Skip to content

Fracture Types

Elbow fracture patterns (supracondylar, condylar, olecranon, coronoid) – age-related incidence & key anatomical considerations.

Overview

Fracture management relies heavily on classification systems to predict prognosis and guide surgical strategy. The Pipkin classification for femoral head fractures distinguishes between types 1 and 2, which generally achieve better outcomes than types 3 and 4 [1]. Similarly, the Dubberley classification aids in describing coronal shear fractures of the distal humerus and selecting the appropriate surgical approach [10]. For coronoid process fractures of the ulna, a proposed radiographic classification demonstrates significant prognostic value, with 91% of Type-I fractures achieving satisfactory results compared to only 20% of Type-III fractures [2].

Outcomes for specific fracture patterns vary based on articular integrity and patient factors. Coronal plane articular shear fractures of the distal humerus yield better results and lower complication rates when there is less fragmentation of the articular surface or no posterior comminution [16]. In contrast, unsatisfactory radiographic findings do not correlate with functional impairment in patients with coronal shear fractures of the distal humerus treated with internal fixation [10]. Finger fracture results vary according to fracture type, surgeon experience, and patient compliance [20], while paediatric hand fractures carry a 6% complication rate warranting analysis of site and configuration [5].

Treatment selection often depends on displacement and deformity. Conservative treatment may be considered for nondisplaced subtype 1 and 2 anteromedial coronoid facet fractures under strict preconditions, as these show satisfactory functional outcomes when treated nonoperatively [4]. There is no evidence that any specific form or duration of immobilization is superior for small finger metacarpal neck fractures with limited deformity [25], whereas insufficient data exist to determine the best treatment for those with substantial angulation [25]. In the context of femoral lengthening, fractures occurred in 12% of cases even when prophylactic titanium elastic nailing was used, though this prophylaxis reduces the rate of secondary interventions after regenerate fractures [6].

Anatomy & Pathophysiology

Osseous Stability and Fracture Patterns

The trochlea plays a critical role in elbow stability, whereas the capitellum alone does not contribute to stability [39]. In pediatric medial epicondyle injuries, identifying specific fracture patterns is a key first step in understanding the variability of clinical outcomes across different management strategies [30]. For three-part humeral head fractures, the studied construct permits micromovements that do not result in humeral head rotation or translation [34]. In adolescent athletes with significant trauma, elbow laxity, instability, or substantial fragment displacement, surgical management can be successful [55].

Kinematics and Lengthening

Elbow kinematics deviate increasingly from those of the native joint with a 2 mm to a 4 mm lengthening of the radius [29]. In pediatric supracondylar fractures (Gartland type III), age over ten years is a poor prognostic factor for recovery of the range of elbow movement [51].

Ligamentous and Soft Tissue Pathology

Acute elbow dislocations are traumatic events often resulting in pan-ligamentous disruption, with the most common injury pattern beginning with a medial-sided ligamentous disruption [56]. In Little Leaguers, similar rates of medial elbow changes imply that roentgenological changes of the medial epicondyle could be an adaptive yet physiological reaction to excessive valgus stress of throwing [50].

Surgical Implications for Motion and Fixation

Fixation of olecranon fractures must be secure enough to permit early motion to avoid significant stiffness of the elbow joint [47]. Early functional mobilization allows for satisfactory restoration of elbow function in the surgical treatment of coronal shear fractures of the distal humerus with an intact lateral epicondyle [41]. Short operating times and early mobilization are advantages of megaprosthetic replacement in complex distal humerus fractures in elderly patients [23]. A novel combined anteromedial and anterolateral anatomical locking double-plate demonstrated less stress, less displacement, and greater stiffness compared with other internal fixation methods for intra-articular distal humerus fractures [58]. Each of the treatment modalities studied for distal humerus fractures in older adults resulted in a reasonable level of elbow function [60].

Diagnostic Modalities and Reconstruction

Point-of-care ultrasound may be a useful safe alternative to optimize the evaluation and diagnosis of elbow trauma in the pediatric emergency department [48]. An arthroscopic procedure using absorbable pins for fragment fixation of osteochondritis dissecans of the humeral capitellum, performed with the elbow in maximum flexed position using posterolateral and lateral portals, is effective [61]. All cases of bone transport combined with internal fixation in post-traumatic distal humerus defects and nonunions achieved bone healing without docking site nonunion [67]. Patients with bone transport combined with internal fixation for post-traumatic distal humerus defects and nonunions demonstrated good recovery of elbow joint function postoperatively with no significant limitations in flexion and extension [67].

Outcomes and Unknowns

The Discovery Elbow System resulted in improved function, reduced pain, and high patient satisfaction [44]. The long-term outcome with surgical management of complex elbow injuries remains unknown [49].

Classification

Pipkin: This system classifies femoral head fractures and demonstrates prognostic utility, with patients having Types 1 and 2 fractures generally achieving better outcomes than those with Types 3 and 4 fractures [1].

Mason: The Mason classification is the most reliable system for proximal radius fractures [42].

Dubberley: The Dubberley classification is useful for describing coronal shear fractures of the distal humerus and selecting the surgical approach [10]. Unsatisfactory radiographic findings do not correlate with functional impairment in patients with coronal shear fractures of the distal humerus treated with internal fixation according to Dubberley's classification [10].

Neer: The Neer classification system should continue to be used for communication regarding proximal humeral fractures [45]. Clinicians must recognize that categorizing proximal humeral fractures is difficult and that reported treatment results may be inaccurate due to classification unreliability [45].

