Skip to content

Clinicians › Hand

DIPJ arthritis

70 citationsUpdated Sep 2026
Illustration: DIPJ arthritis

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Osteoarthritis is the most common indication for distal interphalangeal joint arthrodesis [15]. For patients with symptomatic osteoarthritis who wish to preserve joint motion, open cheilectomy is a safe and effective alternative to fusion [20], and denervation with cheilectomy presents a compelling motion-preserving option [13]. Silicone interpositional arthroplasty serves as an acceptable alternative to arthrodesis, achieving excellent pain relief and a range of movement of 30–40 degrees with a low overall complication rate of 5% [8]. In select patients, percutaneous distal interphalangeal joint arthrodesis is advantageous in comparison with open fusion techniques [2].

Surgical planning must account for specific deformities and hardware compatibility. The swan neck deformity can progress significantly with time because of increasing distal interphalangeal joint flexion contracture [4]. When combined distal interphalangeal joint arthrodesis and proximal interphalangeal joint procedures are performed, unique challenges regarding hardware conflict arise; K-wires offer the easiest compatibility, and headless screws must ideally not reach proximal to the midpoint of the middle phalanx [128]. The combination of distal interphalangeal joint arthrodesis and proximal interphalangeal joint Swanson arthroplasty resulted in a favourable outcome in terms of simultaneous bony union and flexibility [7]. In case of severe painful osteoarthritis of the proximal and distal interphalangeal joints of the same digit, simultaneous surgical intervention is recommended [5].

Implant selection and patient preference influence operative strategy. Given the lack of difference in biomechanical performance between K-wires and compression screws, consideration should be given to other factors such as cost and complication profiles when choosing an implant for distal interphalangeal joint fusion [109]. In aggregate, patients prefer surgical attributes characteristic of proximal interphalangeal joint arthroplasty (ability to preserve joint motion and grip strength) relative to those associated with arthrodesis (decreased need for reoperation, lower costs, and shorter reoperation times) [125]. Treatment of the long finger may be a relative contraindication to proximal interphalangeal joint arthroplasty [1]. Ultimate salvage for the failed proximal interphalangeal joint arthroplasty may require arthrodesis or even amputation [112].

Anatomy & Pathophysiology

Bony Anatomy

The hand skeleton comprises 27 bones, 19 of which are long bones [48]. It is organized into five rays, each forming a polyarticulated chain of metacarpals and phalanges [48]. The thumb ray consists of a metacarpal and two phalanges, while the four finger rays each contain a metacarpal and three phalanges [48]. The index metacarpal is the longest, whereas the thumb metacarpal is the shortest [48]. In the fingers, the proximal and middle phalanges of the middle and ring digits are longer than those of the index finger [48]. Epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal, but at the distal ends of the other metacarpals [48]. The transverse palmar axis is oblique, forming an acute angle of approximately 75 degrees with the longitudinal axis [48].

Extensor Mechanism

DIP joint extension is achieved through conjoined lateral bands composed of tendinous slips from extrinsic and intrinsic tendons [47]. The principal bony insertion of extrinsic digital extensors is on the dorsal proximal aspect of the middle phalanx [47]. The deep head of each dorsal interosseous muscle forms a lateral tendon, or lateral band, at the level of the MP joint [68]. These deep heads extend the middle and distal phalanges [68]. Transverse fibers arch dorsally from each lateral band to join over the dorsum of the finger, flexing the proximal phalanx [68]. Oblique fibers from the lateral bands insert onto the lateral tubercles at the base of the middle phalanx to extend the PIP joint [68]. The lateral bands are joined by lateral slips of the extensor tendon to form the conjoined lateral band [68]. The two conjoined lateral bands unite at the distal third of the middle phalanx to form the terminal tendon, which inserts at the base of the distal phalanx to extend it [68]. The volar interossei form the ulnar lateral band of the index finger and the radial lateral band of the ring and little fingers [68]. The flexor digiti quinti brevis forms the ulnar lateral band of the little finger [68].

Flexor Mechanism

The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx [47]. It flexes the distal interphalangeal joint as well as the proximal interphalangeal and metacarpophalangeal joints [47]. The flexor digitorum superficialis inserts via radial and ulnar slips into the proximal metaphysis of the middle phalanx [74]. Its primary function is digital flexion at the proximal interphalangeal joint [74]. The A5 annular pulley is located over the distal interphalangeal joint [74].

Pathophysiology

Osteoarthritis occurs with the highest prevalence in the distal interphalangeal joint of the hand [25]. DIP joint osteoarthritis is divided into erosive and nonerosive forms [25]. The pathogenesis of early stages is poorly understood, though considerable emphasis has been placed on the role of cartilage, subchondral bone, collateral ligaments, and tendons [25]. Mallet finger develops from a disruption of the dorsal extensor apparatus at the level of the DIP joint [58]. This deformity is produced by unopposed flexor digitorum profundus activity with loss of counterbalancing extension from the conjoined lateral bands [58]. A chronic mallet deformity at the DIP joint can lead to a secondary hyperextension deformity at the PIP joint, known as a swan neck deformity [58]. In a mallet injury, the insertion of the conjoined terminal tendon slides proximally and functions as a secondary extensor of the PIP joint [58]. This proximal sliding creates a second extension force at the PIP joint that is countered by a single flexion force from the flexor digitorum superficialis [58]. Boutonnière and swan neck deformities of the finger can be the result of trauma [30]. Posttraumatic boutonnière and swan neck deformities should not be confused with those associated with inflammatory arthritis because treatment options are often very different [30]. The complex anatomy of the extensor mechanism makes understanding the pathomechanics of boutonnière and swan neck deformities challenging [30].

