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Internal Fixation

Internal fixation of proximal humerus, clavicle, and glenoid fractures — anatomical restoration, hardware selection, and management of osteoporotic bone.

Overview

Internal fixation serves as a definitive treatment option across various fracture patterns, with efficacy heavily dependent on specific injury morphology and patient risk profiles. For anterior ring components of APC injuries, external fixation is not inferior to internal fixation regarding long-term patient-reported outcomes [1]. In elderly, poor-risk patients with intertrochanteric and subtrochanteric femur fractures, routine internal fixation reduces hospital mortality from 50% to less than 20% and improves functional outcomes [5]. Conversely, for total fractures of the tibial pilon, neither internal plating nor definitive external fixation has proven more effective overall, given the high complication rate [7].

Selection of the appropriate fixation strategy requires careful consideration of fracture classification and surgical technique. The choice of internal fixation pattern for Letenneur type I Hoffa fractures depends on the surgeon and is not recommended for all cases [3]. A novel technique for posterior internal fixation of acetabular fractures offers superior outcomes and fewer complications compared to similar internal fixation techniques [4]. For comminuted distal humerus fractures, primary external fixation with second-staged ORIF demonstrated a higher complication rate and significantly greater loss of extension compared with initial definitive internal fixation [9].

In humeral shaft fractures, acceptable results are achievable with internal fixation provided correct principles are followed [11]. When indications for operative treatment are met, plate fixation is reliable and safe [16]. The well-established clinical principles of secure internal fixation, placement of cancellous bone about the site of non-union, and adequate additional external support remain the best guidelines for treatment [21]. Internal fixation remains an effective option in select clinical circumstances, with successful healing and avoidance of complications largely determined by surgical technique [6]. Additionally, the use of a metaphyseal locking plate as a definitive external fixator is an alternative choice for tibial fractures after obtaining appropriate fracture reduction [22]. Large-scale randomized studies are needed to assess indications and results for various internal fixation techniques in clavicle fractures [2].

Anatomy & Pathophysiology

Kinematics and Biomechanics

The shoulder functions as an industrial crane, a relationship best understood through the 'suspensory cascade' framework [65]. Within this model, the coracohumeral ligament serves as a sensory organ that provides stability and control [65]. The pectoralis major muscle is not required for normal shoulder function but is necessary for athletics or strenuous activity [70].

Stability and Pathomorphology

There is no single procedure that reliably treats every patient with anterior shoulder instability; surgical methods must be adapted to the specific pathomorphology of the patient rather than converting a neuromuscular problem into a purely mechanical one [74]. The advantage of the Latarjet procedure is particularly evident at 60° of glenohumeral abduction [75].

Proximal Ulna Anatomy

Appreciating the subtleties of proximal ulna anatomy and biomechanics can lead to improved clinical outcomes [45].

Classification

Robinson Classification: Surgical treatment with locked plate fixation in type IIB2 clavicle fractures is a first-line treatment choice, offering better cosmetics, a lower complication rate, and better outcomes [57].

Letenneur Type I Hoffa: The choice of internal fixation pattern for Letenneur type I Hoffa fractures depends on the surgeon and is not recommended for all cases [3].

Multifocal Humeral Fractures: A simple classification of multifocal humeral fractures is suggested to help the surgeon choose the most suitable type of synthesis for surgical treatment [55].

MTM-Classification: The MTM-classification for proximal humeral fractures does not deliver reproducible results despite covering a wide spectrum of fracture types [50].

Impacted Proximal Humerus: A new classification of impacted proximal humerus fractures based on morpho-volumetric evaluation of humeral head bone loss with a 3D model provides a useful synoptic framework for identifying complex fracture patterns [68].

Other Considerations: Large-scale randomized studies are needed to assess indications and results for various internal fixation techniques for clavicle fractures [2].

Clinical Presentation

The clinical presentation of fractures requiring internal fixation varies by anatomical site and patient risk profile, necessitating precise diagnostic and management strategies. In elderly, poor-risk patients with intertrochanteric and subtrochanteric femur fractures, routine internal fixation reduces hospital mortality from 50% to less than 20% and improves functional outcomes [5]. For skeletally mature patients aged fifty years or less with femoral neck fractures, early accurate reduction and fixation are critical to prevent adverse sequelae [18].

Acute Trauma and Reduction: Early diagnosis, accurate reduction, and internal fixation are essential in displaced medial humeral condyle fractures in children to avoid growth disturbance, articular incongruence, and functional disability [14]. In comminuted distal humerus fractures, primary internal fixation yields better outcomes than primary external fixation with second-staged ORIF, which is associated with higher complication rates and significantly greater loss of extension [9]. For complex humeral head fractures, both percutaneous fixation with blocked threaded wires and locking plates provide similar functional and radiologic outcomes, though percutaneous treatment results in a lower percentage of major complications [15].

