Skip to content

Metacarpal Fractures (including Boxer's Fracture)

Metacarpal neck/shaft/base fractures: angulation tolerance by ray, malrotation assessment, non-operative vs K-wire/plate fixation, WALANT, complications.

Overview

The majority of metacarpal fractures are managed nonoperatively [1, 7], though some fractures and patients can achieve improved patient-centered outcomes with surgical fixation [7]. Operative intervention for thumb metacarpal fractures and involvement of lesser digit metacarpals lessens the return-to-play time in the National Football League [2]. While measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures [4], there is a lack of high-quality evidence to guide treatment for metacarpal shaft fractures in adults [6].

Intramedullary fixation is a viable option for closed, extra-articular metacarpal fractures [8]. Modified retrograde percutaneous intramedullary Kirschner wire fixation is a simple and reliable technique for displaced, unstable metacarpal fractures that provides sufficient stability with low morbidity [3]. Intramedullary screw fixation is a reliable and safe method that results in fewer complications compared to plate and screw constructs [9, 10]. This modality provides quicker return to motion and faster time to full range of motion compared to plate and screw constructs, while yielding similar time to union [10].

For specific fracture patterns, patients with a single displaced spiral and/or oblique finger metacarpal shaft fracture treated with unrestricted mobilization have outcomes comparable to those treated operatively, even despite metacarpal shortening [11]. Minimally invasive hybrid fixation appears safe and effective for unstable metacarpal shaft fractures not typically suited for standard intramedullary fixation [15]. Well-designed, multicenter trials are needed to identify the most effective and cost-efficient treatment for metacarpal shaft fractures in adults [6].

Anatomy & Pathophysiology

The majority of metacarpal fractures are managed nonoperatively [1], with functional outcomes dependent on appropriate treatment and early range of motion whenever possible [5]. Knowledge of the epidemiology and etiology of hand fractures serves as an essential first step in devising strategies to reduce the incidence of these injuries [20]. Return-to-play timelines vary by fracture type, hand dominance, and position; nonthrowing hand injuries allow return to play in 2 to 5 weeks, whereas throwing hand or tackling position injuries require 6 to 10 weeks [30]. Involvement of lesser digit metacarpals lessens the return-to-play time, while operative intervention for thumb metacarpal fractures also lessens the return-to-play time [2].

Fracture Management & Angulation: Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures [4]. Early, accurate diagnosis of fourth and fifth CMC joint fracture-dislocations is crucial for optimizing hand function and postoperative outcomes [29]. Regarding fixation, soft tissues significantly contribute to the strength of metacarpal fracture fixation [23], and articular surface area violation during intramedullary headless screw fixation for metacarpal neck fractures was least during the more clinically relevant sagittal plane arc of motion [31]. No significant long-term differences were noted in functional outcomes between pin and plate fixation for metacarpal fractures [32].

Strength & Functional Outcomes: Finger strength was statistically significantly reduced following non-surgical treatment of spiral and oblique metacarpal shaft fractures with metacarpal shortening, though its clinical relevance remains unclear [25].

Classification

General Management: The majority of metacarpal fractures are closed injuries managed nonoperatively with external immobilization and subsequent rehabilitation [1, 12]. While most fractures are treated nonsurgically, some patients achieve improved patient-centered outcomes with surgical fixation [7]. Functional outcomes depend on appropriate treatment and early range of motion whenever possible [5].

Treatment Variables: Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures [4]. Patients with a single displaced spiral and/or oblique finger metacarpal shaft fracture treated with unrestricted mobilization have outcomes comparable to those treated operatively, despite metacarpal shortening [11]. The only variables that lessen return-to-play time in National Football League players are involvement of lesser digit metacarpals and operative intervention for treatment of thumb metacarpal fractures [2].