Mallet fractures associated with large fragments may result in volar subluxation of the distal phalanx as collateral ligaments remain attached to the fracture fragment [118]. Fracture fragments involving less than 43% of the distal phalanx articular surface usually do not allow volar subluxation [118]. Fracture fragments involving larger than 52% of the joint surface consistently allow volar subluxation [118]. Untreated mallet fractures with volar subluxation may lead to secondary swan neck deformity, premature osteoarthritis, pain, or stiffness [118]. The pathomechanics of avulsion injury of the flexor digitorum profundus tendon include forced hyperextension of the DIP joint while the finger is actively flexing [123]. The ring finger has the least independent motion of all the digits [123]. The insertion of the ring finger flexor digitorum profundus tendon is weaker than that of the long finger [123]. The bipennate structure of the lumbrical muscle of the ring finger highlights its increased susceptibility to flexor digitorum profundus avulsion injury [123]. The most important factor in the development of finger deformities in rheumatoid arthritis is changes occurring in the tendons and related structures, especially in early stages [86]. The quadriga phenomenon is caused by interconnected flexor digitorum profundus tendons [102]. This phenomenon significantly affects strength testing, movement assessment, and rehabilitation exercise selection [102].

Biomechanics & Functional Anatomy

Immobilization of the distal interphalangeal joint of any finger reduces the overall grip strength of the hand [32]. The effect of DIP joint immobilization on grip strength becomes progressively more pronounced from the index to the little fingers [32]. Positioning the middle finger DIP joint in either extension or 20° of flexion did not significantly affect grip strength or dexterity [83]. Simulated arthrodesis of the middle finger affected grip strength more than that of the ring finger [51]. No border digit PIP joint arthrodesis angle was superior for grip and pinch strength [57].

The position of each articulation depends on the equilibrium of forces acting at that level, which is subject to the position of the immediately proximal articulation [75]. The wrist influences the position of the metacarpophalangeal joint, which affects the proximal interphalangeal joint, which in turn affects the distal interphalangeal joint [75]. Single articular movements around a fixed perpendicular axis simply do not exist in the hand [75]. Almost all hand movements are around oblique and variable axes, resulting in combined movements [75]. The active factor in joint equilibrium is the dynamic balance between antagonist muscles [75]. Passive factors in joint equilibrium include the restraining action of ligaments and muscular viscoelasticity [75]. Measurement of individual finger forces can provide more accurate biomechanical models of the hand [67]. Measurement of individual finger forces can determine the effect of disease on hand functions [67]. Individual digit strength is not linked with osteoarthritis involvement of that digit [98]. Biomechanically, dynamic tenodesis for the DIP joint using the remaining flexor digitorum profundus tendon results in a flexion angle greater than 30 degrees [94]. Lateral blocking with incremental joint angles allows a safer application of force for the healing tendon [100]. Active and passive intrinsic reconstruction methods improved basic grasp and release kinematics in experimental cadaver hand models [80].

Classification

Osteoarthritis Phenotypes: Osteoarthritis of the distal interphalangeal joint is divided into an erosive and a nonerosive form [25].

Other Considerations: The interrater reliability of the Kellgren & Lawrence and OARSI classification systems for post-traumatic osteoarthritis in the distal interphalangeal joint after mallet finger fractures is considerably lower than initially assumed [120].

Clinical Presentation

History and Pathogenesis The pathogenesis of early-stage osteoarthritis in the distal interphalangeal joint is poorly understood [25]. Considerable emphasis has been placed on the role of cartilage, subchondral bone, and soft tissue structures such as collateral ligaments and tendons in the development of distal interphalangeal joint osteoarthritis [25]. Cartilage loss and reactive new bone formation at joint margins are accompanied by the proliferation of osteoarticular tissue in the capsule [25].

Specific Etiologies and Diagnostic Criteria Mucous cysts: These lesions are associated with osteoarthritic changes visible on radiographs [31]. They may present with a small deformity on the fingernail [31]. Sea urchin spine arthritis: Diagnosis is based on injury history, a symptom-free period, and the absence of laboratory abnormalities [29]. Synovial chondromatosis: Primary synovial chondromatosis of the distal interphalangeal joint is an extremely rare entity that requires accurate diagnosis to distinguish it from other arthropathies [104]. Synovial chondromatosis is a rare disease, and its localization in the hand is uncommon [121].

Acute Injury Patterns Floating distal interphalangeal joint injuries can be misdiagnosed initially due to minimal deformity [36]. Treatment delay greater than 8 hours of injury may develop significant distal interphalangeal joint stiffness [14]. Palmar subluxation of a distal interphalangeal joint without preexisting arthritic deformity is expected when more than one half of the dorsal articular surface is injured [21].

Chronic Deformity and Functional Impact The swan neck deformity in an individual progressed significantly with time because of increasing distal interphalangeal joint flexion contracture [4]. The effect of distal interphalangeal joint immobilization on grip strength becomes progressively more pronounced from the index to the little fingers [32].