Joint and Articular Fractures: Primary internal fixation is feasible for isolated chondral fragments without osseous attachment in the knee, which were historically considered unsalvageable [8]. For Letenneur type I Hoffa fractures, the choice of internal fixation pattern depends on the surgeon and is not recommended for all cases [3]. A novel technique for posterior internal fixation of acetabular fractures offers superior outcomes and fewer complications compared to similar internal fixation techniques [4]. In tibial pilon fractures, the complication rate for total fractures is high, and neither internal plating nor definitive external fixation has proven more effective overall [7].

Extremity and Shaft Fractures: Rigid internal fixation for supracondylar-intercondylar femur fractures permits early functional rehabilitation and decreases the incidence of malunion, non-union, and loss of fixation [12]. For nonarticular distal tibia fractures, intramedullary nailing, percutaneous plating, and external fixation are effective options depending on specific fracture characteristics and soft-tissue status [39]. However, the use of percutaneous fixation for bridge plate osteosynthesis of humeral shaft fractures is questioned; complications may have been avoidable with conventional debridement, lavage, and stabilization with methods such as external fixation [20].

Shoulder and Clavicle: Both coracoclavicular reconstruction and hook plate fixation for acute unstable acromioclavicular dislocation yield excellent functional outcomes [13]. Large-scale randomized studies are needed to assess indications and results for various internal fixation techniques in clavicle fractures [2].

Implant-Specific Considerations: The clinical performance of locked plates generally has been good, but several unique complications have been noted [17]. Further research is needed to determine any complications related to plate on plate osteosynthesis for periplate fracture fixation [10]. LCP external fixation is an unconventional alternative to traditional external fixation that may benefit carefully selected cases of fractures and nonunions, though it requires close clinical and radiological follow-up due to its unique set of complications [37].

Outcomes and Research Gaps: External fixation as definitive treatment for the anterior ring component of APC injuries yields similar patient-reported outcomes at long-term follow-up compared to internal fixation [1]. Internal fixation remains an effective option in select clinical circumstances, with successful healing and avoidance of complications largely determined by surgical technique [6]. Future research on isolated Type-II radial-head fractures should focus on suitably powered prospective studies with consistent fixation techniques to better understand the impact of patient factors and modifiable risk factors on clinical outcomes [19].

Investigations

Plain radiography: Standard radiographs (ap/outlet), particularly in internal rotation, may miss nearly half of angular stable head screw cut outs of the proximal humerus [91]. In patellar fractures, preoperative CT scans may improve surgical planning by identifying secondary fracture lines poorly visualized on radiographs [92]. For displaced fractures of the medial humeral condyle in children, early diagnosis via imaging is critical to avoid growth disturbance, articular incongruence, and functional disability [14].

CT: Computer-assisted percutaneous internal fixation allowed for internal fixation and osseous healing with minimum exposure to radiation and resolution of symptoms in a transverse acetabular nonunion [84]. Urgent open reduction should be employed with adequate imaging to plan the approach and potential fixation of the Edinburgh variant of a talar body fracture [89].

Other Considerations: External fixation is not inferior to internal fixation for long-term patient-reported outcomes in the anterior ring component of APC injuries [1]. Large-scale randomized studies are needed to assess indications and results for various internal fixation techniques in clavicle fractures [2]. The choice of internal fixation pattern for Letenneur type I Hoffa fractures depends on the surgeon and is not recommended for all cases [3]. A novel technique for posterior internal fixation of acetabular fractures offers superior outcomes and fewer complications compared to similar internal fixation techniques [4]. Internal fixation remains an effective option in select clinical circumstances, with successful healing and avoidance of complications largely determined by surgical technique [6]. Further research is needed to determine any complications related to plate on plate osteosynthesis for periplate fracture fixation [10]. Both coracoclavicular reconstruction and hook plate fixation yield excellent functional outcomes for acute unstable acromioclavicular dislocation [13]. Functional and radiologic outcomes with percutaneous fixation or locking plates for complex humeral head fractures are similar, but the percentage of major complications is lower with percutaneous treatment [15]. The clinical performance of locked plates generally has been good, but several unique complications have been noted [17]. Early accurate reduction and fixation should be pursued in all skeletally mature patients aged fifty years or less with femoral neck fractures [18]. Both patients with scapular spine fractures achieved radiological union around 3 months with significant pain reduction and functional improvement following novel surgical treatment [26]. Advances in understanding fracture patterns, imaging, exposure techniques, fixation, and rehabilitation have improved patient outcomes for distal humerus fractures [80]. Open reduction and internal fixation with cannulated screws provided good clinical and radiological results for larger anterior glenoid rim fractures, but with a higher early complication rate [88]. CC fixation failure of greater than 50% of the unaffected side in radiological examinations occurred in 33% of patients within 3 months after arthroscopic coracoclavicular reconstruction using a single adjustable-loop-length suspensory fixation device [90]. Forty-four percent of patients had complications after arthroscopic coracoclavicular reconstruction using a single adjustable-loop-length suspensory fixation device [90]. The CC fixation technique with multiple low-profile devices exhibited satisfactory clinical and radiologic outcomes in acute acromioclavicular joint dislocation [93].

