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Distal humerus fracture

34 citationsUpdated Aug 2026

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Overview

Reported outcomes for acute distal humerus fractures remain inconsistent across the orthopedic literature, making it difficult for surgeons to retrospectively compare surgical techniques and clinical outcomes across studies [3]. The systematic review by [9] is the largest report of complications and reoperations of intra-articular distal humeral fractures after ORIF in the current literature [9]. Decision regarding the treatment for intra-articular fractures of the distal humerus should be based on a combination of the best available evidence and preference of the surgeon [7].

Open reduction and internal fixation (ORIF) is a viable treatment option for distal humeral fractures in the elderly, but careful patient selection is required [14]. Older patients who underwent ORIF of the distal humerus using a parallel construct demonstrated good functional outcomes and similar complications to those in previously reported studies [1]. For comminuted distal humerus fractures in young patients, ORIF appears to be the preferred surgical option, offering superior functional outcomes and a lower incidence of complications and heterotopic ossification [20].

Total elbow arthroplasty provides a successful treatment alternative for selected distal humerus fractures, particularly in elderly patients with low anticipated physical demands, severe osteopenia, or comminution [22]. Distal humerus hemiarthroplasty is a viable option in the treatment of unreconstructible distal humerus fractures, with good to excellent outcomes expected [2]. Distal humeral hemiarthroplasty is a suitable option for unreconstructable distal humeral fractures and offers good functional outcomes with acceptable complication rates [8]. Elbow hemiarthroplasty is a viable option for complex distal humeral fractures in select patients, offering functional outcomes comparable to total elbow arthroplasty while potentially avoiding complications related to the ulnar component [15].

Open reduction and internal fixation with bone grafting is the treatment of choice for nonunion of distal humerus fractures if no excessive damage of the articular surface is present [5].

Anatomy & Pathophysiology

Osseous

Coronal shear fractures of the distal humerus involve the capitellum and trochlea [35]. Posterior shear fractures of the distal humerus mostly involve the posterior aspect of the capitellum and are often associated with elbow dislocation [29]. Malunion of distal humerus fractures is a common complication influenced by biology, reduction quality, fixation methods, and mechanical failure [6].

Fixation Geometry: Precontoured locking plates may have geometric limitations in specific complex morphologies of coronal shear fractures, supporting individualized hybrid fixation strategies [27]. The 90°-configuration of LCPs considerably decreases fragment movement compared to conventional reconstruction plates [32].

Vascular & Neural

There is a lack of consensus on defining and diagnosing different types of ulnar nerve dysfunction [31].

Classification

Dubberley: Useful in describing coronal shear fractures of the distal humerus and selecting the surgical approach [30].

Other Considerations: Outcomes for capitellum fractures are unclear due to multiple classification systems and a literature consisting of small case series without comparative groups [34].

Clinical Presentation

History: Older adults with isolated distal humerus fractures face substantial mortality at 1 and 2 years, a risk strongly predicted by comorbidity burden and preinjury ambulation [17]. Management remains problematic in elderly patients with osteoporosis and comminution where open reduction internal fixation (ORIF) may be impossible [18].

Inspection & Palpation: Malunion is a common complication, influenced by biology, reduction quality, fixation methods, and mechanical failure [6].

Range-of-Motion & Stability: Internal fixation is the standard of care for intra-articular fractures, with rigid anatomic fixation combined with early motion associated with favorable results [16]. For unusual pediatric patterns, management focuses on restoring the anatomic axis, the triangle of stability, and the articular surface to ensure a stable elbow joint that allows for early motion and full range of motion [4].

Operative Decision Axes: Complete fractures are treated using a posterior approach with dual plating [10]. Current evidence indicates that OO, TRA, TS, and TT posterior approaches provide comparable overall clinical outcomes in AO/OTA type C complete intra-articular distal humerus fractures, with most outcome measures showing no statistically significant differences [19]. Elbow arthroplasty may be indicated for selected patients with severely comminuted fractures and osteoporotic bone [10].

Investigations

CT: A thorough smoking history and CT Hounsfield Unit measurements in the coronal plane may identify patients with poorer bone quality at higher risk for postoperative mechanical complications following distal humerus fracture fixation [21].

Treatment

Non-Operative

The management of distal humerus fractures remains problematic in elderly patients with osteoporosis and comminution where ORIF may be impossible [18].