Post-Traumatic Degeneration Radiological osteoarthritis after a mallet finger fracture is similar to the natural degenerative process in the distal interphalangeal joint [19]. This radiological osteoarthritis is accompanied by a decrease in range of motion of the distal interphalangeal joint [19]. However, the decrease in range of motion of the distal interphalangeal joint following mallet finger fracture does not clinically affect patient-reported outcomes [19].

Radiographic Evaluation Radiographic evaluation represents the most standardized method to quantify disease progression in the distal interphalangeal joint [25].

Investigations

Plain radiography: Post-operative follow-up for PIPJ arthroplasty requires radiographs in PA and lateral projections at 1, 2, and 5 years [24]. Radiographic analysis involves measuring subsidence in the proximal and middle phalanges on PA images, defined as the distance from the joint surface of the MCP or distal interphalangeal (DIP) joint, respectively, to the end of the prosthesis stem [24]. In patients with arthrodesis of the DIP joint, PIPJ prosthesis subsidence is measured from the end of the distal phalanx [24]. Implant migration within the medullary canal is assessed on lateral images using a four-point scale described by Sweets and Stern (2011) [24]. The Stern classification defines prosthesis position as Grade 0 for a well-aligned implant, Grade 1 for macroscopically evident migration, Grade 2 for severe migration with the stem opposing the cortex, and Grade 3 for breach of the cortex by the stem [24].

MRI: MRI and histology have confirmed the existence of a distinct collagen septum between the extensor tendon and skin at the DIP joint [64].

Other Considerations: A size mismatch exists between the anatomic dimensions of the DIP joint and commercially available headless compression screws [63]. Palmar subluxation of a DIP joint without preexisting arthritic deformity is expected when more than one half of the dorsal articular surface is injured [21]. Collateral ligament injury contributes to instability at the DIP joint in a mallet fracture, increasing the likelihood of palmar subluxation [137].

Treatment

Non-Operative

Conservative therapeutic interventions for osteoarthritic finger joints have been systematically reviewed [113]. DIPJ splinting reduces pain and improves extension at the joint [34]. This intervention does not give rise to non-compliance, increased stiffness, or restriction of range of motion [34]. Custom-made splint treatment serves as a therapeutic intervention for osteoarthritis of the distal interphalangeal joints [122].

Operative

Indications: DIPJ arthrodesis is the standard surgical treatment for DIPJ arthritis if conservative measures fail [18]. Osteoarthritis was the most common indication for DIPJ arthrodesis in a retrospective cohort study of 149 cases [15]. Simultaneous surgical intervention is recommended in case of severe painful OA of the PIP and DIP joints of the same digit [5]. The only treatment that can ensure a mucous cyst will not recur is DIP joint arthrodesis [40].

Surgical Approach / Technique: Intramedullary screw fixation preceded by DIPJ arthrotomy for cartilage and subchondral bone resection is commonly used for DIPJ arthrodesis [18]. A minimally invasive percutaneous technique incorporating articular surface reaming for DIPJ arthrodesis has been described and reported for clinical outcomes [18]. In select patients, percutaneous DIP joint arthrodesis is advantageous in comparison with open fusion techniques [2]. The results of a lateral approach and plate fixation for DIP joint arthrodesis are equivalent to traditional methods but with fewer major complications [6]. The smile incision and reverse shotgun approach may be a good surgical option for DIPJ arthrodesis when more volar part joint preparation and more volar implant insertion sites are necessary [11]. The nonaxial multiple small screws (NMSS) technique is a feasible option for DIPJ and thumb IPJ arthrodesis, especially when a small finger is indicated and a significant flexion angle is required [17]. A new technique for DIPJ arthrodesis is simple and reliable, giving consistent clinical results with a very low non-union rate and an acceptable complication rate [126].

Implant Selection: Silicone interpositional arthroplasty of the DIP joint is an acceptable alternative to arthrodesis, achieving excellent pain relief and a range of movement of 30–40 degrees with a low overall complication rate of 5% [8]. Open DIP joint cheilectomy is a safe and effective alternative to DIP joint arthrodesis in patients with symptomatic osteoarthritis who wish to preserve joint motion [20]. Denervation with cheilectomy of the DIP joint presents a compelling motion-preserving alternative to arthrodesis for symptomatic DIP joint osteoarthritis [13].

Other Considerations: Postoperative complications for DIPJ arthrodesis occurred at a rate similar to that reported in existing literature [15]. The combination of DIP arthrodesis and PIP Swanson arthroplasty resulted in a favourable outcome in terms of simultaneous bony union and flexibility [7]. A customized structural bone graft addresses issues of bone stock loss and medullary absence in failed DIPJ silicone arthroplasty, achieving reliable union rates and high patient satisfaction [23].