Fixation Modalities: Intramedullary fixation: Should be considered for closed, extra-articular metacarpal fractures [8]. Intramedullary screw fixation: Is a simple and reliable technique for displaced, unstable metacarpal fractures that provides sufficient stability to the fracture site with low morbidity [3]. Complications following intramedullary screw fixation of metacarpal fractures are relatively uncommon [9]. Plate fixation: Is safe and reliable for closed multiple metacarpal fractures with consistently reproducible outcomes, particularly when fracture patterns are unsuitable for screw fixation alone [14]. Minimally invasive hybrid fixation: Appears safe and effective for unstable metacarpal shaft fractures not typically suited for standard intramedullary fixation [15].

Malunion and Evidence Gaps: A scarf osteotomy is a useful option in the management of malunited metacarpal fractures [16]. There is a lack of high-quality evidence to guide treatment for metacarpal shaft fractures in adults, supporting the need for well-designed, multicenter trials to identify the most effective and cost-efficient treatment [6]. Additional clinical correlation of biomechanical results comparing intramedullary nail crossed K-wires and plate-screw constructs to fracture healing and outcomes is needed [13].

Clinical Presentation

The majority of metacarpal fractures are closed injuries amenable to conservative treatment with external immobilization and subsequent rehabilitation [12], with most managed nonoperatively [1]. While functional outcomes depend on appropriate treatment and early range of motion whenever possible [5], some fractures and patients may achieve improved patient-centered outcomes with surgical fixation [7]. Measured fracture angulation exerts a small but significant influence on treatment recommendations specifically for little finger metacarpal neck fractures [4].

For single displaced spiral and/or oblique finger metacarpal shaft fractures, outcomes are comparable between unrestricted mobilization and operative treatment despite the presence of metacarpal shortening [11]. However, there is currently a lack of high-quality evidence to guide treatment for metacarpal shaft fractures in adults, supporting the need for well-designed, multicenter trials to identify the most effective and cost-efficient treatment [6].

Return-to-play determinants: In National Football League players, the only variables that lessen return-to-play time are involvement of lesser digit metacarpals and operative intervention for treatment of thumb metacarpal fractures [2]. Follow-up compliance: Patients who do not attend a scheduled 1-month follow-up after a single isolated metacarpal fracture are sociologically distinct from those who do attend [19].

Investigations

Plain radiography: The majority of metacarpal fractures are closed injuries amenable to conservative treatment with external immobilization and subsequent rehabilitation [12], though the majority are managed nonoperatively [1]. Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures [4]. Results regarding K-wire trajectory for transverse percutaneous fixation of small finger metacarpal fractures can serve as a guide to help surgeons in accurate placement and may aid in surgeon training [21].

Other Considerations: Functional outcomes depend on appropriate treatment and early range of motion whenever possible [5]. While most metacarpal fractures can be treated nonsurgically, some fractures and patients can have improved patient-centered outcomes with surgical fixation [7]. Intramedullary fixation should be considered for closed, extra-articular metacarpal fractures [8], where complications following intramedullary screw fixation are relatively uncommon [9]. Intramedullary screw fixation provides quicker return to motion, faster time to full range of motion, and similar time to union with fewer complications compared to plate and screw construct [10]. Plate fixation is safe and reliable for closed multiple metacarpal fractures with consistently reproducible outcomes, particularly when fracture patterns are unsuitable for screw fixation alone [14]. A hybrid technique appears safe and effective for unstable metacarpal shaft fractures not typically suited for standard intramedullary fixation [15]. Lag screw fixation could be used for treating oblique metacarpal shaft fractures, though it is technically demanding [18]. A scarf osteotomy is a useful option in the management of malunited metacarpal fractures [16]. Soft tissues significantly contribute to the strength of metacarpal fracture fixation [23]. There is a lack of high-quality evidence to guide treatment for metacarpal shaft fractures in adults, supporting the need for well-designed, multicenter trials [6]. Additional clinical correlation of biomechanical results comparing intramedullary nail crossed K-wires and plate-screw constructs to fracture healing and outcomes is needed [13].