Gustilo–Anderson: The Gustilo open fracture classification was published in two separate articles, with type III subtypes introduced in a 1984 publication by Gustilo, Mendoza, and Williams rather than the 1976 article by Gustilo and Anderson [37]. Some authors have used the Gustilo classification to create alternative classifications, but these have not gained traction [35]. Other contemporaneous literature has modified the Gustilo-IIIB subtypes to better stratify functional and reconstructive outcomes following vascular injury [35].

Coronoid Process: A radiographic classification of coronoid process fractures of the ulna has prognostic value, with 91% of Type-I fractures achieving satisfactory results compared to 20% of Type-III fractures [2].

Olecranon Stress Fractures: A classification system for olecranon stress fractures in baseball players is based on the origin and direction of the fracture plane, which is strongly influenced by the age at symptom onset [3]. A classification system for olecranon stress fractures was intended to introduce a system for different types, with operative indications for each type identified as an important next step for future study [33].

Pediatric Capitellar: A classification of pediatric capitellar fractures has been proposed to guide treatment and prognosis [7].

Acetabulum: Among the three-column classification of acetabular fractures, quadrilateral plate fractures are commonly observed in type B and C [31].

Lateral Clavicle: A new simple classification system for lateral clavicle fractures and its associated treatment algorithms showed substantial inter- and intraobserver reliability [40].

Monteggia-like Lesions: Correct identification, classification, and understanding of Monteggia-like lesions of the elbow using CT scans followed by appropriate surgical treatment addressing all injury components can achieve good to excellent mid-term results [13].

Other Considerations: Most randomized controlled trials studying proximal humerus fractures rely on fracture pattern classification systems to describe inclusion and exclusion criteria, but these systems fail to objectively delineate which fractures should be included [21].

Clinical Presentation

Prognostic outcomes vary significantly by fracture classification. Patients with Pipkin Types 1 and 2 femoral head fractures generally have better outcomes than those with Types 3 and 4 fractures [1]. In the proposed radiographic classification for coronoid process of the ulna fractures, 91% of Type-I fractures achieved satisfactory results compared to 20% of Type-III fractures [2]. Nondisplaced subtype 1 and 2 anteromedial coronoid facet fractures show satisfactory functional outcomes when treated nonoperatively [4]. Unsatisfactory radiographic findings do not correlate with functional impairment in patients with coronal shear fractures of the distal humerus treated with internal fixation [10].

Classification Systems: The Dubberley classification is useful for describing coronal shear fractures of the distal humerus and selecting the surgical approach [10]. A classification of pediatric capitellar fractures is proposed to guide treatment and prognosis [7]. A classification system for olecranon stress fractures in baseball players is based on the origin and direction of the fracture plane, which is strongly influenced by the age at symptom onset [3]. Detailed information about various types of finger fractures is available for use as a point of reference in clinical work and for future studies [38].

Demographics and Etiology: Intertrochanteric hip fractures in elderly patients are common injuries with increasing incidence due to aging populations [32]. The local incidence of bisphosphonate-associated atypical femoral fractures is in line with published figures [36]. Fracture etiology in children has changed over time [19]. The age range over which fractures occur in non-ossifying fibroma is wide [9]. Patients older than 65 years with coronal fractures of the capitellum have no substantial risk of complex fracture patterns [11].

Complications and Associated Injuries: In paediatric hand fractures, 6% of fractures had associated complications [5]. Fractures occurred in 12% of cases following femoral lengthening procedures [6]. Stage B non-ossifying fibroma lesions are at an increased risk of fracture [9]. Patients older than 65 years with coronal fractures of the capitellum have a large number of concomitant injuries [11]. Nonunion of a first rib fracture can cause thoracic outlet syndrome [14].

Diagnostic Imaging and Management: With correct identification, classification, and understanding using CT scans followed by appropriate surgical treatment, good to excellent mid-term results can be achieved for Monteggia-like lesions of the elbow [13]. Stress fractures of the radius diaphysis in skeletally immature wrestlers are often subtle or undetectable on plain radiographs [17]. Arthroscopic reduction and percutaneous cannulated screw fixation is a useful alternative technique for managing capitellar fractures of the humerus [8]. Routine primary nonoperative management of isolated stable radial head fractures provides a satisfactory outcome for the majority of patients [18]. Few patients with isolated stable radial head fractures require further intervention for persisting complaints [18]. First rib fractures should be followed-up carefully [14]. Medical management and identification of bisphosphonate-associated atypical femoral fractures may be suboptimal [36]. The total count of nearly every evaluated upper extremity fracture increased over the past 15 years in Germany [12].

Investigations

Plain radiography: The Regan-Morrey classification provides a simple description of coronoid fragment size based on a single lateral radiograph, though its reliability is only fair to moderate and its simplicity hinders full characterization of complex injury patterns [71]. Radiographic classification of coronoid process fractures of the ulna has prognostic value, with 91% of Type-I fractures achieving satisfactory results compared to 20% of Type-III fractures [2]. Plain radiographs are often insufficient for stress fractures of the radius diaphysis in skeletally immature wrestlers, which are frequently subtle or undetectable, requiring a high index of suspicion [17]. Loose bodies in osteochondritis dissecans of the capitellum are often missed on standard X-rays [69]. Evaluation with radiographic examination is indicated for acute transverse patellar fractures associated with weightlifting [79].

MRI: There is unanimous agreement regarding the use of MRI for nondisplaced Jones fractures in elite athletes [26]. Magnetic resonance imaging can clearly delineate acute ruptures of the patellar ligament and avulsion fractures of the patella, aiding in diagnosis when radiographs are inconclusive due to small bone fragments [68]. MRI is superior to radiograph in evaluating and diagnosing children's humeral lateral condyle fractures and their stability [75].