Contextual PIPJ Arthroplasty: PIPJ implant arthroplasty is a good and reliable option for symptomatic PIPJ degenerative, post-traumatic or inflammatory arthritis given the proper clinical setting [3]. Treatment of the long finger may be a relative contraindication to PIPJ arthroplasty [1]. Pyrocarbon hemiarthroplasty of the PIPJ has an acceptable long-term implant survival, and the significant improvement in pain scores and patient-reported outcomes is maintained over time [9]. The minimum 2 years of follow-up evaluation of the SLFJ implant PIP joint arthroplasty demonstrated good pain relief and good overall patient satisfaction while maintaining joint range of motion [12]. Proximal interphalangeal joint arthroplasties performed in border digits had similar pain relief, survivorship, complications, and reoperation rates compared with those performed in non-border digits [35]. Overall clinical outcomes for reoperations following PIP joint nonconstrained arthroplasties demonstrated no significant change in range of motion, and most patients had mild or no pain [28]. Although achieving solid fusion with arthrodesis as a salvage for failed PIPJ arthroplasty is not completely reliable or without complication, patients' subjective and functional outcomes demonstrate fair to good results [132].

Complications

Stiffness / Arthrofibrosis: Treatment delay greater than 8 hours after injury may develop significant DIP joint stiffness [14]. In the context of deformity correction, hyperextension of the PIP joint is corrected well by volar transfer of the lateral band, but severe extension lag of the DIP joint remains uncorrected postoperatively [42]. Additionally, the swan neck deformity in an individual progressed significantly with time because of increasing DIPJ flexion contracture [4].

Wound complications: Arthrodesis of the distal interphalangeal joint often leads to complications [26]. In a cohort of 209 fingers, 40 of 187 patients (21.4%) had a postoperative complication following DIP joint fusion [50]. Postoperative complications in DIP and thumb IP joint arthrodesis occurred at a rate similar to that reported in existing literature [15].

Instability: A lateral approach and plate fixation for DIP joint arthrodesis yielded results equivalent to traditional methods but with fewer major complications [6].

Other Considerations: In the same cohort of 209 fingers, 30 of 187 patients (16.0%) underwent reoperation following DIP joint fusion [50]. Reoperations were primarily for removal of hardware (n = 18) and revision fusion (n = 7) [50]. The use of autograft was significantly associated with decreased risk of reoperation following DIP joint fusion (P = .003) [50]. The use of autograft was associated with a decreased risk of complication following DIP joint fusion, but did not cross the threshold of significance after Bonferroni correction (P = .005) [50]. Neither smoking nor the presence of diabetes mellitus had a significant effect on complications or reoperations following DIP joint fusion in bivariate analysis [50]. The type of implant used was not significantly associated with increased complications or reoperation following DIP joint fusion [50]. No difference in complications was noted for laterality, number of digits, or diagnosis following DIP joint fusion [50]. Silicone interpositional arthroplasty of the DIP joint achieved a low overall complication rate of 5% [8].

Recovery

Other Considerations: The provided evidence base does not contain specific data regarding recovery timelines, rehabilitation protocols, or functional milestones for DIPJ arthritis interventions. Consequently, the standard recovery phases (Light activity, Full activity, Complete recovery) and specific rehabilitation details are omitted due to the absence of supporting evidence in this section.

The following recovery-relevant clinical considerations and outcome observations are derived from the available literature:

DIPJ Arthritis Management: Denervation with cheilectomy presents a compelling motion-preserving alternative to arthrodesis for symptomatic DIP joint osteoarthritis [13]. Osteoarthritis was the most common indication for DIP and thumb interphalangeal joint arthrodesis, with postoperative complications occurring at a rate similar to that reported in existing literature [15]. Radiological osteoarthritis after a mallet finger fracture is similar to the natural degenerative process in the DIP joint and is accompanied by a decrease in range of motion that does not clinically affect patient-reported outcomes [19]. Treatment delay greater than 8 hours after an open dorsal DIP joint dislocation may develop significant DIP joint stiffness [14]. Patient function was good despite limited flexion of the DIP joint to 30 degrees following dorsal dislocation with fracture of the volar base [10].

PIPJ Arthritis Management: Pyrocarbon hemiarthroplasty of the PIPJ has an acceptable long-term implant survival, and significant improvement in pain scores and patient-reported outcomes is maintained over time [9]. Despite substantially good survivorship, clinical outcomes for PIP joint replacements with pyrocarbon implants are variable [39]. Longer follow-up and prospective randomized comparisons are needed to better define rates of revision, failure, and complications for PIPJ prosthetic arthroplasty [54].

Combined PIPJ and DIPJ Interventions: The authors recommend simultaneous surgical intervention in case of severe painful OA of the PIP and DIP joints of the same digit [5].

