for non-compliant patients or patients with immense comorbidities [72].

Preoperative Planning and Imaging: Using 3D CT images did not improve the intraobserver and interobserver reliabilities of the classification and treatment recommendations for pilon fractures, whereas using 2D CT images improved the intraobserver and interobserver reliabilities of the fracture classifications and interobserver agreement for treatment recommendations [29].

Complications

General Outcomes and Prognosis: Tibial plafond fractures exert a significant negative impact on general health-related quality of life regardless of the operative treatment used, a finding that reflects the inherent severity of the injury [80]. Long-term outcomes correlate directly with the severity of the bone and soft-tissue injury and the quality of the reduction, with more severe injuries consistently demonstrating poorer results [44]. Psychosocial characteristics of patients may also influence the outcomes of tibial plafond fractures [80].

Wound Complications: The use of computer-assisted preoperative planning yields a lower rate of soft-tissue complications compared with conventional planning methods in patients with a pilon fracture [11]. Open reduction and internal fixation of open pilon fractures is accomplished with a low prevalence of soft-tissue complications [13]. Additionally, a novel anterior curved incision combined with MIPO for the treatment of Pilon fractures achieves a low complication rate [10].

Infection: Deep infections requiring surgery occurred in 6% of patients treated with primary ORIF within 48 hours of injury for AO OTA type 43.C pilon fractures, excluding those with local soft-tissue factors such as gross contamination or hemorrhagic fracture blisters [76].

Hardware and Mechanical Complications: Increased callus formation in comminuted pilon fractures treated with plate fixation was associated with loss of coronal plane alignment at six months [33]. In a case report of a closed pilon fracture treated with definitive open reduction and internal plate fixation at 11 days, broken screws were observed at seven months follow-up with the fracture appropriately consolidated in acceptable alignment [30]. In the same case report, the medial plate broke one month after screw removal, and the patient declined further intervention [30].

Other Considerations: Early fixation may not yield acceptable results in patients with notable regional or systemic comorbidities such as alcohol abuse, schizophrenia, diabetes, peripheral neuropathy, or hemorrhagic fracture blisters [76]. Acute hindfoot nailing as an index treatment option for pilon fractures may have fewer clinical implications regarding subtalar arthritis than has been anticipated [14].

Recovery

Other Considerations: Long-term sequelae of pilon fractures can persist and significantly impact patient health and well-being for more than three years after injury [6]. Regarding specific surgical interventions, appropriate surgical treatment of impaction is not associated with increased rates of ankle arthrosis or ankle joint failure [34]. Additionally, acute hindfoot nailing as an index treatment option may have fewer clinical implications than anticipated regarding the prevalence of subtalar arthritis [14].

Infection management and follow-up protocols are critical for recovery. A follow-up duration of 1 year is preferable for diagnosing fracture-related infections, as most develop before this time, especially when fracture union has occurred [68]. For open pilon fractures, staged wound debridement—including relatively aggressive bone debridement in conjunction with systemic and local antibiotics, external fixators, and patient-tailored conversion from spanning external fixator to fine wire frame—achieves low rates of wound infection and complications [15].