Operative

Indications: Internal fixation is generally accepted as the standard of care for intra-articular distal humerus fractures, with rigid anatomic fixation combined with early motion associated with favorable results [16]. ORIF is a viable treatment option for distal humeral fractures in the elderly, provided careful patient selection is applied [14]. Distal humerus hemiarthroplasty is a viable option for unreconstructible distal humerus fractures, with good to excellent outcomes expected [2]. Total elbow arthroplasty (TEA) is a successful treatment alternative for selected distal humerus fractures, particularly in elderly patients with low anticipated physical demands, severe osteopenia, or comminution [22]. TEA constitutes a viable treatment option for complex distal humeral fractures in elderly and medically compromised patients [38]. Elbow arthroplasty may be indicated for selected patients with severely comminuted fractures and osteoporotic bone [10].

Surgical Approach / Technique: Complete distal humerus fractures are treated using a posterior approach with dual plating [10]. Posterior approaches including OO, TRA, TS, and TT provide comparable overall clinical outcomes in the management of AO/OTA type C complete intra-articular distal humerus fractures, with most outcome measures showing no statistically significant differences [19].

Implant Selection: Open reduction and internal fixation (ORIF) using parallel precontoured plates demonstrates good functional outcomes and complication rates similar to previously reported studies in elderly patients [1]. Both orthogonal and parallel plating techniques can be used to treat distal humerus fractures with excellent outcomes [12]. Distal humeral hemiarthroplasty is a suitable option for unreconstructable distal humeral fractures, offering good functional outcomes with acceptable complication rates [8]. Distal humerus hemiarthroplasty yields satisfactory functional outcomes and range of motion in complex distal humerus fractures not amenable to fixation, particularly in elderly patients [11].

Revision: Salvage TEA is a viable option for managing post-traumatic sequelae following distal humeral fracture treatment, although it is associated with a significantly increased rate of complications and significantly inferior functional outcomes compared with acute TEA [13].

Other Considerations: Management decisions for intra-articular fractures of the distal humerus should be based on a combination of the best available evidence and surgeon preference [7].

Complications

General Outcomes and Mortality: Reported outcomes for acute distal humerus fractures remain inconsistent across the orthopedic literature, complicating retrospective comparisons of surgical techniques and clinical outcomes [3]. A systematic review serves as the largest report of complications and reoperations of intra-articular distal humeral fractures after ORIF in current literature [9]. Mortality at 1 and 2 years is substantial in older adults with isolated distal humerus fractures and is strongly predicted by comorbidity burden and preinjury ambulation [17].

Nonunion and Malunion: Malunion is a common complication after distal humerus fractures, influenced by biology, reduction quality, fixation methods, and mechanical failure [6]. Nonunion of distal humerus fractures is treated with open reduction and internal fixation with bone grafting if there is no excessive damage to the articular surface [5].

Bone Quality and Mechanical Failure: Smoking history and computed tomography Hounsfield Unit (HU) measurements in the coronal plane may identify patients with poorer bone quality at higher risk for postoperative mechanical complications following distal humerus fracture fixation [21]. Management of distal humerus fractures remains problematic in elderly patients with osteoporosis and comminution where ORIF may be impossible [18]. Older patients undergoing open reduction and internal fixation (ORIF) of the distal humerus using a parallel construct demonstrate good functional outcomes and similar complication rates to previously reported studies [1].

Olecranon Osteotomy: There is a high risk of complications associated with olecranon osteotomy in the treatment of distal humerus fractures [39].

Salvage Arthroplasty: Salvage total elbow arthroplasty (TEA) is a viable option for post-traumatic sequelae following distal humerus fracture treatment, but patients have significantly increased complication rates and inferior functional outcomes compared to those undergoing acute TEA [13]. Elbow hemiarthroplasty offers functional outcomes comparable to total elbow arthroplasty while potentially avoiding complications related to the ulnar component in select patients with complex distal humeral fractures [15].

Recovery

Light activity (weeks): Evidence does not specify a week range for light activity or return to desk work.

Full activity (months): Evidence does not specify a month range for full activity or strength return.

Complete recovery / outcome plateau (months): Evidence does not specify a month range for outcome plateau.

Rehabilitation protocol: Management of unusual pediatric distal humerus fracture patterns focuses on restoring the anatomic axis, the triangle of stability, and the articular surface to ensure a stable elbow joint that allows for early motion and full range of motion [4].

Functional milestones: Older patients undergoing open reduction and internal fixation (ORIF) of the distal humerus using a parallel precontoured plate construct demonstrate good functional outcomes and complication rates similar to previously reported studies [1]. Long-term results of well-performed open reduction and internal fixation demonstrate satisfactory outcomes in most patients with bicolumnar distal humerus fractures [42]. Distal humerus hemiarthroplasty is a viable treatment option for unreconstructible distal humerus fractures, with good to excellent outcomes expected [2]. Encouraging results have been reported using total elbow arthroplasty (TEA) as a primary mode of treatment for carefully selected comminuted distal humerus fractures in elderly patients, particularly if the patient also has significant rheumatoid arthritic changes [43].