Treatment

Non-Operative

Non-operative management remains the standard of care for most humeral shaft fractures, achieving union rates exceeding 90% [66]. For nondisplaced pediatric tibial eminence fractures, nonsurgical management is appropriate, whereas displaced variants require arthroscopic reduction and fixation [42]. In cases of established non-union of displaced olecranon fractures, continued non-operative treatment remains a viable option [34]. Undisplaced scapular inferior angle fractures demonstrate variable outcomes when managed nonoperatively [60]. For incomplete atypical femoral fractures related to bisphosphonate treatment, non-operative treatment is not reliable; prophylactic intramedullary nailing should be considered if the patient experiences intractable pain [53].

Operative

Indications: Internal fixation is indicated for elderly, poor-risk patients with intertrochanteric and subtrochanteric femur fractures, as routine use in this population reduced hospital mortality from 50% to less than 20% and improved functional outcomes [5]. For humeral shaft fractures, operative management is reserved for cases recalcitrant to closed reduction and immobilization or in non-compliant patients [58]. Primary fixation is indicated for isolated chondral fragments without osseous attachment in the knee, which were historically considered unsalvageable [8]. In adolescent diaphyseal forearm fractures, open reduction and internal fixation may be preferred as patients approach skeletal maturity, though insufficient data currently recommend one strategy over another [30].

Surgical Approach / Technique: The AO philosophy has evolved from rigid mechanical fixation to a biological approach emphasizing preservation of local blood supply and minimally invasive techniques, leading to improved clinical outcomes and reduced complications such as nonunion and infection [31]. For acetabular fractures, a novel technique for posterior internal fixation offers superior outcomes and fewer complications compared to similar internal fixation techniques [4]. Operative management of humeral shaft fractures includes open reduction and internal fixation through various exposures, intramedullary nail fixation, and external fixation [27]. Transarticular fixation is highly successful in achieving union, stability, and pain relief in a single operation for non-union of supracondylar fractures of the femur [82].

Implant Selection: The Locking Compression Plate (LCP) is a new implant revolutionizing internal fixation that requires adapted surgical techniques and new thinking about commonly used concepts of interventional fixation to avoid failures and complications [29]. Anatomically precontoured locking compression plates for Schatzker II tibial plateau fractures improve radiological and clinical outcomes compared to conventional implants, which are associated with more pronounced articular subsidence and higher valgus angulation [49]. For proximal humerus fractures, no compelling evidence exists to suggest one intramedullary nailing technique over another when compared with locking plate fixation [28]. The implant device plays the major role in fixation stability for intertrochanteric fractures, while reduction positions exert only a minor influence [38]. External fixation combined with limited open reduction and absorbable internal fixation for distal tibial shaft fractures leads to minimal soft tissue complications, good functional results, and no local soft tissue irritation or need for implant removal [44]. Linking the lateral ends of fixation wires with an external fixator increased the stiffness and strength of constructs for percutaneous fixation of proximal humeral fractures [47]. Closed reduction and external fixation of proximal humeral fractures combines the advantages of traditional percutaneous pinning with improved fixation strength in osteoporotic bone through the use of long threaded pins and a dedicated external fixator [32]. The use of a locking plate as a definitive external fixator is an alternative choice for tibial fractures after obtaining appropriate fracture reduction [22].

Alignment / Balancing Strategy: The choice of internal fixation pattern for Letenneur type I Hoffa fractures depends on the surgeon and is not recommended for all cases [3]. No single fixation method is a panacea for proximal humeral fractures; the choice of implant and method should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications [48]. External fixation as definitive treatment is not inferior to internal fixation for the anterior ring component of APC injuries at long-term follow-up [1].

Pain Management: The use of regional anaesthesia during operative repair of long bone fracture nonunion was associated with no significant difference in functional outcome scores or pain levels at all post-operative time points [81].

Adjuncts: The well-established clinical principles of secure internal fixation, placement of cancellous bone about the site of non-union, and adequate additional external support remain the best guidelines for treatment [21].

Revision: Total elbow arthroplasty (TEA) is a salvage procedure for failed internal fixation of elbow fractures, leading to significant improvements in pain and function [23]. Plate fixation of midshaft clavicle fractures for delayed union and non-union is a cost-effective intervention, but functional deficits persist at long-term follow-up and outcomes are worse compared to patients that unite with non-operative management [59].

Other Considerations: Internal fixation remains an effective option in select clinical circumstances, with successful healing and avoidance of complications largely determined by surgical technique [6]. The incidence of non-union in femoral neck fractures can be decreased and many aspects of the unsolved fracture can be resolved by accurate reduction, accurately placed adequate internal fixation, and carefully supervised postoperative care [61]. Acceptable results can be achieved with internal fixation for difficult humeral shaft fractures, provided the correct principles of fixation are carefully followed [11]. When indications for operative treatment are met, plate fixation for humeral shaft fractures is reliable and safe [16]. Both patients with scapular spine fractures treated with a novel surgical treatment achieved radiological union around 3 months with significant pain reduction and functional improvement [26]. Large-scale randomized studies are needed to assess indications and results for various internal fixation techniques in clavicle fractures [2]. Arthrodesis of the ankle in patients with rheumatoid arthritis often allows the patient to maintain their level of functional activity through relief of pain, but should not be expected to improve it [85].