Key Evidence

  • [L5] There is no level I evidence for optimal management of high-energy pilon fractures. [1] (10.1302/2058-5241.1.000016)
  • [L4] Staged operative care is emphasized to prevent wound and infectious complications which have historically plagued pilon fracture surgery. [2] (10.1016/j.injury.2007.07.024)
  • [L4] Posterior pilon variant fractures appear less common than previously reported and can be satisfactorily treated through a modified posteromedial approach. [3] (10.1016/j.injury.2019.10.007)
  • [L4] The authors recommend this approach as a simple and reliable incision for open reduction of pilon fractures. [4] (10.1016/s0020-1383(99)00202-8)
  • [L5] Complications after treatment of tibial pilon fractures can be minimized by preoperative planning, meticulous operative technique, and delaying surgery 5 to 14 days until swelling subsides. [5] (10.5435/00124635-200007000-00006)
  • [L2] At more than three years after the injury, pilon fractures can have persistent and devastating consequences on patients' health and well-being. [6] (10.2106/00004623-200408000-00035)
  • [L3] Pilon fractures treated with a single plate had more callus formation six months after surgery compared to those treated with dual plate fixation, and there was no difference in reoperation rates. [7] (10.1016/j.injury.2020.04.023)
  • [Paper] The authors believe that this new Scallop Plate is effective for the treatment of pilon fractures and should be used in conjunction with a staged procedure in the acute trauma setting. [8] (10.1007/s00402-006-0219-1)
  • [L4] This retrospective study is the first to assess the application of a curved incision on the anterior area of ankle with MIPO for the treatment of Pilon fractures, which achieves high functional recovery with a low complication rate. [10] (10.1186/s12891-020-03207-3)
  • [L3] In patients with a pilon fracture, the use of computer-assisted preoperative planning yielded better functional and radiographic outcomes and a lower rate of soft-tissue complications compared with the use of conventional planning methods. [11] (10.2106/jbjs.24.00473)
  • [L4] Open reduction and internal fixation of open pilon fractures was accomplished with an acceptable outcome and a low prevalence of soft-tissue complications. [13] (10.2106/jbjs.h.01678)
  • [L2] This suggests that acute hindfoot nailing as an index treatment option for pilon fractures may have fewer clinical implications than has been anticipated. [14] (10.2106/jbjs.25.00233)
  • [L4] The study suggests that the use of staged wound debridement including relatively aggressive bone debridement in conjunction with systemic and local antibiotics, external fixators and patient tailored conversion from spanning external fixator to fine wire frame achieves low rates of wound infection and complications for patients with open pilon fractures. [15] (10.1016/j.injury.2020.08.029)
  • [L5] Surgical management of pilon fractures is technically demanding and requires thoughtful planning to avoid complications associated with the soft-tissue envelope. [16] (10.5435/00124635-201110000-00005)
  • [L4] Open reduction and internal fixation is indicated in types II and III pilon fractures. [17] (10.1016/0020-1383(88)90085-x)
  • [Paper] There is no 'one-size-fits-all' approach to complex pilon fractures; surgeons must weigh the advantages and disadvantages of all techniques and select the method based on soft tissue status, comorbidities, and specific injury patterns. [18] (10.1097/corr.0000000000001669)
  • [L3] Open reduction with plating was a reasonably effective procedure for the treatment of Ruedi type I pilon fractures. [20] (10.1007/s00402-006-0225-3)
  • [L4] The most important factor affecting outcome in surgically treated tibia pilon fractures was quality of reduction. [21] (10.1016/j.injury.2013.06.016)
  • [L4] Hybrid external fixation is an effective method of stabilising tibial pilon fractures, particularly those with marked comminution. [22] (10.1016/j.injury.2016.07.045)
  • [L4] Delayed internal fixation with interval temporizing external fixation represents the preferred technique for managing most high-energy pilon fractures presenting with characteristically substantial soft-tissue trauma. [23] (10.2106/jbjs.21.01377)
  • [L4] Blade plate ankle fusion using a posterior approach is a reliable method for the treatment of a small subset of patients with severely comminuted, non-reconstructable pilon fractures. [25] (10.2106/jbjs.m.00544)
  • [L3] The trans-fibular fracture approach provides a better surgical option for specific types of posterior pilon fractures with a high rate of anatomic repositioning and a good near-term outcome. [26] (10.1186/s13018-022-03106-4)
  • [L3] The sagittal plane alignment does not appear to be affected by the surgical approach. [28] (10.1016/j.injury.2020.01.020)
  • [L4] Using 3D CT images did not improve the intraobserver and interobserver reliabilities of the classification and treatment recommendations for pilon fractures, whereas using 2D CT images improved the intraobserver and interobserver reliabilities of the fracture classifications and interobserver agreement for treatment recommendations. [29] (10.1016/j.otsr.2019.07.011)
  • [L4] [30] (10.1016/j.injury.2019.07.023)
  • [L3] Increased callus formation in comminuted pilon fractures treated with plate fixation was associated with loss of coronal plane alignment at six months. [33] (10.1016/j.injury.2020.10.080)
  • [L3] When impaction is surgically treated appropriately, it is not associated with increased rates of ankle arthrosis or ankle joint failure. [34] (10.1016/j.injury.2020.01.008)
  • [L3] Comorbid MH conditions are associated with higher postoperative complication, readmission, and revision surgery rates for treated femoral, tibial, and pilon fractures. [35] (10.1097/bot.0000000000001438)
  • [L3] The established nomogram model based on age, preoperative blood sugar, operative time, Tscherne classification, and fracture classification demonstrated good discrimination and calibration power for predicting surgical site infection risk in patients with pilon fractures. [41] (10.1186/s13018-023-04058-z)
  • [L4] [43] (10.1007/s00402-019-03259-8)
  • [L4] Surgical approach strategies for complex tibial Pilon fractures based on axial CT scans accurately reconstruct the articular surface and achieve solid internal fixation of assembled locking plates, while early postoperative functional exercises contribute to the functional recovery of affected limbs and reduce related complications. [48] (10.1186/s13018-020-01770-y)
  • [L3] [65] (10.1016/j.injury.2017.03.023)
  • [L3] Follow-up of 1 year is preferable because most FRIs will develop before that time, especially when fracture union has occurred. [68] (10.1097/corr.0000000000001911)
  • [Paper] A high energetic axial impulse on a fixed ankle specimen in light dorsiflexion and supination can successfully simulate realistic pilon fractures in cadaveric specimens with intact soft tissue envelope. [71] (10.1007/s00402-020-03538-9)
  • [L4] [72] (10.1016/s0020-1383(12)70031-1)
  • [L4] Diminished miR-122-5p emerges as a potential prognostic indicator for nonunion in Pilon fractures. miR-122-5p accelerates the healing of Pilon fractures by targeting and inhibiting PDCD4. [74] (10.1186/s13018-025-06120-4)
  • [L5] [76] (10.5435/jaaos-d-17-00160)
  • [L3] [80] (10.1016/j.injury.2015.06.025)
  • [L1] [83] (10.2106/00004623-199611000-00003)
  • [L4] The study confirms the importance of the fibular lesion within a single biomechanical entity of distal tibial fractures and supports double surgical fixation as a complement to stability and assistance to reduction when external fixation or nailing is indicated. [87] (10.1016/j.otsr.2010.07.002)
  • [L5] Medial-lateral syndesmotic reduction was affected by the conditions of the posterior malleolus fixation, with malreduction of the posterior malleolus leading to syndesmotic malreduction. [93] (10.2106/jbjs.17.00217)
  • [L3] A simple, standardized, and reliable technique was developed to quantify tibiotalar joint space following tibial pilon fracture on WBCT. [95] (10.2106/jbjs.19.00816)
  • [L4] Computerized tomography is helpful in identifying the fracture pattern. [100] (10.1186/s13018-020-01961-7)

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Using Creative Commons Public Licenses

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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.