Other Considerations: A systematic review provides the largest report of complications and reoperations of intra-articular distal humeral fractures after ORIF in the current literature [9]. Salvage TEA is a viable option for managing post-traumatic sequelae following distal humeral fracture treatment, but patients undergoing salvage TEA have a significantly increased rate of complications and significantly inferior functional outcomes compared with those undergoing acute TEA [13]. In older adults with isolated distal humerus fractures, mortality at 1 and 2 years is substantial and strongly predicted by comorbidity burden and preinjury ambulation [17]. A thorough smoking history and computed tomography Hounsfield Unit (HU) measurements in the coronal plane may identify patients with poorer bone quality at higher risk for postoperative mechanical complications following distal humerus fracture fixation [21]. In older cohorts, intra-articular fractures are consistently and temporally associated with a more than two-fold increased risk of TEA compared with extra-articular fractures at every time point studied, with nearly 5.5% of patients progressing to TEA by 10 years [41].

Key Evidence

  • [L4] Older patients who underwent ORIF of the distal humerus using a parallel construct demonstrated good functional outcomes and similar complications to those in previously reported studies. [1] (10.1016/j.jhsa.2022.01.030)
  • [L4] Distal humerus hemiarthroplasty is a viable option in the treatment of unreconstructible distal humerus fractures, with good to excellent outcomes expected. [2] (10.1016/j.jse.2022.02.015)
  • [L1] Reported outcomes for acute distal humerus fractures remain inconsistent across the orthopedic literature, making it difficult for surgeons to retrospectively compare surgical techniques and clinical outcomes across studies. [3] (10.1016/j.otsr.2018.08.017)
  • [L5] Management principles focus on restoring the anatomic axis, the triangle of stability, and the articular surface to ensure a stable elbow joint that allows for early motion and full range of motion. [4] (10.5435/jaaos-d-17-00326)
  • [L5] Open reduction and internal fixation with bone grafting is the treatment of choice for nonunion of distal humerus fractures if no excessive damage of the articular surface is present. [5] (10.1016/j.jisako.2024.07.002)
  • [L5] Malunion is a common complication after distal humerus fractures influenced by biology, reduction, fixation methods, and mechanical failure. [6] (10.1016/j.jisako.2024.05.009)
  • [L5] Decision regarding the treatment for intra-articular fractures of the distal humerus should be based on a combination of the best available evidence and preference of the surgeon. [7] (10.5397/cise.2019.22.2.113)
  • [L4] Distal humeral hemiarthroplasty is a suitable option for unreconstructable distal humeral fractures and offers good functional outcomes with acceptable complication rates. [8] (10.1177/17585732211023100)
  • [L1] This systematic review is the largest report of complications and reoperations of intra-articular distal humeral fractures after ORIF in the current literature. [9] (10.1016/j.jse.2021.02.017)
  • [L4] Complete fractures are treated using a posterior approach with dual plating, while elbow arthroplasty may be indicated for selected patients with severely comminuted fractures and osteoporotic bone. [10] (10.1016/j.otsr.2013.11.002)
  • [L1] DHH yields satisfactory functional outcomes and range of motion in complex distal humerus fractures not amenable to fixation, particularly in elderly patients. [11] (10.1016/j.jseint.2026.101695)
  • [L5] Distal humerus fractures are complex, and both orthogonal and parallel plating techniques can be used to treat these difficult fractures with excellent outcomes. [12] (10.1016/j.hcl.2010.05.008)
  • [L1] Salvage TEA represents a viable option for the management of post-traumatic sequelae following the treatment of a distal humeral fracture, although patients who underwent salvage TEA had a significantly increased rate of complications and significantly inferior functional outcomes compared with those who underwent TEA acutely. [13] (10.1302/0301-620x.108b1.bjj-2025-0475.r1)
  • [Paper] Open reduction and internal fixation is a viable treatment option for distal humeral fractures in the elderly, but careful patient selection is required. [14] (10.1016/j.injury.2007.08.006)
  • [L4] Elbow hemiarthroplasty is a viable option for complex distal humeral fractures in select patients, offering functional outcomes comparable to total elbow arthroplasty while potentially avoiding complications related to the ulnar component. [15] (10.1177/1758573216640210)
  • [L5] Internal fixation is generally accepted as the standard of care for the treatment of intra-articular distal humerus fractures, with rigid anatomic fixation combined with early motion associated with favorable results. [16] (10.1016/j.hcl.2007.09.001)