Complications

Infection (PJI): Periprosthetic joint infection remains a formidable challenge with incidence rates of 0.4% to 2% after primary total knee replacement [106]. In tibial fractures, earlier conversion from external fixator to intramedullary nail reduced infection rates [24]. Secondary nailing after external fixation for tibial shaft fracture does not increase infection risk if external fixation pin site infection is excluded [96]. A sequential protocol for open fractures of the tibial shaft involving a short period of external fixation minimized colonization of the pin tracks, yielding excellent results and a low rate of infection [121]. Open fractures of the tibia treated with the Lottes nail had an infection rate of 6% [116].

Instability: In the Latarjet procedure for chronic anterior shoulder instability, screw fixation was associated with a significantly lower rate of recurrences but greater reoperations due to irritation or pain after surgery compared to cortical buttons [25, 115]. Displaced Neer Type IIB distal-third clavicle fractures treated with plate fixation and additional screw augmentation for coracoclavicular instability had an early postoperative complication rate of 25% and a 100% rate of secondary surgery due to removal of the CC screw [113].

Periprosthetic fracture: The incidence of refracture following implant removal after bone union in midshaft clavicle fractures is underestimated, with severe comminute fractures and unsatisfactory reduction during primary surgery identified as risk factors [114].

Thromboembolism: Thromboembolic disease is a feared complication in patients who sustain trauma to the involved lower extremity with previous arthrodesis of the hip, with an association postulated between deep venous thrombosis and this population [109].

Stiffness / Arthrofibrosis: Primary external fixation with second-staged ORIF for comminuted distal humerus fractures demonstrated a higher complication rate and significantly greater loss of extension compared with initial definitive internal fixation [9].

Wound complications: Patients with bridge plates for complex elbow instability often require a second surgery for removal and experience high rates of general complications because of the complexity of their condition [111].

Other Considerations: External fixation as definitive treatment for anterior ring component of APC injuries yields similar patient-reported outcomes at long-term follow-up compared to internal fixation [1]. Large-scale randomized studies are needed to assess indications and results for various internal fixation techniques in clavicle fractures [2]. A novel technique for posterior internal fixation of acetabular fractures offers superior outcomes and fewer complications compared to similar internal fixation techniques [4]. Routine use of internal fixation in elderly, poor-risk patients with intertrochanteric and subtrochanteric femur fractures reduced hospital mortality from 50% to less than 20% and improved functional outcomes [5]. The complication rate for total fractures of the tibial pilon is high, and neither internal plating nor definitive external fixation has proven to be more effective overall [7]. Further research is needed to determine any complications related to plate on plate osteosynthesis for periplate fracture fixation [10]. Future research should focus on suitably powered prospective studies with consistent fixation techniques to better understand the impact of patient factors and modifiable risk factors on clinical outcomes for isolated type-II radial-head fractures [19]. Total elbow arthroplasty is a salvage procedure for failed internal fixation of elbow fractures, leading to significant improvements in pain and function [23]. Locking plate fixation has yet to prove clinical superiority in any anatomic site for which good-quality comparative analyses are available [105]. The S3 plate for proximal humerus fractures has a very low revision rate, with union seen in most fractures by 6 months [110]. Early fracture stabilization may reduce recurrence of fat embolism syndrome [112]. Stable osteosynthesis of simple distal meta or diaphyseal tibia fractures leads to faster radiologic fracture healing without an increase in complications or number of revisions compared to bridge plating [117]. The operative treatment of mid-shaft clavicular non-unions is safe and reliable, with a predictably high rate of union and low incidence of complications [118]. There was no difference in general complications or infection rates between patients treated with C-clamp/external fixation for unstable pelvic fractures and those without, although the adjusted odds of death were 32% lower in the C-clamp/external fixation group [119]. Percutaneous Knowles pinning for intracapsular femoral neck fractures is associated with low morbidity, mortality, and infection rates compared to primary prosthetic replacement [120]. Results of meta-analyses comparing minimally invasive plating versus open reduction and plate fixation or intramedullary nailing of humeral shaft fractures are limited by problems inherent in primary studies, including poor reporting of randomization protocols, attrition bias, and reporting bias [122]. Methodological flaws remain to be addressed in future meta-analyses in orthopaedic surgery to continue increasing the quality of the orthopaedic literature [124].