Key Evidence

  • [L1] Treatment of the long finger may be a relative contraindication to PIPJ arthroplasty. [1] (10.1177/1558944718791186)
  • [L4] In select patients, this percutaneous DIP joint arthrodesis is advantageous in comparison with open fusion techniques. [2] (10.1007/s11552-010-9265-9)
  • [L4] PIPJ implant arthroplasty is a good and reliable option for symptomatic PIPJ degenerative, post-traumatic or inflammatory arthritis given the proper clinical setting. [3] (10.1177/17531934241265837)
  • [L5] The swan neck deformity in this individual progressed significantly with time because of increasing DIPJ flexion contracture. [4] (10.1016/j.jht.2009.11.005)
  • [L3] The authors recommend simultaneous surgical intervention in case of severe painful OA of the PIP and DIP joints of the same digit. [5] (10.1177/17531934231191255)
  • [L4] The results obtained in this small series are equivalent to the traditional methods of DIP joint arthrodesis but with fewer major complications. [6] (10.1016/j.jhsa.2007.09.004)
  • [L4] The combination of DIP arthrodesis and PIP Swanson arthroplasty resulted in a favourable outcome in terms of simultaneous bony union and flexibility. [7] (10.1177/17531934231215790)
  • [L4] The study confirms that silicone interpositional arthroplasty of the DIP joint is an acceptable alternative to arthrodesis, achieving excellent pain relief and a range of movement of 30–40 degrees with a low overall complication rate of 5%. [8] (10.1177/1753193411422679)
  • [L4] Pyrocarbon hemiarthroplasty of the PIPJ has an acceptable long-term implant survival, and the significant improvement in pain scores and patient-reported outcomes is maintained over time. [9] (10.1016/j.jhsa.2023.11.007)
  • [L5] The patient's function was good, despite limited flexion of the DIP joint to 30 degrees. [10] (10.1016/s0020-1383(97)00121-6)
  • [L4] This technique may be a good surgical option for DIPJ arthrodesis when more volar part joint preparation and more volar implant insertion sites are necessary. [11] (10.1186/s12891-024-08016-6)
  • [L4] The minimum 2 years of follow-up evaluation of the SLFJ implant PIP joint arthroplasty demonstrated good pain relief and good overall patient satisfaction while maintaining joint range of motion. [12] (10.1177/1558944717726136)
  • [L4] It presents a compelling motion-preserving alternative to arthrodesis for symptomatic DIP joint osteoarthritis. [13] (10.1016/j.jhsa.2026.01.027)
  • [L4] Treatment delay > 8 hours of injury may develop significant DIP joint stiffness. [14] (10.1016/j.otsr.2021.102852)
  • [L3] Osteoarthritis was the most common indication for arthrodesis and postoperative complications occurred at a rate similar to that reported in the existing literature. [15] (10.1186/s12891-024-07361-w)
  • [L4] Thus, the NMSS technique could be used as a feasible option in DIPJ and thumb IPJ arthrodesis, especially when a small finger is indicated and a significant flexion angle is required. [17] (10.1186/s12891-022-05473-9)
  • [L4] [18] (10.1177/17531934251409628)
  • [L4] Radiological OA after an MFF is similar to the natural degenerative process in the DIP joint and is accompanied by a decrease in range of motion of the DIP joint, which does not clinically affect PROMs. [19] (10.1016/j.jhsa.2023.03.027)
  • [L4] Open DIP joint cheilectomy is a safe and effective alternative to DIP joint arthrodesis in patients with symptomatic osteoarthritis who wish to preserve joint motion. [20] (10.1016/j.jhsa.2017.07.006)
  • [L5] Palmar subluxation of a DIP joint without preexisting arthritic deformity is expected when more than one half of the dorsal articular surface is injured. [21] (10.1016/j.jhsa.2007.09.006)
  • [L4] Pinning is more expensive and may result in more DIPJ stiffness (ie, loss of active flexion), but it may be justified in certain patients (eg, medical professionals, food service workers) who would have difficulty working with an orthosis. [22] (10.1097/sap.0000000000000315)
  • [L4] A customized structural bone graft using the described technique addresses issues of bone stock loss and medullary absence in failed DIPJ silicone arthroplasty, achieving reliable union rates and high patient satisfaction. [23] (10.1177/17531934231151217)
  • [L4] [24] (10.1177/1753193413479527)
  • [L5] [25] (10.1016/j.jhsa.2010.09.003)
  • [L3] Arthrodesis of the distal interphalangeal joint often leads to complications. [26] (10.1177/17531934221111641)
  • [L4] Overall clinical outcomes demonstrated no significant change in range of motion, and most patients had mild or no pain. [28] (10.1016/j.jhsa.2011.06.002)
  • [L4] Diagnosis of sea urchin spine arthritis is based on injury history, a symptom-free period, and absence of laboratory abnormalities. [29] (10.1016/j.jhsa.2007.11.016)
  • [L5] [30] (10.5435/jaaos-d-14-00272)
  • [L5] [31] (10.1007/s00402-008-0794-4)
  • [L4] Immobilization of the distal interphalangeal joint of any finger reduces the overall grip strength of the hand, with the effect becoming progressively more pronounced from the index to the little fingers. [32] (10.1177/1753193418765068)
  • [L2] It does not give rise to non-compliance, increased stiffness or restriction of range of motion. [34] (10.1016/j.jht.2013.08.004)
  • [L4] Proximal interphalangeal joint arthroplasties performed in border digits had similar pain relief, survivorship, complications, and reoperation rates compared with those performed in non-border digits. [35] (10.1177/1753193420926127)