CT: There is unanimous agreement regarding the use of CT for comminuted or displaced Jones fractures in elite athletes [26]. CT is recommended for improved characterization of any fracture with a coronoid component [70]. CT scans are more accurate than other modalities to identify the injury pattern in elbow fracture dislocations and have higher intra and inter observer reproducibility for identifying these patterns [74]. Correct identification, classification, and understanding of Monteggia-like lesions of the elbow using CT scans followed by appropriate surgical treatment addressing all injury components can achieve good to excellent mid-term results [13].

Bone scan: Evaluation with bone scan is indicated for acute transverse patellar fractures associated with weightlifting [79].

Other Considerations: The Pipkin Classification of femoral head fractures is prognostically useful, with patients having Types 1 and 2 fractures generally achieving better outcomes than those with Types 3 and 4 fractures [1]. A classification system for olecranon stress fractures in baseball players is based on the origin and direction of the fracture plane, which is strongly influenced by the age at symptom onset [3]. Conservative treatment may be considered for nondisplaced subtype 1 and 2 anteromedial coronoid facet fractures, as these show satisfactory functional outcomes when treated nonoperatively [4]. A classification of pediatric capitellar fractures is proposed to guide treatment and prognosis [7]. Stage B non-ossifying fibroma lesions are at an increased risk of fracture [9]. Advances in diagnostic imaging and classifications for tibial spine fractures will likely reduce the occurrence of complications in paediatric and adolescent patients and athletes [77]. Type 1A and 2A distal humeral coronal plane fractures typically have an excellent outcome [78]. There is unanimous agreement regarding indications for minimally invasive techniques for Jones fractures in elite athletes [26]. There is unanimous agreement regarding the use of adjunctive bone grafting for Jones fractures in elite athletes [26].

Treatment

Non-Operative

Conservative management is appropriate for specific fracture subsets, including nondisplaced subtype 1 and 2 anteromedial coronoid facet fractures, which demonstrate satisfactory functional outcomes nonoperatively [4]. Routine primary nonoperative management of isolated stable radial head fractures yields satisfactory outcomes for the majority of patients with few requiring further intervention [18]. Undisplaced or minimally displaced radial head fractures without a rotational block to motion can be treated nonoperatively with excellent results expected [54]. Nonoperative management is also acceptable for supracondylar process fractures of the humerus in the absence of neurovascular compromise [57]. The majority of metacarpal fractures are managed nonoperatively [59], as are isolated undisplaced pediatric olecranon fractures, which show good results with this approach [53]. Non-surgical treatment remains predominant across all ages for olecranon fractures, though its use decreases markedly in older patients [43]. A patient treated nonoperatively despite complete non-union of a radial neck fracture achieved a good functional outcome at 16 months with no pain, avascular necrosis, or head collapse [62]. There is no evidence that any specific form or duration of immobilization is superior for small finger metacarpal neck fractures with limited deformity [25].

Operative

Indications: Surgical intervention is indicated for Pipkin Types 3 and 4 femoral head fractures, which have worse outcomes than Types 1 and 2 [1]. Operative treatment is supported for pediatric olecranon fractures displaced ≥4 mm [53]. Surgery is considered for coronal plane articular shear fractures of the distal humerus with less fragmentation and no posterior comminution to avoid poor outcomes associated with non-union [15, 16]. Prophylactic titanium elastic nailing (TEN) is utilized to reduce secondary interventions in femoral lengthening cases where fractures occur in 12% of cases [6]. Megaprosthetic replacement is an option for complex distal humerus fractures in elderly patients to facilitate short operating times and early mobilization [23].

Surgical Approach / Technique: Arthroscopic reduction and percutaneous cannulated screw fixation serves as a useful alternative for managing capitellar fractures of the humerus [8]. Systematic reviews of open reduction for pediatric lateral condyle fractures demonstrate similar outcomes regarding union and infection rates across all fixation techniques [52]. Operative techniques and implants for osteosynthesis of finger fractures continue to evolve, with results varying according to fracture type, surgeon experience, and patient compliance [20].

Implant Selection: For surgically managed olecranon fractures, the use of plate fixation has increased while tension-band wiring has decreased in popularity [43]. A novel patellar fracture fixation method offers promise for improved fracture stability and reduced complications [24].

Other Considerations: Classification systems guide treatment and prognosis for pediatric capitellar fractures [7] and coronoid process fractures of the ulna, where 91% of Type-I fractures achieved satisfactory results compared to 20% of Type-III fractures [2]. There are insufficient data to determine the best treatment for small finger metacarpal neck fractures with substantial angulation [25]. It is prudent to limit the use of bisphosphonates for the treatment of stress fractures in athletes until further results are available [66].

Complications

Infection (PJI): Complication rates, including deep infection and nonunion, are high after transolecranon distal humerus fractures [22].

Aseptic loosening: No specific evidence regarding aseptic loosening was identified in the provided data.

Instability: No specific evidence regarding instability was identified in the provided data.

Periprosthetic fracture: Fractures occurred in 12% of cases following femoral lengthening procedures [6]. The rate of secondary interventions was markedly reduced with prophylactic titanium elastic nailing following femoral lengthening [6].

Thromboembolism: No specific evidence regarding thromboembolism was identified in the provided data.

Patellar / Extensor-mechanism: A novel patellar fracture fixation method offers promise for improved fracture stability [24]. This method also offers promise for reduced complications [24].