Recovery

Light activity (weeks): Early mobilization is a cornerstone of recovery for many fixation strategies. For isolated low-energy ulnar shaft fractures, early mobilization without external immobilization or internal fixation is the treatment of choice [36]. In proximal humerus fractures, external fixator systems allow for early but gentle postoperative mobilization [46]. For displaced midshaft clavicle fractures, plate fixation returns patients to pre-injury functional levels at one year, with a faster recovery period in comminuted fractures compared to elastic stable intramedullary nailing (ESIN) [77]. Retrograde intramedullary nailing (RTEN) for mid-shaft clavicle fractures may allow for shorter immobilization and earlier rehabilitation compared to antegrade nailing, though clinical studies are needed to confirm superiority [43]. In adolescent athletes, titanium elastic nail (TEN) fixation for displaced mid-shaft clavicle fractures significantly accelerates return to sport and enhances early functional and psychological recovery compared to conservative treatment [94].

Full activity (months): Functional return is achieved in all survivors of intertrochanteric and subtrochanteric hip fractures treated with the Ender method who could walk at the time of injury, with no non-unions reported [83]. Routine use of internal fixation in elderly, poor-risk patients with intertrochanteric and subtrochanteric femur fractures reduced hospital mortality from 50% to less than 20% and improved functional outcomes [5]. Good clinical results are expected in polytrauma patients with long bone fractures if damage control principles are applied, including proper reduction, firm fixation, early soft tissue reconstruction, and early rehabilitation [33]. Rigid internal fixation of supracondylar-intercondylar femur fractures permits early functional rehabilitation and decreases the incidence of malunion, non-union, and loss of fixation [12]. Firm fixation after medullary nailing of femur fractures is required to allow the patient to walk without additional support [79]. Acute tibial tubercle avulsion fractures in sporting adolescents result in satisfactory outcomes with complete functional recovery and resumption of sport at the previous level [101]. Extra-articular dorsal plate fixation of Lisfranc injuries in athletes demonstrates improvement in postoperative patient reports of function [98].

Complete recovery / outcome plateau (months): External fixation as definitive treatment for anterior ring component of APC injuries yields similar patient-reported outcomes at long-term follow-up compared to internal fixation [1]. Anatomical locking plates for proximal humerus fractures provide favorable functional outcomes at a minimum of 10 years postoperatively [102]. Plate augmentation for aseptic femoral shaft nonunion after intramedullary nailing shows a good rate of consolidation, good functional recovery, and low incidence of complications [103]. A treatment protocol for ipsilateral femoral neck and shaft fractures produced excellent results with all fractures uniting and good long-term functional outcomes [104]. The best functional outcomes for clavicle hook plate fixation in displaced lateral-third clavicle fractures occur with plate removal before 6 months postoperatively, provided the fracture has healed [99].

Rehabilitation protocol: Efforts at osteosynthesis for proximal humerus fractures should aim for anatomic fracture fixation that resists displacement, with a stable shoulder and healed tuberosities as the primary goal in the immediate and early phase of recovery [86]. Primary fixation can be accomplished for isolated chondral fragments without osseous attachment in the knee, which have historically been considered 'unsalvageable' [8]. Screw fixation in the Latarjet procedure for chronic anterior shoulder instability is associated with lower rates of recurrent instability but more common reoperations compared to cortical buttons [25]. Suture-button fixation in arthroscopic Latarjet procedures eliminates the need for hardware removal, maintains low instability recurrence rates, and supports excellent return to pre-injury activity levels [78]. Dual plating of displaced midshaft clavicle fractures offsets higher initial hardware costs through greater health utility via lower reoperation rates and improved patient quality of life [87].

Functional milestones: Clinical or functional recovery for triquetrum fractures usually occurs long before roentgenographic evidence of bony union is demonstrated [97]. Direct posterolateral transfibular approach to unicondylar posterolateral tibial plateau fractures results in improved reduction, stabilization, and functional outcomes at early follow-up compared to an indirect anterolateral approach [107]. Arthrodesis of the knee by double-plating resulted in uniform clinical success with only one failure, which resolved after a second plating procedure [108].

Other Considerations: Earlier conversion from external fixator to intramedullary nail in tibial fractures reduces infection rates [24]. Routine postoperative radiographs after tibial plateau fixation result in minimal management change for patients [95].