  • [L3] In older adults with isolated distal humerus fractures, mortality at 1 and 2 years is substantial and strongly predicted by comorbidity burden and preinjury ambulation. [17] (10.1016/j.jse.2026.02.013)
  • [L5] The management of distal humeral fractures remains problematic, particularly in elderly patients with osteoporosis and comminution where ORIF may be impossible. [18] (10.1016/j.jse.2010.11.012)
  • [L1] Current evidence indicates that OO, TRA, TS, and TT posterior approaches provide comparable overall clinical outcomes in the management of AO/OTA type C complete intra-articular distal humerus fractures, with most outcome measures showing no statistically significant differences. [19] (10.1186/s13018-026-06739-x)
  • [L4] For comminuted distal humerus fractures in young patients, ORIF appears to be the preferred surgical option, offering superior functional outcomes and a lower incidence of complications and heterotopic ossification. [20] (10.1016/j.xrrt.2025.07.014)
  • [L3] A thorough smoking history and CT HU measurements in the coronal plane may identify patients with poorer bone quality at higher risk for postoperative mechanical complications following distal humerus fracture fixation. [21] (10.5435/jaaos-d-26-00191)
  • [L4] Total elbow arthroplasty provides a successful treatment alternative for selected distal humerus fractures, particularly in elderly patients with low anticipated physical demands, severe osteopenia, or comminution. [22] (10.1016/j.hcl.2015.06.008)
  • [L4] Precontoured locking plates may have geometric limitations in specific complex morphologies, supporting individualized hybrid fixation strategies. [27] (10.1186/s12891-026-09582-7)
  • [L4] Posterior shear fractures of the distal humerus mostly involve the posterior of the capitellum and are often associated with elbow dislocation. [29] (10.1016/j.jse.2026.05.003)
  • [L4] The study confirms the utility of the Dubberley classification in describing the fracture and selecting the surgical approach. [30] (10.1016/j.jse.2025.05.033)
  • [L5] There is a lack of consensus on defining and diagnosing different types of ulnar nerve dysfunction, necessitating prospective studies with standardized definitions. [31] (10.1016/j.jhsa.2011.11.023)
  • [L5] The 90°-configuration of LCPs was found to considerably decrease fragment movement compared to conventional reconstruction plates. [32] (10.1016/j.injury.2003.09.022)
  • [L4] The article summarizes the existing body of evidence on capitellum fractures, noting that outcomes are unclear due to multiple classification systems and a literature consisting of small case series without comparative groups, and proposes areas for future study. [34] (10.1177/1558944719878817)
  • [L4] Anatomic reduction with sufficient stability to allow for early joint mobilization is a general principal for treatment. [35] (10.1016/j.hcl.2004.08.001)
  • [L4] Total elbow arthroplasty constitutes a viable treatment option for complex distal humeral fractures in elderly and medically compromised patients. [38] (10.1016/j.injury.2009.01.123)
  • [L2] The high risk of complications in olecranon osteotomy must be considered in the decision to perform this procedure in the treatment of distal humerus fractures. [39] (10.5397/cise.2021.00591)
  • [L4] In the older cohort, intra-articular fractures were consistently and temporally associated with a more than two-fold increased risk of TEA compared with extra-articular fractures at every time point studied, with nearly 5.5% of patients progressing to TEA by 10 years. [41] (10.1177/17585732261451863)
  • [L5] Long-term results of well-performed open reduction and internal fixation demonstrate satisfactory outcomes in most patients. [42] (10.5435/00124635-201001000-00004)
  • [L4] Encouraging results have been reported using TEA as a primary mode of treatment for carefully selected comminuted distal humerus fractures in elderly patients, particularly if the patient also has significant rheumatoid arthritic changes. [43] (10.1016/j.hcl.2004.06.006)

See Also

References

[1] The Outcomes of Intra-Articular Distal Humerus Open Reduction and Internal Fixation Using Parallel Precontoured Plates in the Elderly. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.01.030

[2] Distal humerus hemiarthroplasty for trauma: a systematic review of the outcomes and complications. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.02.015

[3] Outcomes of distal humerus fractures: What are we measuring?. Orthopaedics & Traumatology: Surgery & Research. 2018. DOI: 10.1016/j.otsr.2018.08.017

[4] Approaching Unusual Pediatric Distal Humerus Fracture Patterns. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00326

[5] Nonunion of distal humeral fractures: Current concepts. Journal of ISAKOS. 2024. DOI: 10.1016/j.jisako.2024.07.002

[6] Malunion of distal humeral fractures: Current concepts. Journal of ISAKOS. 2024. DOI: 10.1016/j.jisako.2024.05.009