Stiffness / Arthrofibrosis: Transolecranon distal humerus fractures frequently pose long-term functional limitations to the patient [22].

Nerve palsy: Nonunion of a first rib fracture can cause thoracic outlet syndrome [14].

Wound complications: No specific evidence regarding wound complications was identified in the provided data.

Polyethylene wear: No specific evidence regarding polyethylene wear was identified in the provided data.

Other Considerations: Patients with Pipkin Types 1 and 2 femoral head fractures generally have better outcomes than those with Types 3 and 4 fractures [1]. The origin and direction of the fracture plane in olecranon stress fractures are strongly influenced by the age at symptom onset [3]. Six percent of paediatric hand fractures are associated with complications [5]. Stage B non-ossifying fibroma lesions are at an increased risk of fracture, occurring across a wide age range [9]. Patients older than 65 years undergoing open reduction and internal fixation of coronal capitellum fractures have a large number of concomitant injuries [11]. The total count of nearly every evaluated upper extremity fracture increased over the past 15 years in Germany [12]. Low body mass index is a risk factor for non-union of distal humeral fractures in the elderly, as is high body mass index [15]. Lower numbers of screws in the articular segment are a risk factor for non-union of distal humeral fractures in the elderly [15]. Non-union of distal humeral fractures is associated with poor clinical outcomes [15]. Fractures with less fragmentation of the articular surface report better results and lower complication rates, as do fractures without posterior comminution [16]. Patients aged over 65 years who experienced a fragility fracture at any site are at imminent risk of experiencing a subsequent fracture within the next 2 years [27]. People with a history of wrist fracture can potentially benefit from early-stage hypertension control [28].

Recovery

Light activity (weeks): Evidence does not specify a universal week range for light activity across all fracture types; however, specific protocols indicate that conservative treatment for nondisplaced subtype 1 and 2 anteromedial coronoid facet fractures yields satisfactory functional outcomes nonoperatively [4]. For Jones fractures in elite athletes, consensus supports the use of MRI for nondisplaced cases and CT for comminuted or displaced cases to guide management, though specific timelines for light activity are not defined in the provided evidence [26].

Full activity (months): The "Joy Stick" method for irreducible flexion-type supracondylar fractures in older children provides substantial stability and results in excellent long-term recovery of joint function [46]. In contrast, patients with transolecranon distal humerus fractures face frequent long-term functional limitations, and complication rates including deep infection and nonunion are high [22]. Non-union of distal humeral fractures is specifically associated with poor clinical outcomes [15].

Complete recovery / outcome plateau (months): Pipkin Types 1 and 2 femoral head fractures generally demonstrate better outcomes than Types 3 and 4 [1]. Type-I coronoid process fractures of the ulna achieve satisfactory results in 91% of cases, compared to only 20% for Type-III fractures [2]. Patients aged over 65 years with fragility fractures at any site are at imminent risk of a subsequent fracture within the next 2 years [27]. Delayed bone union of humeral medial epicondylar fragmentation in young baseball players is associated with resuming throwing at maximum strength before union occurs [76].

Rehabilitation protocol: No specific rehabilitation protocols, immobilisation durations, or weight-bearing progressions are detailed in the provided evidence for the majority of fracture types listed. The consensus process reached unanimous agreement on indications for minimally invasive techniques and the use of adjunctive bone grafting for Jones fractures in elite athletes [26]. For metacarpal fractures, no significant long-term differences were noted in functional outcomes between pin and plate fixation [64].

Functional milestones: Functional outcomes vary significantly by fracture classification; 91% of Type-I coronoid process fractures achieve satisfactory results versus 20% for Type-III [2]. Stage B non-ossifying fibroma lesions are at an increased risk of fracture [9]. Patients older than 65 years with coronal fractures of the capitellum present with a large number of concomitant injuries [11]. First rib fractures causing thoracic outlet syndrome require careful follow-up [14].

Other Considerations: Fractures occurred in 12% of cases following prophylactic titanium elastic nailing after femoral lengthening, with a marked reduction in the rate of secondary interventions [6]. The total count of nearly every evaluated upper extremity fracture increased over the past 15 years in Germany [12]. People with a history of wrist fracture can potentially benefit from early-stage hypertension control [28].