  • [Case_report] Floating DIP joint injuries can be misdiagnosed initially due to minimal deformity; open reduction and internal fixation is a viable treatment option for chronic cases, though osteoarthritis may develop. [36] (10.1016/j.jhsa.2010.05.025)
  • [L4] Despite substantially good survivorship, clinical outcomes for PIP joint replacements with pyrocarbon implants are variable. [39] (10.1302/2058-5241.2.160041)
  • [L4] The only treatment that can ensure a cyst will not recur is DIP joint arthrodesis. [40] (10.1016/j.jhsa.2010.01.029)
  • [L4] Hyperextension of the PIP joint is corrected well, but the severe extension lag of the DIP joint remains uncorrected postoperatively. [42] (10.1177/15589447221127337)
  • [L3] [50] (10.1177/15589447251334671)
  • [L4] Simulated arthrodesis of the middle finger affected the grip strength more than that of the ring finger. [51] (10.1007/s00402-021-04317-w)
  • [L4] Longer follow-up and prospective randomized comparisons are needed to better define rates of revision, failure, and complications. [54] (10.1016/j.jhsa.2010.04.005)
  • [L4] No border digit PIP joint arthrodesis angle was superior for grip and pinch strength. [57] (10.1016/j.jhsa.2019.11.008)
  • [L5] [58] (10.1016/s0749-0712(21)00059-7)
  • [L4] A size mismatch existed between the anatomic dimensions of the DIP joint and commercially available headless compression screws. [63] (10.1016/j.jhsa.2014.02.007)
  • [L5] We confirmed the existence of a distinct collagen septum between the extensor tendon and skin at the DIP joint using MRI and histology. [64] (10.1016/j.jhsa.2008.11.030)
  • [L4] Measurement of individual finger forces can provide more accurate biomechanical models of the hand and determine the effect of disease on hand functions. [67] (10.1016/j.jht.2020.04.002)
  • [L5] Active and passive intrinsic reconstruction methods improved basic grasp and release kinematics in experimental cadaver hand models. [80] (10.1016/j.jhsa.2014.09.031)
  • [L2] Positioning the middle finger DIP joint in either extension or 20° of flexion did not significantly affect grip strength or dexterity, allowing other considerations such as appearance to be prioritized. [83] (10.1016/j.jhsa.2014.06.021)
  • [L4] The most important factor in the development of finger deformities is the changes occurring in the tendons and related structures, especially in early stages. [86] (10.2106/00004623-195739030-00006)
  • [L5] Biomechanically, dynamic tenodesis for the DIP joint using the remaining FDP tendon is a valuable procedure because it results in a flexion angle greater than 30 degrees. [94] (10.1016/j.jhsg.2020.08.007)
  • [L3] Individual digit strength is not linked with OA involvement of that digit. [98] (10.1258/ht.2010.010010)
  • [L5] This study supports the concept that lateral blocking with incremental joint angles allows a safer application of force for the healing tendon. [100] (10.1016/j.jht.2020.07.004)
  • [L5] The quadriga phenomenon, caused by interconnected flexor digitorum profundus tendons, significantly affects clinical situations including strength testing, movement assessment, and rehabilitation exercise selection; understanding its anatomy and biomechanics improves diagnosis and treatment. [102] (10.1177/1753193411430810)
  • [Case_report] Primary synovial chondromatosis of the distal interphalangeal joint is an extremely rare entity that requires accurate diagnosis to distinguish from other arthropathies. [104] (10.1177/15589447211049520)
  • [L5] Given the lack of difference in biomechanical performance between K-wires and compression screws, consideration should be given to other factors such as cost and complication profiles when choosing an implant for DIPJ fusion. [109] (10.1177/1558944715627211)
  • [L5] Ultimate salvage for the failed PIP joint arthroplasty may require arthrodesis or even amputation. [112] (10.1016/j.hcl.2017.12.011)
  • [L1] [113] (10.1016/j.jht.2018.01.001)
  • [L5] [118] (10.1177/1753193414554772)
  • [L4] The interrater reliability of the Kellgren & Lawrence and OARSI classification systems for post-traumatic osteoarthritis in the distal interphalangeal joint after mallet finger fractures is considerably lower than initially assumed. [120] (10.1016/j.jhsa.2024.03.012)
  • [L5] Synovial chondromatosis is a rare disease, and its localization in the hand is uncommon. [121] (10.21873/anticanres.13425)
  • [L4] [122] (10.1016/j.jhsa.2010.01.012)
  • [L4] [123] (10.5435/00124635-201103000-00004)
  • [L3] In aggregate, patients prefer surgical attributes characteristic of arthroplasty (ability to preserve joint motion and grip strength) relative to those associated with arthrodesis (decreased need for reoperation, lower costs, and shorter reoperation times). [125] (10.1016/j.jhsa.2018.03.001)
  • [L4] The technique is simple and reliable giving consistent clinical results with a very low non-union rate and an acceptable complication rate. [126] (10.1007/s00402-007-0457-x)
  • [L5] Combined DIP arthrodesis and PIP procedures present unique challenges regarding hardware conflict; K-wires offer the easiest compatibility, while headless screws must ideally not reach proximal to the midpoint of the middle phalanx. [128] (10.1016/j.jhsa.2024.08.006)
  • [L4] Although achieving solid fusion with arthrodesis is not completely reliable or without complication, patients' subjective and functional outcomes demonstrate fair to good results. [132] (10.1016/j.jhsa.2010.10.030)
  • [L5] Collateral ligament injury contributes to instability at the DIP joint in a mallet fracture, increasing the likelihood of palmar subluxation. [137] (10.1016/j.jhsa.2025.11.007)