Treatment

The majority of metacarpal fractures are managed nonoperatively [1] and are closed injuries amenable to conservative treatment with external immobilization and subsequent rehabilitation [12]. Functional outcomes depend on appropriate treatment and early range of motion whenever possible [5]. While most metacarpal fractures can be treated nonsurgically, some fractures and patients can have improved patient-centered outcomes with surgical fixation [7]. Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures [4]. Patients with a single displaced spiral and/or oblique finger metacarpal shaft fracture treated with unrestricted mobilization have outcomes comparable to those treated operatively, despite metacarpal shortening [11].

Indications: Surgical fixation is considered when nonoperative management is insufficient or when specific fracture patterns require stabilization. Intramedimary screw fixation should be considered for closed, extra-articular metacarpal fractures [8]. Plate fixation is safe and reliable for closed multiple metacarpal fractures with consistently reproducible outcomes, particularly when fracture patterns are unsuitable for screw fixation alone [14]. A hybrid technique appears safe and effective for unstable metacarpal shaft fractures not typically suited for standard intramedullary fixation [15].

Implant Selection: Intramedullary screw fixation is a reliable and safe method for metacarpal fractures, providing quicker return to motion, faster time to full range of motion, and similar time to union with fewer complications compared to plate and screw construct [10]. Complications following intramedullary screw fixation of metacarpal fractures are relatively uncommon [9]. Intramedullary screw fixation provides sufficient stability to the fracture site with low morbidity for displaced, unstable metacarpal fractures [3]. Lag screw technique could be used for treating oblique metacarpal shaft fractures, though it is technically demanding [18].

Other Considerations: The only variables that lessen the return-to-play time are involvement of lesser digit metacarpals and operative intervention for treatment of thumb metacarpal fractures [2]. The proximity of metacarpal plates to adjacent joints is associated with subsequent implant removal [17]. A scarf osteotomy is a useful option in the management of malunited metacarpal fractures [16]. There is a lack of high-quality evidence to guide treatment, supporting the need for well-designed, multicenter trials to identify the most effective and cost-efficient treatment for metacarpal shaft fractures in adults [6]. Additional clinical correlation of biomechanical results comparing intramedullary nail crossed K-wires and plate-screw constructs to fracture healing and outcomes is needed [13].

Complications

Stiffness / Arthrofibrosis: Functional outcomes are contingent upon appropriate treatment and the initiation of early range of motion whenever feasible [5]. Retrograde fixation using intramedullary cannulated headless compression screws facilitates early active motion without immobilization, providing stable fixation [22]. Intramedullary screw fixation specifically enables a quicker return to motion and a faster time to full range of motion compared to plate and screw constructs [10]. Similarly, intramedullary headless screw fixation for base of thumb metacarpal fractures allows for early postoperative motion and good functional recovery [24].

Implant-Related Complications: Complications following intramedullary screw (IMS) fixation of metacarpal fractures are relatively uncommon [9]. Intramedullary screw fixation demonstrates similar time to union with fewer complications compared to plate and screw constructs [10]. However, the proximity of metacarpal plates to adjacent joints is associated with subsequent implant removal [17].

Other Considerations: The majority of metacarpal fractures are managed nonoperatively [1], though some fractures and patients may achieve improved patient-centered outcomes with surgical fixation [7]. Intramedullary fixation should be considered for closed, extra-articular metacarpal fractures [8]. Plate fixation is safe and reliable for closed multiple metacarpal fractures with consistently reproducible outcomes, particularly when fracture patterns are unsuitable for screw fixation alone [14]. Patients with a single displaced spiral and/or oblique finger metacarpal shaft fracture treated with unrestricted mobilization have outcomes comparable to those treated operatively, despite metacarpal shortening [11]. There is a lack of high-quality evidence to guide treatment for metacarpal shaft fractures in adults [6]. Patients who do not attend a scheduled 1-month follow-up after a single isolated metacarpal fracture are sociologically distinct from those who do attend [19]. Knowledge of epidemiology and etiology of hand fractures can serve as an essential first step in devising strategies to reduce the incidence of these types of injuries [20].