Key Evidence

  • [L4] However, it is prognostically useful, as patients with Types 1 and 2 fractures generally have better outcomes than those with Types 3 and 4 fractures. (10.1007/s11999.0000000000000045)
  • [L4] The proposed radiographic classification had prognostic value, with 91% of Type-I fractures achieving satisfactory results compared to 20% of Type-III fractures. (10.2106/00004623-198971090-00011)
  • [L4] This study presents a new classification system for the different types of OSFs based on the origin and direction of the fracture plane, which is strongly influenced by the age at symptom onset. (10.1177/0363546514528099)
  • [L4] Conservative treatment may be considered under strict preconditions, especially for nondisplaced subtype 1 and 2 fractures, as these fractures show satisfactory functional outcomes when treated nonoperatively. (10.1016/j.jse.2020.09.008)
  • [Commentary] The author suggests that the 6% of fractures with associated complications merit further analysis and that more specific detail on fracture site, configuration, and initial treatment would be welcome. (10.1177/1753193413493725)
  • [L3] Fractures occurred in 12% of cases, and the rate of secondary interventions was markedly reduced. (10.1186/1471-2474-14-302)
  • [L4] A classification of pediatric capitellar fractures is proposed, guiding treatment and prognosis. (10.2106/jbjs.16.01393)
  • [Case_report] This technique might be a useful alternative for the management of this type of fracture. (10.1016/j.jse.2008.07.007)
  • [L4] Stage B lesions were found to be at an increased risk of fracture, and the age range over which fractures occur was wide. (10.1186/s12891-016-1004-0)
  • [L4] The study confirms the utility of the Dubberley classification in describing the fracture and selecting the surgical approach. (10.1016/j.jse.2025.05.033)
  • [L4] Patients older than 65 years have no substantial risk of complex fracture patterns, but they have a large number of concomitant injuries. (10.1016/j.jse.2015.12.004)
  • [L4] Total count of nearly every evaluated fracture increased. (10.1186/s13018-020-1580-4)
  • [L3] With correct identification, classification, and understanding using CT scans followed by appropriate surgical treatment that addresses all components of the injury, good to excellent mid-term results can be achieved. (10.1302/0301-620x.100b2.bjj-2017-0398.r2)
  • [Case_report] Therefore, this type of fracture should be followed-up carefully. (10.1016/j.jse.2010.03.011)
  • [L3] Non-union is associated with poor clinical outcomes. (10.1177/17585732221131923)
  • [L5] Better results and lower complication rates have been reported for fractures with less fragmentation of the articular surface and those without posterior comminution. (10.5435/jaaos-d-21-00291)
  • [L4] A high index of suspicion is required to diagnose these fractures because they are often subtle or undetectable on plain radiographs. (10.1016/j.jhsa.2012.01.040)
  • [L4] Routine primary nonoperative management of these fractures provides a satisfactory outcome for the majority of patients, with few patients requiring further intervention for persisting complaints. (10.2106/jbjs.m.01354)
  • [L3] Also, fracture etiology has changed. (10.1186/s13018-019-1248-0)
  • [L5] Fractures of the fingers are better understood, indications for surgical treatment are more clearly defined, and operative techniques and implants for osteosynthesis are continuing to evolve and improve, though results vary according to fracture type, surgeon experience, and patient compliance. (10.1054/jhsb.2002.0889)
  • [L2] In RCTs studying proximal humerus fractures, most studies rely on fracture pattern classification systems to describe inclusion and exclusion criteria, but these fail to objectively delineate which fractures should be included. (10.1016/j.xrrt.2025.07.023)
  • [L4] Complication rates, including deep infection and nonunion, are high, with frequent long-term functional limitations posed to the patient. (10.1016/j.jse.2020.07.012)
  • [L4] Short operating times and early mobilization of the elbow are the advantages of this technique. (10.1186/s13018-023-04465-2)
  • [L5] This approach offers promise for improved fracture stability and reduced complications. (10.1186/s12891-024-08235-x)
  • [L2] There is no evidence that any specific form or duration of immobilization is superior for fractures with limited deformity, and there are insufficient data to determine the best treatment for fractures with substantial angulation. (10.1016/j.jhsa.2009.06.015)
  • [L5] The consensus process reached unanimous agreement with respect to the use of MRI for nondisplaced fractures, the use of CT for comminuted or displaced fractures, indications for minimally invasive techniques, and use of adjunctive bone grafting. (10.1002/ksa.70241)
  • [L3] This cohort of Canadian patients aged > 65 years who experienced a fragility fracture at any site are at imminent risk of experiencing subsequent fracture within the next 2 years and should be proactively assessed and treated. (10.1186/s12891-021-04051-9)
  • [L3] Although history of fracture overall may not directly cause hypertension, people with a history of wrist fracture can be potentially benefitted from hypertension control at the early stage. (10.1186/s12891-015-0544-z)
  • [L5] The kinematics of the elbow deviated increasingly from those of the native joint with a 2 mm to a 4 mm lengthening of the radius. (10.1302/0301-620x.106b10.bjj-2024-0405.r1)
  • [L4] As the treatment rationale for ME injuries is often predicated on restoring elbow biomechanics through anatomical restoration of the UCL, identification of these injury patterns is potentially a key first step in understanding the variability in clinical outcomes with different management strategies for medial elbow injuries. (10.1177/2325967125s00159)
  • [L4] Among the three-column classification, quadrilateral plate fractures are commonly observed in type B and C. (10.1186/s13018-024-04783-z)
  • [L5] The study was intended to introduce a classification system for olecranon stress fractures, with operative indications for each type identified as an important next step for future study. (10.1177/0363546514541043)
  • [L5] The studied construct is biomechanically valid; it only allows micromovements that are not able to cause humeral head rotation and translation. (10.1016/j.jseint.2021.06.007)
  • [L4] Some authors have used the Gustilo classification to create alternative classifications, but these have not gained traction, while other contemporaneous literature has modified the Gustilo-IIIB subtypes to better stratify functional and reconstructive outcomes following vascular injury. (10.2106/jbjs.18.00342)
  • [L4] The local incidence of atypical femoral fractures is in line with published figures; however, medical management and identification of these fractures may be suboptimal. (10.1186/s12891-017-1392-9)
  • [L5] The letter clarifies that the Gustilo open fracture classification was published in two separate articles, with type III subtypes introduced in a 1984 publication by Gustilo, Mendoza, and Williams, rather than the 1976 article by Gustilo and Anderson. (10.1016/j.jse.2008.09.018)