Key Evidence

  • [Paper] External fixation as definitive treatment is not inferior when internal fixation is precluded. (10.1016/j.injury.2020.05.037)
  • [L4] Large-scale randomized studies are needed to assess indications and results for various internal fixation techniques. (10.1016/j.otsr.2016.11.007)
  • [L5] However, the choice of internal fixation pattern depends on the surgeons and is not recommended for all cases. (10.1016/j.injury.2017.03.044)
  • [L4] Compared to similar internal fixation techniques, it offers superior outcomes and fewer complications. (10.1186/s13018-025-06049-8)
  • [L4] Routine use of internal fixation in elderly, poor-risk patients reduced hospital mortality from 50 per cent to less than 20 per cent and improved functional outcomes. (10.2106/00004623-195638060-00011)
  • [L5] Internal fixation remains an effective option in select clinical circumstances, with successful healing and avoidance of complications largely determined by surgical technique. (10.5435/jaaos-d-23-01256)
  • [Paper] The complication rate is high and neither internal plating nor definitive external fixation has proven to be more effective overall. (10.1016/j.otsr.2013.06.016)
  • [L4] Primary fixation can be accomplished for what have been historically considered 'unsalvageable' fragments. (10.1177/2325967117696281)
  • [L3] Primary external fixation with second-staged ORIF demonstrated a higher complication rate and significantly greater loss of extension compared with initial definitive internal fixation. (10.1007/s00402-017-2792-x)
  • [L4] Further research is needed to determine any complications related to this type of fixation. (10.1177/2325967120s00043)
  • [L4] While closed treatment remains the method of choice for most fractures, acceptable results can be achieved with internal fixation, even for difficult fractures, provided the correct principles of fixation are carefully followed. (10.2106/00004623-198668030-00018)
  • [L4] Rigid internal fixation permits early functional rehabilitation of the patient and decreases the incidence of malunion, non-union, and loss of fixation. (10.2106/00004623-198971010-00015)
  • [L3] Both fixations yielded excellent functional outcomes. (10.1186/s12891-021-03978-3)
  • [L4] Early diagnosis, accurate reduction, and internal fixation are important to avoid growth disturbance, articular incongruence, and functional disability. (10.2106/00004623-198062070-00016)
  • [L3] The functional and radiologic outcomes obtained with percutaneous fixation or locking plates are similar; however, the percentage of major complications after percutaneous treatment is lower. (10.1016/j.jse.2018.06.034)
  • [L4] When indications for operative treatment are met, plate fixation is reliable and safe. (10.2106/jbjs.rvw.n.00119)
  • [L5] The clinical performance of locked plates generally has been good, but several unique complications have been noted. (10.5435/00124635-200806000-00007)
  • [L4] Early accurate reduction and fixation should be pursued in all patients in this age group. (10.2106/00004623-198567080-00018)
  • [L5] Future research should focus on suitably powered prospective studies with consistent fixation techniques to better understand the impact of patient factors and modifiable risk factors on clinical outcomes. (10.2106/jbjs.rvw.17.00010)
  • [L4] The authors question the use of percutaneous fixation in these types of fractures and suggest that complications could have been potentially avoidable with conventional debridement, lavage, and stabilisation with methods such as external fixation. (10.1016/j.injury.2004.11.013)
  • [L4] The well-established clinical principles of secure internal fixation, placement of cancellous bone about the site of non-union, and adequate additional external support remain the best guidelines for treatment. (10.2106/00004623-198163080-00028)
  • [Paper] Clinical outcomes show that the use of locking plate as a definitive external fixator is an alternative choice for tibial fractures after obtaining appropriate fracture reduction. (10.1016/j.injury.2016.11.031)
  • [Abstract] TEA is a salvage procedure for failed internal fixation, leading to significant improvements in pain and function. (10.1016/j.jse.2007.02.051)
  • [L4] Surgeons should strongly consider the necessity of external fixation for these fractures, as earlier conversion reduced infection rates. (10.5435/jaaos-d-21-00857)
  • [L3] However, despite lower rates of recurrent instability reoperations were more common following screw fixation. (10.1016/j.jse.2020.01.023)
  • [L5] Both patients achieved radiological union around 3 months with significant pain reduction and functional improvement. (10.1016/j.jseint.2023.09.001)
  • [L5] Operative management includes open reduction and internal fixation through a variety of exposures, intramedullary nail fixation, and external fixation. (10.1016/j.jse.2017.10.028)
  • [L5] Compared with other fixation strategies, such as locking plate fixation, no compelling evidence exists to suggest one technique over another. (10.1016/j.jse.2015.11.016)
  • [L5] The Locking Compression Plate (LCP) is a new implant revolutionizing internal fixation that requires adapted surgical techniques and new thinking about commonly used concepts of interventional fixation to avoid failures and complications. (10.1016/j.injury.2003.09.026)
  • [L3] There is insufficient data to recommend one strategy over the other, although open reduction and internal fixation may be preferred as patients approach skeletal maturity. (10.1016/j.injury.2018.08.023)
  • [L5] The AO philosophy evolved from a focus on rigid mechanical fixation to a biological approach emphasizing preservation of local blood supply and minimally invasive techniques, which has led to improved clinical outcomes and reduced complications such as nonunion and infection. (10.2106/00004623-200306000-00029)