Recovery

Light activity (weeks): Most metacarpal fractures are managed nonoperatively [1] and are closed injuries amenable to conservative treatment with external immobilization and subsequent rehabilitation [12]. Functional outcomes depend on appropriate treatment and early range of motion whenever possible [5]. While most metacarpal fractures can be treated nonsurgically, some fractures and patients can have improved patient-centered outcomes with surgical fixation [7]. Intramedullary screw fixation provides quicker return to motion compared to plate and screw construct [10] and faster time to full range of motion compared to plate and screw construct [10]. Modified retrograde percutaneous intramedullary Kirschner wire fixation provides sufficient stability to the fracture site with low morbidity for displaced, unstable metacarpal fractures [3]. Antegrade intramedullary K-wire fixation is recommended as a reliable method that minimizes functional loss and allows for early return to daily activities in office workers with fifth metacarpal neck fractures [28].

Full activity (months): The only variables that lessen the return-to-play time are involvement of lesser digit metacarpals and operative intervention for treatment of thumb metacarpal fractures [2]. Patients with a single displaced spiral and/or oblique finger metacarpal shaft fracture treated with unrestricted mobilization have outcomes comparable to those treated operatively, despite metacarpal shortening [11]. Intramedullary screw fixation results in similar time to union compared to plate and screw construct [10].

Complete recovery / outcome plateau (months): Intramedullary screw fixation results in fewer complications compared to plate and screw construct [10]. Intramedullary fixation should be considered for closed, extra-articular metacarpal fractures [8].

Rehabilitation protocol: Functional outcomes depend on appropriate treatment and early range of motion whenever possible [5]. Patients with a single displaced spiral and/or oblique finger metacarpal shaft fracture treated with unrestricted mobilization have outcomes comparable to those treated operatively, despite metacarpal shortening [11].

Functional milestones: There is a lack of high-quality evidence to guide treatment for metacarpal shaft fractures in adults, supporting the need for well-designed, multicenter trials to identify the most effective and cost-efficient treatment [6].

Other Considerations: Patients who do not attend a scheduled 1-month follow-up after a single isolated metacarpal fracture are sociologically distinct from those who do attend [19].