See Also

References

[1] Prosthetic Arthroplasty of Proximal Interphalangeal Joints for Treatment of Osteoarthritis and Posttraumatic Arthritis: Systematic Review and Meta-Analysis Comparing the Three Ulnar Digits With the Index Finger. HAND. 2018. DOI: 10.1177/1558944718791186

[2] Treatment of Symptomatic Distal Interphalangeal Joint Arthritis with Percutaneous Arthrodesis: A Novel Technique in Select Patients. HAND. 2010. DOI: 10.1007/s11552-010-9265-9

[3] Proximal interphalangeal joint arthroplasty: current trends and evidence-based practice. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241265837

[4] Swan Neck Deformity after Distal Interphalangeal Joint Flexion Contractures: A Biomechanical Analysis. Journal of Hand Therapy. 2010. DOI: 10.1016/j.jht.2009.11.005

[5] Does distal interphalangeal joint arthrodesis affect proximal interphalangeal joint arthroplasty outcomes in the same finger?. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231191255

[6] Alternative to the Distal Interphalangeal Joint Arthrodesis: Lateral Approach and Plate Fixation. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2007.09.004

[7] Simultaneous anterograde screw arthrodesis of distal interphalangeal joint and silastic proximal interphalangeal joint replacement for osteoarthritis. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231215790

[8] Joint replacement in 131 painful osteoarthritic and post-traumatic distal interphalangeal joints. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411422679

[9] Pyrolytic Carbon Hemiarthroplasty for Proximal Interphalangeal Joint Arthritis, Long-Term Follow-Up. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2023.11.007

[10] Dorsal dislocation of the distal interphalangeal joint with fracture of the volar base: an unusual type. Injury. 1997. DOI: 10.1016/s0020-1383(97)00121-6

[11] Smile incision and reverse shotgun approach in distal interphalangeal joint arthrodesis. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-08016-6

[12] Outcomes of Surface Replacement Proximal Interphalangeal Joint Arthroplasty Using the Self Locking Finger Joint Implant: Minimum Two Years Follow-up. HAND. 2017. DOI: 10.1177/1558944717726136

[13] Denervation with Cheilectomy of the Distal Interphalangeal Joint: Technique and Medium-Term Results. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2026.01.027

[14] Open dorsal distal interphalangeal joint dislocations: A report of 20 cases. Orthopaedics & Traumatology: Surgery & Research. 2021. DOI: 10.1016/j.otsr.2021.102852

[15] Arthrodesis of distal interphalangeal and thumb interphalangeal joint: a retrospective cohort study of 149 cases. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07361-w

[17] Distal interphalangeal joint arthrodesis with nonaxial multiple small screws: a biomechanical analysis with axial headless compression screw and clinical result of 15 consecutive cases. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05473-9

[18] Percutaneous reamed arthrodesis for distal interphalangeal joint arthritis: surgical technique and case series. Journal of Hand Surgery (European Volume). 2026. DOI: 10.1177/17531934251409628

[19] Posttraumatic Osteoarthritis of the Distal Interphalangeal Joint: A Follow-Up Study of 12 Years After Nonsurgical Treatment of Mallet Finger Fractures. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2023.03.027

[20] Cheilectomy for Treatment of Symptomatic Distal Interphalangeal Joint Osteoarthritis: A Review of 78 Patients. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.07.006

[21] A Biomechanical Study of Distal Interphalangeal Joint Subluxation After Mallet Fracture Injury. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2007.09.006

[22] Comparison of Extension Orthosis Versus Percutaneous Pinning of the Distal Interphalangeal Joint for Closed Mallet Injuries. Annals of Plastic Surgery. 2016. DOI: 10.1097/sap.0000000000000315

[23] Salvage of failed Swanson’s arthroplasty of the distal interphalangeal joint. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231151217

[24] Ten years’ experience with a pyrocarbon prosthesis replacing the proximal interphalangeal joint. A prospective clinical and radiographic follow-up. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413479527

[25] Osteoarthritis of the Distal Interphalangeal Joint. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.09.003

[26] Risk factors in distal interphalangeal joint arthrodesis in the hand: a retrospective study of 173 cases. Journal of Hand Surgery (European Volume). 2022. DOI: 10.1177/17531934221111641

[28] Reoperations Following Proximal Interphalangeal Joint Nonconstrained Arthroplasties. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.06.002

[29] Sea Urchin Spine Arthritis of the Hand. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2007.11.016

[30] Posttraumatic Boutonnière and Swan Neck Deformities. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-d-14-00272

[31] Malignant Natural-Killer cell neoplasm presenting as a mucous cyst on the distal interphalangeal joint of the finger. Archives of Orthopaedic and Trauma Surgery. 2008. DOI: 10.1007/s00402-008-0794-4

[32] Effect of immobilization of the distal interphalangeal joint of fingers on grip strength. Journal of Hand Surgery (European Volume). 2018. DOI: 10.1177/1753193418765068

[34] Splinting of the Distal Interphalangeal Joint Reduces Pain and Improves Extension at the Joint; Results Front the Splint-OA Study. Journal of Hand Therapy. 2014. DOI: 10.1016/j.jht.2013.08.004

[35] Results of proximal interphalangeal arthroplasty: border digits versus middle digits. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420926127

[36] Floating Distal Interphalangeal Joint Injury: Case Report. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.05.025

[39] Proximal interphalangeal (PIP) joint replacements with pyrolytic carbon implants in the hand. EFORT Open Reviews. 2017. DOI: 10.1302/2058-5241.2.160041

[40] Mucous Cysts. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.01.029

[42] Volar Transfer of the Lateral Band With Transverse Retinacular Ligament for the Correction of Swan Neck Deformity. HAND. 2022. DOI: 10.1177/15589447221127337

[47] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > Image DISORDERS OF THE MUSCULATURE OF THE HAND.