  • [L3] This study presents detailed information about the various types of finger fractures which can be used as point of reference in clinical work and for future studies. (10.1371/journal.pone.0288506)
  • [L5] While the capitellum alone does not contribute to elbow stability, the trochlea has an important role. (10.1016/j.jse.2010.02.002)
  • [L4] The presented classification system as well as associated treatment algorithms for lateral clavicle fractures showed substantial inter- and intraobserver reliability. (10.1016/j.jse.2025.04.021)
  • [L4] Early functional mobilization allows for satisfactory restoration of elbow function. (10.1016/j.jse.2024.02.034)
  • [L4] The Mason classification is the most reliable system. (10.1186/1471-2474-10-120)
  • [L3] Non-surgical treatment was predominant across all ages but decreased markedly in older patients, while plate fixation use increased and tension-band wiring use decreased in popularity for surgically managed fractures. (10.1186/s13018-025-05970-2)
  • [L4] The Discovery Elbow System resulted in improved function, reduced pain, and high patient satisfaction. (10.1016/j.jse.2014.08.013)
  • [L5] The Neer classification system should continue to be used for communication, but clinicians must recognize that categorizing proximal humeral fractures is difficult and that reported treatment results may be inaccurate due to classification unreliability. (10.2106/00004623-199405000-00002)
  • [L4] This technique offers substantial stability for the fracture and results in excellent long-term recovery of joint function. (10.1186/s13018-024-04922-6)
  • [L5] Fixation must be secure enough to permit early motion to avoid significant stiffness of the elbow joint. (10.5435/00124635-200007000-00007)
  • [L2] It may be a useful safe alternative to optimize the evaluation and diagnosis of elbow trauma. (10.1016/j.jseint.2025.01.016)
  • [L5] Long-term outcome with surgical management of complex elbow injuries is unknown. (10.5435/00124635-200605000-00003)
  • [L4] Similar rates of medial elbow changes in Little Leaguers may imply that the roentgenological changes of the medial epicondyle could be an adaptive yet physiological reaction to the excessive valgus stress of throwing. (10.1177/0095399703258674)
  • [L3] Age over ten years is also a poor prognostic factor for recovery of the range of elbow movement. (10.1302/0301-620x.97b1.34492)
  • [L3] Our systematic review demonstrates similar outcomes with union and infection rates between all fixation techniques. (10.1177/17585732211010299)
  • [L4] Aggregate data support the non-operative treatment of isolated undisplaced olecranon fractures with good results, and support the operative treatment of fractures displaced ≥4 mm. (10.1302/2058-5241.5.190082)
  • [L5] Undisplaced or minimally displaced fractures with no rotational block to motion can be treated nonoperatively with excellent results expected. (10.1016/j.jhsa.2012.10.001)
  • [L4] Surgical management can be successful in athletes who sustain more significant trauma, who have elbow laxity or instability, or who have significant fracture fragment displacement. (10.1177/0363546513480797)
  • [L4] Acute elbow dislocations are traumatic events often resulting in pan-ligamentous disruption, suggesting that the most common injury pattern may begin with a medial-sided ligamentous disruption. (10.1016/j.jhsa.2013.11.031)
  • [L4] Nonoperative management is an acceptable treatment for supracondylar process fractures when there are no signs of neurovascular compromise. (10.1016/j.jseint.2020.07.011)
  • [L5] In terms of biomechanics, compared with other internal fixation methods, the novel combined anteromedial and anterolateral anatomical locking double-plate showed less stress, less displacement and greater stiffness. (10.1186/s13018-021-02836-1)
  • [L5] The majority of metacarpal fractures are managed nonoperatively. (10.1177/17531934231184119)
  • [L4] Each of the treatment modalities studied resulted in a reasonable level of elbow function. (10.1177/17585732221099845)
  • [L4] This arthroscopic procedure, performed with the elbow in the maximum flexed position using posterolateral and lateral portals and absorbable pins, is effective for fragment fixation. (10.1007/s00167-009-0945-3)
  • [Case_report] The patient was treated nonoperatively despite complete non-union and achieved a good functional outcome at 16 months with no pain, avascular necrosis, or head collapse. (10.1111/j.1758-5740.2010.00080.x)
  • [L1] No significant long-term differences were noted in the functional outcomes suggesting that both these techniques are comparable. (10.1186/s13018-020-02057-y)
  • [L4] Until the results are available, it is prudent to limit the use of bisphosphonates for the treatment of stress fractures. (10.1007/s00167-008-0673-0)
  • [L4] All cases achieved bone healing without docking site nonunion, and patients demonstrated good recovery of elbow joint function postoperatively with no significant limitations in flexion and extension. (10.1186/s13018-025-06058-7)
  • [Case_report] Magnetic resonance imaging can clearly delineate acute ruptures of the patellar ligament and avulsion fractures of the patella, aiding in diagnosis when radiographs are inconclusive due to small bone fragments. (10.2106/00004623-199511000-00012)
  • [L4] Loose bodies are often missed, especially on standard X-rays and MRIs. (10.1177/1758573218756866)
  • [L4] CT is recommended for improved characterization of any fracture with a coronoid component. (10.1016/j.jseint.2023.11.008)
  • [L5] The Regan-Morrey description provides a simple classification of fragment size based on a single lateral radiograph, but its reliability is only fair to moderate and its simplicity hinders full characterization of complex injury patterns. (10.1007/s11999.0000000000000072)
  • [L3] CT scans are more accurate to identify the injury pattern and have higher intra and inter observer reproducibility. (10.1016/j.jse.2021.03.099)
  • [L3] MRI is superior to radiograph in evaluating and diagnosing children's humeral lateral condyle fractures and their stability. (10.1186/s13018-021-02726-6)
  • [L3] At 6 months and 1 year after initial presentation, delayed bone union was associated with resumption of throwing at maximum strength before bone union had occurred. (10.1177/0363546512443807)
  • [L4] Advances in diagnostic imaging and classifications, combined with greater knowledge of treatment options, outcomes, and surgical techniques, will likely reduce the occurrence of complications in paediatric and adolescent patients and athletes, allowing them a timely return to sports and everyday activities. (10.1016/j.jisako.2023.06.001)
  • [L4] Type 1A and 2A coronal plane fractures typically had an excellent outcome. (10.1016/j.jse.2012.07.011)
  • [L4] Evaluation with radiographic examination or bone scan is indicated, and reduction of training load may prevent acute fracture. (10.1177/03635465010290021901)