Key Evidence

  • [L5] The majority of metacarpal fractures are managed nonoperatively. (10.1177/17531934231184119)
  • [L4] The only variables that lessen the return-to-play time are involvement of lesser digit metacarpals and operative intervention for treatment of thumb metacarpal fractures. (10.1016/j.jhsa.2022.01.011)
  • [L4] This is a simple and reliable technique for displaced, unstable metacarpal fractures that provides sufficient stability to the fracture site and with low morbidity. (10.1097/prs.0b013e3182402e6a)
  • [L3] Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures. (10.1016/j.jhsa.2014.05.023)
  • [Paper] Functional outcomes depend on appropriate treatment and early range of motion whenever possible. (10.1016/j.hcl.2013.09.004)
  • [L2] There is a lack of high-quality evidence to guide treatment, supporting the need for well-designed, multicenter trials to identify the most effective and cost-efficient treatment for metacarpal shaft fractures in adults. (10.1177/1558944720974363)
  • [L4] While most metacarpal fractures can be treated nonsurgically, some fractures and patients can have improved patient-centered outcomes with surgical fixation. (10.5435/jaaos-d-25-00323)
  • [L4] Intramedullary fixation should be considered for closed, extra-articular metacarpal fractures. (10.1016/j.jhsg.2024.08.020)
  • [L4] Complications following IMS fixation of metacarpal fractures are relatively uncommon. (10.1016/j.jhsa.2023.01.012)
  • [L2] Intramedullary screw fixation is a reliable and safe method for metacarpal fractures, providing quicker return to motion, faster time to full range of motion, and similar time to union with fewer complications compared to plate and screw construct. (10.5435/jaaos-d-24-00241)
  • [L2] Patients with a single displaced spiral and/or oblique finger metacarpal shaft fracture treated with unrestricted mobilization have outcomes comparable to those treated operatively, despite metacarpal shortening. (10.2106/jbjs.22.00573)
  • [L5] The majority of metacarpal fractures are closed injuries amenable to conservative treatment with external immobilization and subsequent rehabilitation. (10.1053/jssh.2002.36788)
  • [L5] Additional clinical correlation of these biomechanical results to fracture healing and outcomes is needed. (10.1111/os.12195)
  • [L4] Plate fixation is safe and reliable for closed multiple metacarpal fractures with consistently reproducible outcomes, particularly when fracture patterns are unsuitable for screw fixation alone. (10.1177/1753193409105451)
  • [L4] This hybrid technique appears safe and effective for unstable metacarpal shaft fractures not typically suited for standard intramedullary fixation. (10.1016/j.jhsa.2026.04.012)
  • [L4] The authors suggest that a scarf osteotomy is a useful option in the management of malunited metacarpal fractures. (10.1177/17531934251321322)
  • [L4] The proximity of metacarpal plates to adjacent joints is associated with subsequent implant removal. (10.1016/j.jhsa.2022.01.026)
  • [L5] Therefore, this technique could be used for treating oblique metacarpal shaft fractures, though it is technically demanding. (10.1186/s13018-022-02963-3)
  • [L4] Patients who do not attend a scheduled 1-month follow-up after a single isolated metacarpal fracture are sociologically distinct from those who do attend. (10.1016/j.jhsa.2011.08.003)
  • [L4] Knowledge of epidemiology and etiology of hand fractures can serve as an essential first step in devising strategies to reduce the incidence of these types of injuries. (10.1016/j.injury.2009.01.074)
  • [L5] These results can serve as a guide to help surgeons in the accurate placement of percutaneous K-wires for small finger metacarpal fractures and may aid in surgeon training. (10.1177/1558944717691128)
  • [L4] The technique allows for early active motion without immobilization and provides stable fixation. (10.1016/j.hansur.2017.12.005)
  • [L5] Soft tissues significantly contribute to the strength of metacarpal fracture fixation. (10.1097/01.blo.0000069003.56218.d0)
  • [L4] The intramedullary headless screw fixation is safe and reliable for base of thumb metacarpal fractures, allowing for early postoperative motion and good functional recovery. (10.1177/1753193420924215)
  • [L4] Finger strength was statistically significantly reduced, but its clinical relevance remains unclear. (10.1186/s12891-025-08776-9)
  • [L2] Antegrade intramedullary K-wire fixation is recommended as a reliable method that minimizes functional loss and allows for early return to daily activities in office workers with fifth metacarpal neck fractures. (10.1016/j.injury.2016.01.034)
  • [L4] Early, accurate diagnosis of fourth and fifth CMC joint fracture-dislocations is crucial for optimizing hand function and postoperative outcomes. (10.1177/1558944720948241)
  • [L5] Return to play timelines vary by fracture type, hand dominance, and position; nonthrowing hand injuries allow return in 2 to 5 weeks, while throwing hand or tackling position injuries require 6 to 10 weeks. (10.1016/j.hcl.2012.05.031)
  • [L5] Articular surface area violation was least during the more clinically relevant sagittal plane arc of motion. (10.1016/j.jhsa.2012.09.029)
  • [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)

See Also

References

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

[2] Metacarpal Fractures in the National Football League: Injury Characteristics, Management, and Return to Play. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.01.011

[3] Prospective Multicenter Trial of Modified Retrograde Percutaneous Intramedullary Kirschner Wire Fixation for Displaced Metacarpal Neck and Shaft Fractures. Plastic and Reconstructive Surgery. 2012. DOI: 10.1097/prs.0b013e3182402e6a

[4] Interobserver Variability in the Treatment of Little Finger Metacarpal Neck Fractures. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.05.023