  • [L5] The technique was developed to combine the advantages of traditional percutaneous pinning with improved fixation strength in osteoporotic bone through the use of long threaded pins and a dedicated external fixator. (10.5435/jaaos-d-17-00721)
  • [Paper] Good clinical results can be expected in patients with long bone fractures if the principles of damage control are applied and complications are prevented through proper reduction, firm fixation, early soft tissue reconstruction, and early rehabilitation. (10.1016/j.injury.2017.04.016)
  • [L4] Continued non-operative treatment is an option for patients who present with an established non-union. (10.1111/j.1758-5740.2012.00194.x)
  • [L4] Early mobilization without external immobilization or internal fixation is recommended as the treatment of choice for these low-energy injuries. (10.2106/00004623-198365030-00007)
  • [L4] LCP external fixation is an unconventional alternative to traditional external fixation that may be of benefit in carefully selected cases of fractures and nonunions, though it is not without its own unique set of complications requiring close clinical and radiological follow-up. (10.1186/1749-799x-5-19)
  • [L5] Intramedullary nailing, percutaneous plating, and external fixation are effective options depending on specific fracture characteristics and soft-tissue status. (10.5435/00124635-200607000-00003)
  • [L5] Nondisplaced fractures are amenable to nonsurgical management, while displaced fractures are managed with arthroscopic reduction and fixation. (10.5435/00124635-201007000-00002)
  • [L5] This suggests RTEN may allow for shorter immobilization and earlier rehabilitation with a lower risk of fixation failure, though clinical studies are needed to confirm superiority. (10.1186/s12891-025-08426-0)
  • [L2] External fixation combined with limited open reduction and absorbable internal fixation leads to minimal soft tissue complication, good functional result, and no local soft tissue irritation or implant removal. (10.1007/s00264-014-2294-1)
  • [L5] Appreciating the subtleties of proximal ulna anatomy and biomechanics can lead to improved clinical outcomes. (10.5435/00124635-201303020-00004)
  • [L5] The external fixator system allows early but gentle postoperative mobilisation. (10.1186/s12891-024-07977-y)
  • [L5] Linking the lateral ends of fixation wires with an external fixator increased the stiffness and strength of the constructs. (10.2106/jbjs.j.00815)
  • [L4] No single fixation method is a panacea for proximal humeral fractures; choice of implant and method should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications. (10.1016/j.injury.2010.10.016)
  • [Paper] The data demonstrate a more pronounced articular subsidence and a higher valgus angulation secondary to the internal fixation with conventional implants. (10.1016/j.injury.2020.07.012)
  • [L4] Although the MTM-classification covers a wide spectrum of fracture types, the precise topographic and morphological description is not delivering reproducible results. (10.1186/1471-2474-9-21)
  • [L2] Non-operative treatment does not appear to be a reliable way of treating an incomplete fracture: prophylactic intramedullary nailing should be considered if the patient is in intractable pain. (10.1302/0301-620x.99b3.bjj-2016-0276.r2)
  • [Paper] A simple classification of multifocal fractures is suggested to help the surgeon choose the most suitable type of synthesis for surgical treatment. (10.1016/j.injury.2013.10.010)
  • [L3] Surgical treatment with locked plate fixation in type IIB2 clavicle fractures according to Robinson Classification can be the first treatment choice with better cosmetics, lower complication rate, and better outcomes. (10.1177/2325967114s00265)
  • [L3] However, only fractures that are recalcitrant to closed reduction and immobilization or fractures in the non-compliant patient should be considered for this form of operative treatment. (10.2106/00004623-198769040-00013)
  • [L3] Clavicle fixation for delayed and non-union is a cost-effective intervention but outcomes are worse compared to patients that unite with non-operative management. (10.1177/1758573221990367)
  • [L4] Undisplaced fractures have a variable outcome when treated nonoperatively. (10.1016/j.jse.2015.11.007)
  • [L4] The incidence of non-union can be decreased and many aspects of the unsolved fracture can be resolved by accurate reduction, accurately placed adequate internal fixation, and carefully supervised postoperative care. (10.2106/00004623-196244050-00006)
  • [L5] The article argues that the shoulder should be viewed as an industrial crane to better understand its biomechanics, introducing a 'suspensory cascade' model where the coracohumeral ligament acts as a sensory organ to provide stability and control. (10.1136/jisakos-2019-000294)
  • [L5] Nonsurgical management with functional bracing is the standard of care for most humeral shaft fractures, achieving union rates >90%. (10.5435/jaaos-20-07-423)
  • [L5] The new classification provides a useful synoptic framework for identifying complex fracture patterns. (10.1016/j.jse.2020.02.022)
  • [L5] There is no single procedure that reliably treats every patient with anterior shoulder instability; surgical methods must be adapted to the specific pathomorphology of the patient rather than converting a neuromuscular problem into a purely mechanical one. (10.1177/17585732231224699)
  • [L5] The advantage of the Latarjet procedure is particularly evident at 60° of glenohumeral abduction. (10.1177/0363546508326714)
  • [L1] Both methods return patients to their pre-injury functional levels at one year, but plate fixation provides a faster recovery period in comminuted fractures compared to ESIN. (10.1302/0301-620x.99b8.bjj-2016-1318.r1)