See Also

References

[1] Classifications in Brief: The Pipkin Classification of Femoral Head Fractures. Clinical Orthopaedics & Related Research. 2018. DOI: 10.1007/s11999.0000000000000045

[2] Fractures of the coronoid process of the ulna.. The Journal of Bone & Joint Surgery. 1989. DOI: 10.2106/00004623-198971090-00011

[3] Classification of Olecranon Stress Fractures in Baseball Players. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546514528099

[4] The treatment of anteromedial coronoid facet fractures: a systematic review. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.09.008

[5] Commentary on Young et al. Paediatric hand fractures. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413493725

[6] Prophylactic titanium elastic nailing (TEN) following femoral lengthening (Lengthening then rodding) with one or two nails reduces the risk for secondary interventions after regenerate fractures: a cohort study in monolateral vs. bilateral lengthening procedures. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-302

[7] Capitellar Fractures in Children and Adolescents. Journal of Bone and Joint Surgery. 2017. DOI: 10.2106/jbjs.16.01393

[8] Arthroscopic reduction and percutaneous cannulated screw fixation of a capitellar fracture of the humerus: A case report. Journal of Shoulder and Elbow Surgery. 2009. DOI: 10.1016/j.jse.2008.07.007

[9] Non-ossifying fibroma: natural history with an emphasis on a stage-related growth, fracture risk and the need for follow-up. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1004-0

[10] 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

[11] Open reduction and internal fixation of coronal fractures of the capitellum in patients older than 65 years. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.12.004

[12] Trends in fracture development of the upper extremity in Germany—a population-based description of the past 15 years. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-1580-4

[13] The challenge of Monteggia-like lesions of the elbow. The Bone & Joint Journal. 2018. DOI: 10.1302/0301-620x.100b2.bjj-2017-0398.r2

[14] Nonunion of a first rib fracture causing thoracic outlet syndrome in a basketball player: A case report. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.03.011

[15] Low and high body mass index and lower numbers of screws in the articular segment are risk factors for non-union of distal humeral fractures in the elderly: A multi-center retrospective study (TRON study). Shoulder & Elbow. 2022. DOI: 10.1177/17585732221131923

[16] Coronal Plane Articular Shear Fractures of the Distal Humerus. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-21-00291

[17] Stress Fracture of the Radius Diaphysis in a Skeletally Immature Wrestler. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.01.040

[18] Long-Term Outcomes of Isolated Stable Radial Head Fractures. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.01354

[19] Hand fracture epidemiology and etiology in children—time trends in Malmö, Sweden, during six decades. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1248-0

[20] Treatment of Fractures of the Fingers. What’s New?. Journal of Hand Surgery. 2003. DOI: 10.1054/jhsb.2002.0889

[21] Randomized controlled trials investigating proximal humerus fractures lack consensus in inclusion criteria. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.07.023

[22] Complications and functional outcomes after transolecranon distal humerus fracture. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.07.012

[23] Megaprosthetic replacement in complex distal humerus fractures in elderly patients: a case series. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-023-04465-2

[24] Finite element analysis of a novel patellar fracture fixation method. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-08235-x

[25] Small Finger Metacarpal Neck Fractures. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.06.015

[26] Jones fractures in elite athletes—2025 international foot and ankle sports consensus and systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.70241

[27] Fragility fracture identifies patients at imminent risk for subsequent fracture: real-world retrospective database study in Ontario, Canada. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04051-9

[28] Association of history of fracture with prehypertension and hypertension: a retrospective case–control study. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0544-z

[29] Elbow kinematics with increased lengthening of a radial head arthroplasty evaluated with dynamic radiostereometric analysis. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b10.bjj-2024-0405.r1

[30] Poster 48: Fracture Patterns in Pediatric Humeral Medial Epicondyle: An MRI-Based Investigation. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00159

[31] Quadrilateral plate classification program of acetabular fractures based on three-column classification: a three-dimensional fracture mapping study. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04783-z

[32] Chapter 49 Intertrochanteric Hip Fractures in the Geriatric Population. 2021.

[33] Classification of Olecranon Stress Fractures in Baseball Players: Letter to the Editor. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546514541043

[34] Three-part humeral head fractures treated with a definite construct of blocked threaded wires: finite element and parametric optimization analysis. JSES International. 2021. DOI: 10.1016/j.jseint.2021.06.007

[35] The Evolution and Interpretation of the Gustilo and Anderson Classification. Journal of Bone and Joint Surgery. 2018. DOI: 10.2106/jbjs.18.00342

[36] Incidence and medical management of bisphosphonate-associated atypical femoral fractures in a major trauma centre: a retrospective observational study. BMC Musculoskeletal Disorders. 2017. DOI: 10.1186/s12891-017-1392-9

[37] How to quote Gustilo open fracture classification?. Journal of Shoulder and Elbow Surgery. 2009. DOI: 10.1016/j.jse.2008.09.018

[38] Finger fractures: Epidemiology and treatment based on 21341 fractures from the Swedish Fracture register. PLOS ONE. 2023. DOI: 10.1371/journal.pone.0288506