[5] Current Management of Metacarpal Fractures. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2013.09.004

[6] A Systematic Review of Treatment Interventions for Metacarpal Shaft Fractures in Adults. HAND. 2020. DOI: 10.1177/1558944720974363

[7] Metacarpal Fractures: An Evidence-Based Review to Guide Treatment. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-25-00323

[8] Intramedullary Fixation for Metacarpal Fractures: A Multi-Institutional Prospective Outcomes Study. Journal of Hand Surgery Global Online. 2025. DOI: 10.1016/j.jhsg.2024.08.020

[9] Complications Following Intramedullary Screw Fixation for Metacarpal Fractures: A Systematic Review. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2023.01.012

[10] Comparing Fixation Techniques in Metacarpal Fractures: Intramedullary Screw Versus Open Reduction Internal Fixation With Plate and Screw Construct. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-00241

[11] Nonoperative Versus Operative Treatment for Displaced Finger Metacarpal Shaft Fractures. Journal of Bone and Joint Surgery. 2022. DOI: 10.2106/jbjs.22.00573

[12] Metacarpal fractures. Journal of the American Society for Surgery of the Hand. 2002. DOI: 10.1053/jssh.2002.36788

[13] Fixation of Metacarpal Shaft Fractures: Biomechanical Comparison of Intramedullary Nail Crossed K‐Wires and Plate‐Screw Constructs. Orthopaedic Surgery. 2015. DOI: 10.1111/os.12195

[14] Re: Souer JS, Mudgal CS. Plate fixation in closed ipsilateral multiple metacarpal fractures. J Hand Surg Eur. 2008, 33: 740–4. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193409105451

[15] Minimally Invasive Hybrid Fixation for Unstable Metacarpal Shaft Fractures: A New Approach to Extend Intramedullary Screw Indications. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2026.04.012

[16] The use of a scarf osteotomy to manage a malunited metacarpal fracture. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251321322

[17] Factors Associated With Implant Removal Following Plate-and-Screw Fixation of Isolated Metacarpal Fractures. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2022.01.026

[18] Comparison of the fixation ability between lag screw and bone plate for oblique metacarpal shaft fracture. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-02963-3

[19] Patients Lost to Follow-Up After Metacarpal Fractures. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2011.08.003

[20] Fifth metacarpal fractures—Do only “Boxers” get them? (An epidemiology study). Injury. 2009. DOI: 10.1016/j.injury.2009.01.074

[21] Anatomic Assessment of K-Wire Trajectory for Transverse Percutaneous Fixation of Small Finger Metacarpal Fractures: A Cadaveric Study. HAND. 2017. DOI: 10.1177/1558944717691128

[22] Retrograde fixation of metacarpal fractures with intramedullary cannulated headless compression screws. Hand Surgery and Rehabilitation. 2018. DOI: 10.1016/j.hansur.2017.12.005

[23] Role of Soft Tissues in Metacarpal Fracture Fixation. Clinical Orthopaedics & Related Research. 2003. DOI: 10.1097/01.blo.0000069003.56218.d0

[24] Retrograde intramedullary headless compression screws for treatment of extra-articular thumb metacarpal base fractures. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420924215

[25] Impact of metacarpal shortening on finger strength following non-surgical treatment of spiral and oblique metacarpal shaft fractures. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08776-9

[28] A minimally invasive fixation technique for selected patients with fifth metacarpal neck fracture. Injury. 2016. DOI: 10.1016/j.injury.2016.01.034

[29] Surgical Management of Ulnar Metacarpal Base Fracture-Dislocations: A Systematic Review. HAND. 2020. DOI: 10.1177/1558944720948241

[30] Sport-Specific Commentary on Bennett and Metacarpal Fractures in Football. Hand Clinics. 2012. DOI: 10.1016/j.hcl.2012.05.031

[31] Quantitative 3-Dimensional CT Analyses of Intramedullary Headless Screw Fixation for Metacarpal Neck Fractures. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2012.09.029

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

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.