[48] Exam Of The Hand Wrist 2Ed. 1.1 SKELETON OF THE HAND > The osseous skeleton.

[50] Factors Associated With Complications and Reoperations in Distal Interphalangeal Joint Fusion. HAND. 2025. DOI: 10.1177/15589447251334671

[51] The impact of various simulated arthrodesis angles of the proximal interphalangeal joint of the ring and middle finger on grip strength. Archives of Orthopaedic and Trauma Surgery. 2022. DOI: 10.1007/s00402-021-04317-w

[54] Proximal Interphalangeal Joint Prosthetic Arthroplasty. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.04.005

[57] The Optimal Position for Arthrodesis of the Proximal Interphalangeal Joints of the Border Digits. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2019.11.008

[58] EXTENSOR TENDON INJURIES AT THE DISTAL INTERPHALANGEAL JOINT. Hand Clinics. 1995. DOI: 10.1016/s0749-0712(21)00059-7

[63] Distal Interphalangeal Joint Bony Dimensions Related to Headless Compression Screw Sizes. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.02.007

[64] Dorsal Digital Septum of the Distal Interphalangeal Joint. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2008.11.030

[67] Evaluation of individual finger forces during activities of daily living in healthy individuals and those with hand arthritis. Journal of Hand Therapy. 2020. DOI: 10.1016/j.jht.2020.04.002

[68] Green S Operative Hand Surgery. Interosseous and Hypothenar Muscles.

[74] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > FLEXOR TENDON INJURY.

[75] Exam Of The Hand Wrist 2Ed. 1.3 MOVEMENTS OF THE HAND AND WRIST > Gliding mechanisms.

[80] The Effect of Intrinsic Loading and Reconstruction Upon Grip Capacity and Finger Extension Kinematics. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.09.031

[83] Simulated Distal Interphalangeal Joint Fusion of the Index and Middle Fingers in 0° and 20° of Flexion: A Comparison of Grip Strength and Dexterity. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.06.021

[86] Finger Deformities Caused by Rheumatoid Arthritis. The Journal of Bone & Joint Surgery. 1957. DOI: 10.2106/00004623-195739030-00006

[94] The Effect of Flexor Digitorum Profundus Dynamic Tenodesis on the Distal Interphalangeal Joint: A Cadaver Study. Journal of Hand Surgery Global Online. 2020. DOI: 10.1016/j.jhsg.2020.08.007

[98] Assessment of strength of individual digits in persons with osteoarthritis of the hand. Hand Therapy. 2010. DOI: 10.1258/ht.2010.010010

[100] Tensile load on the flexor digitorum profundus tendon during palmar and lateral blocking exercises: Influence on blocking force and distal interphalangeal joint flexion angle. Journal of Hand Therapy. 2021. DOI: 10.1016/j.jht.2020.07.004

[102] The quadriga phenomenon: a review and clinical relevance. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411430810

[104] Primary Distal Interphalangeal Joint Tenosynovial Chondromatosis of the Small Finger: A Case Report With Literature Review. HAND. 2022. DOI: 10.1177/15589447211049520

[109] Biomechanical Analysis of Internal Fixation Methods for Distal Interphalangeal Joint Arthrodesis. HAND. 2016. DOI: 10.1177/1558944715627211

[112] Salvaging a Failed Proximal Interphalangeal Joint Implant. Hand Clinics. 2018. DOI: 10.1016/j.hcl.2017.12.011

[113] Conservative therapeutic interventions for osteoarthritic finger joints: A systematic review. Journal of Hand Therapy. 2019. DOI: 10.1016/j.jht.2018.01.001

[118] Mallet fingers with bone avulsion and DIP joint subluxation. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414554772

[120] Rater Agreement of Post-Traumatic Osteoarthritis of the Distal Interphalangeal Joint 12 Years After a Mallet Finger Fracture. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2024.03.012

[121] A Rare Case of Distal Interphalangeal Chondromatosis in the Middle Finger: Case Report With Review of Literature. Anticancer Research. 2019. DOI: 10.21873/anticanres.13425

[122] Custom-Made Splint Treatment for Osteoarthritis of the Distal Interphalangeal Joints. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.01.012

[123] Avulsion Injuries of the Flexor Digitorum Profundus Tendon. American Academy of Orthopaedic Surgeon. 2011. DOI: 10.5435/00124635-201103000-00004

[125] Understanding Patient Preferences in Proximal Interphalangeal Joint Surgery for Osteoarthritis: A Conjoint Analysis. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.03.001

[126] Arthrodesis of the distal interphalangeal joint: description of a new technique and clinical follow-up at 2 years. Archives of Orthopaedic and Trauma Surgery. 2007. DOI: 10.1007/s00402-007-0457-x

[128] Combined Distal Interphalangeal Joint Arthrodesis With Proximal Interphalangeal Joint Arthroplasty or Arthrodesis: Technical Considerations. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2024.08.006

[132] Arthrodesis as a Salvage for Failed Proximal Interphalangeal Joint Arthroplasty. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2010.10.030

[137] The Role of the Collateral Ligaments in Stabilizing the Distal Interphalangeal Joint in Fingers With Small Mallet Fractures: A Biomechanical Study. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2025.11.007

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.