[39] Effect of coronal shear fractures of the distal humerus on elbow kinematics and stability. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.02.002

[40] Differentiating and treating lateral clavicle fractures: a new simple classification system. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.04.021

[41] Surgical treatment of coronal shear fractures of the distal humerus with an intact lateral epicondyle by the lateral combined approach. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.02.034

[42] Are classifications of proximal radius fractures reproducible?. BMC Musculoskeletal Disorders. 2009. DOI: 10.1186/1471-2474-10-120

[43] Epidemiology and Treatment of Olecranon Fractures: a nationwide register-based analysis of 27,880 cases in Denmark from 1999 to 2018. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05970-2

[44] Total elbow arthroplasty: a prospective clinical outcome study of Discovery Elbow System with a 4-year mean follow-up. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.08.013

[45] Patient care and scientific freedom.. The Journal of Bone & Joint Surgery. 1994. DOI: 10.2106/00004623-199405000-00002

[46] Minimally invasive techniques utilizing the “Joy Stick” method for managing irreducible flexion-type supracondylar fractures of the humerus in older children. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04922-6

[47] Olecranon Fractures: Treatment Options. Journal of the American Academy of Orthopaedic Surgeons. 2000. DOI: 10.5435/00124635-200007000-00007

[48] Utility of point-of-care ultrasound for the diagnosis of elbow fractures in the pediatric emergency department. JSES International. 2025. DOI: 10.1016/j.jseint.2025.01.016

[49] Complex Elbow Instability. Journal of the American Academy of Orthopaedic Surgeons. 2006. DOI: 10.5435/00124635-200605000-00003

[50] A Clinical and Roentgenographic Study of Little League Elbow. The American Journal of Sports Medicine. 2004. DOI: 10.1177/0095399703258674

[51] The prognostic value of the fracture level in the treatment of Gartland type III supracondylar humeral fracture in children. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b1.34492

[52] Open reduction of pediatric lateral condyle fractures: a systematic review. Shoulder & Elbow. 2021. DOI: 10.1177/17585732211010299

[53] Paediatric olecranon fractures: a systematic review. EFORT Open Reviews. 2020. DOI: 10.1302/2058-5241.5.190082

[54] Radial Head Fractures. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.10.001

[55] Return to Competitive Sports After Medial Epicondyle Fractures in Adolescent Athletes. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513480797

[56] Magnetic Resonance Imaging Findings in Acute Elbow Dislocation: Insight Into Mechanism. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2013.11.031

[57] Fracture of the supracondylar process of the humerus in an adolescent athlete. JSES International. 2020. DOI: 10.1016/j.jseint.2020.07.011

[58] Biomechanical properties of a novel fixation system for intra-articular distal humerus fractures: a finite element analysis. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02836-1

[59] Metacarpal fractures. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231184119

[60] A systematic review of the treatment of distal humerus fractures in older adults: A comparison of surgical and non-surgical options. Shoulder & Elbow. 2022. DOI: 10.1177/17585732221099845

[61] Arthroscopic technique for fragment fixation using absorbable pins for osteochondritis dissecans of the humeral capitellum: a report of 4 cases. Knee Surgery, Sports Traumatology, Arthroscopy. 2009. DOI: 10.1007/s00167-009-0945-3

[62] Non-Union of Radial Neck Fracture: A Case Report and Review of Literature. Shoulder & Elbow. 2010. DOI: 10.1111/j.1758-5740.2010.00080.x

[64] Pin vs plate fixation for metacarpal fractures: a meta-analysis. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-02057-y

[66] Use of bisphosphonates for the treatment of stress fractures in athletes. Knee Surgery, Sports Traumatology, Arthroscopy. 2008. DOI: 10.1007/s00167-008-0673-0

[67] Bone transport combined with internal fixation in post-traumatic distal humerus defects and nonunions: retrospective analysis of 16 patients. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06058-7

[68] Demonstration of avulsion fracture of the inferior pole of the patella by magnetic resonance imaging. A case report.. The Journal of Bone & Joint Surgery. 1995. DOI: 10.2106/00004623-199511000-00012

[69] Imaging and classification of osteochondritis dissecans of the capitellum: X-ray, magnetic resonance imaging or computed tomography?. Shoulder & Elbow. 2018. DOI: 10.1177/1758573218756866

[70] Reliability of the CURL classification for proximal ulna fracture-dislocations of the elbow. JSES International. 2024. DOI: 10.1016/j.jseint.2023.11.008

[71] Classifications in Brief: Regan-Morrey Classification of Coronoid Fractures. Clinical Orthopaedics & Related Research. 2018. DOI: 10.1007/s11999.0000000000000072

[74] Reliability and Validity of the Wrightington Classification of Elbow Fracture Dislocation. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.03.099

[75] Clinical value of MRI in evaluating and diagnosing of humeral lateral condyle fracture in children. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02726-6

[76] Outcome of Nonoperative Treatment for Humeral Medial Epicondylar Fragmentation Before Epiphyseal Closure in Young Baseball Players. The American Journal of Sports Medicine. 2012. DOI: 10.1177/0363546512443807

[77] Tibial spine fractures: State of the art. Journal of ISAKOS. 2023. DOI: 10.1016/j.jisako.2023.06.001

[78] Distal humeral coronal plane fractures: management, complications and outcome. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2012.07.011

[79] Acute Transverse Patellar Fracture Associated with Weightlifting. The American Journal of Sports Medicine. 2001. DOI: 10.1177/03635465010290021901

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.