[7] Surgical Treatment Strategy for Distal Humerus Intra-articular Fractures. Clinics in Shoulder and Elbow. 2019. DOI: 10.5397/cise.2019.22.2.113

[8] Outcomes and complications of distal humeral hemiarthroplasty for distal humeral fractures – A systematic review. Shoulder & Elbow. 2021. DOI: 10.1177/17585732211023100

[9] Complications of articular distal humeral fracture fixation: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.02.017

[10] Articular fractures of the distal humerus. Orthopaedics & Traumatology: Surgery & Research. 2014. DOI: 10.1016/j.otsr.2013.11.002

[11] Distal humerus hemiarthroplasty for complex intra-articular fractures in elderly or nonfixable patients: a meta-analysis of clinical and functional outcomes. JSES International. 2026. DOI: 10.1016/j.jseint.2026.101695

[12] Use of Orthogonal or Parallel Plating Techniques to Treat Distal Humerus Fractures. Hand Clinics. 2010. DOI: 10.1016/j.hcl.2010.05.008

[13] Total elbow arthroplasty for the management of post-traumatic sequelae of distal humeral fractures. The Bone & Joint Journal. 2026. DOI: 10.1302/0301-620x.108b1.bjj-2025-0475.r1

[14] Management of distal humeral fractures in the elderly. Injury. 2007. DOI: 10.1016/j.injury.2007.08.006

[15] Elbow hemiarthroplasty for the management of distal humeral fractures: current technique, indications and results. Shoulder & Elbow. 2016. DOI: 10.1177/1758573216640210

[16] Distal Humerus Fractures. Hand Clinics. 2007. DOI: 10.1016/j.hcl.2007.09.001

[17] Predictors of mortality after isolated distal humerus fractures in older adults. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.02.013

[18] Distal humeral fractures: fixation versus arthroplasty. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.11.012

[19] Comparative efficacy and safety of different posterior surgical approaches for Intra-articular distal humerus fractures. Journal of Orthopaedic Surgery and Research. 2026. DOI: 10.1186/s13018-026-06739-x

[20] Hemiarthroplasty vs. open reduction and internal fixation for comminuted distal humerus fractures in patients under 65 years: a systematic review. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.07.014

[21] Can Computed Tomography Hounsfield Units Predict Distal Humerus Fracture Mechanical Complications?. Journal of the American Academy of Orthopaedic Surgeons. 2026. DOI: 10.5435/jaaos-d-26-00191

[22] Total Elbow Arthroplasty for Distal Humerus Fractures. Hand Clinics. 2015. DOI: 10.1016/j.hcl.2015.06.008

[27] Fracture mapping of coronal shear fractures of the distal humerus: morphological analysis and fixation efficacy. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09582-7

[29] Surgical treatment for posterior distal humeral shear fractures. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.05.003

[30] Unsatisfactory radiographic findings do not correlate with functional impairment in patients with coronal shear fractures of the distal humerus treated with internal fixation: a long-term retrospective study according to Dubberley's classification. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.05.033

[31] Distal Humerus Fractures: Handling of the Ulnar Nerve. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2011.11.023

[32] The LCP-concept in the operative treatment of distal humerus fractures – biological, biomechanical and surgical aspects. Injury. 2003. DOI: 10.1016/j.injury.2003.09.022

[34] Coronal Shear Fractures of the Distal Humerus: A Review of Diagnosis, Treatment, and Outcomes. HAND. 2019. DOI: 10.1177/1558944719878817

[35] Coronal shear fractures of the distal humerus: the capitellum and trochlea. Hand Clinics. 2004. DOI: 10.1016/j.hcl.2004.08.001

[38] Total elbow arthroplasty for the treatment of insufficient distal humeral fractures. A retrospective clinical study and review of the literature. Injury. 2009. DOI: 10.1016/j.injury.2009.01.123

[39] Complications of olecranon osteotomy in the treatment of distal humerus fracture. Clinics in Shoulder and Elbow. 2022. DOI: 10.5397/cise.2021.00591

[41] What is the incidence of total elbow arthroplasty after intra-articular versus extra-articular distal humerus open reduction and internal fixation?. Shoulder & Elbow. 2026. DOI: 10.1177/17585732261451863

[42] Current Treatment Strategies for Bicolumnar Distal Humerus Fractures. American Academy of Orthopaedic Surgeon. 2010. DOI: 10.5435/00124635-201001000-00004

[43] Total elbow anthroplasty and distal humerus elbow fractures. Hand Clinics. 2004. DOI: 10.1016/j.hcl.2004.06.006

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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.