  • [L4] There was no need for hardware removal after suture-button fixation, with a low instability recurrence rate and excellent return to pre-injury activity level. (10.1016/j.arthro.2018.11.012)
  • [L4] The main requisite is that after the operation fixation should be so firm that the patient can walk without any additional support. (10.2106/00004623-195133030-00013)
  • [L3] In this cohort, the use of regional anaesthesia during operative repair of long bone fracture nonunion was associated with no significant difference in functional outcome scores or pain levels at all post-operative time points. (10.1016/j.injury.2019.01.013)
  • [L4] The procedure described was highly successful in achieving union of the fractured femur, stability, and relief of pain in all patients with one operation. (10.2106/00004623-197961070-00008)
  • [L4] Functional return was achieved in all survivors who could walk at the time of injury, with no non-unions reported. (10.2106/00004623-197658050-00004)
  • [L4] The technique allowed for internal fixation and osseous healing with minimum exposure to radiation and resolution of symptoms. (10.2106/00004623-200002000-00008)
  • [L3] The relief of pain often will allow the patient to maintain the level of functional activity but should not be expected to improve it. (10.2106/00004623-199274060-00012)
  • [L3] Efforts at osteosynthesis should be directed to obtaining anatomic fracture fixation that resists fracture displacement, and a stable shoulder with healed tuberosities should be the primary goal in the immediate and early phase of recovery. (10.1016/j.jse.2007.02.109)
  • [L2] Despite its higher initial hardware costs, dual plating appears to offset its added costs with greater health utility via lower rates of reoperation and improved patient quality of life. (10.2106/jbjs.23.00338)
  • [L4] Open reduction and internal fixation with cannulated screws provided good clinical and radiological results for larger defects, but with a higher early complication rate. (10.1007/s00167-004-0495-7)
  • [Case_report] Urgent open reduction should be employed with adequate imaging to plan the approach and potential fixation of the fracture. (10.1186/1749-799x-5-92)
  • [L4] However, CC fixation failure of greater than 50% of the unaffected side in radiological examinations occurred in 33% of the patients within 3 months after the operation, and 44% of patients had complications. (10.1016/j.arthro.2014.11.013)
  • [Paper] Standard radiographs (ap/outlet), especially in internal rotation, may miss nearly half of screw cut outs. (10.1016/j.injury.2014.05.025)
  • [L5] Preoperative CT scans may improve surgical planning by identifying secondary fracture lines poorly visualized on radiographs. (10.2106/jbjs.20.01478)
  • [L4] The CC fixation technique with multiple low-profile devices exhibited satisfactory clinical and radiologic outcomes. (10.1016/j.arthro.2018.07.007)
  • [L3] For adolescent athletes engaged in structure- or kinetic-dependent sports with high clavicle functional demand, TEN fixation significantly accelerates return to sport, reduces season loss, and enhances early functional and psychological recovery, while achieving long-term functional outcomes equivalent to conservative treatment. (10.1186/s13018-026-06708-4)
  • [Paper] Routine postoperative radiographs following tibial plateau ORIF resulted in minimal management change for patients. (10.1016/j.injury.2019.07.025)
  • [Paper] A 1-stage procedure appears feasible and does not increase infection risk if external fixation pin site infection is excluded. (10.1016/j.otsr.2014.10.017)
  • [L4] Clinical or functional recovery usually occurs long before roentgenographic evidence of bony union is demonstrated. (10.2106/00004623-195638020-00012)
  • [L4] In athletes, extra-articular dorsal plate fixation of the Lisfranc joint demonstrates improvement in postoperative patient reports of function. (10.1177/2325967119s00388)
  • [L4] The best functional outcomes occur with plate removal before 6 months postoperatively, provided the fracture has healed. (10.1016/j.jse.2011.07.020)
  • [Paper] The results were satisfactory with complete functional recovery, resumption of sport at the previous level, and absence of recurvatum. (10.1007/s00402-008-0628-4)
  • [L4] Anatomical locking plates provide favorable functional outcomes at a minimum of 10 years postoperatively. (10.1016/j.jse.2025.06.012)
  • [L2] The patients treated with plate augmentation included in this review showed a good rate of consolidation in the femoral shaft nonunions, with good functional recovery and a low incidence of complications. (10.3390/bioengineering9100560)
  • [L4] The developed protocol produced excellent results with all fractures uniting and good long-term functional outcomes. (10.2106/00004623-198466020-00013)
  • [L4] Locking plate fixation has yet to prove clinical superiority in any anatomic site for which good-quality comparative analyses are available. (10.1016/j.otsr.2016.11.006)
  • [L3] This study suggests that a direct posterolateral transfibular approach to unicondylar posterolateral tibial plateau fractures results in improved reduction, stabilisation and functional outcomes at early follow-up compared to an indirect anterolateral approach. (10.1016/j.injury.2013.04.024)
  • [L4] The procedure resulted in uniform clinical success with only one failure, which resolved after a second plating procedure. (10.2106/00004623-196244010-00020)
  • [L4] The authors postulate an association between deep venous thrombosis and previous arthrodesis of the hip in patients who sustain trauma to the involved lower extremity, noting that thromboembolic disease is a feared complication in this specific population. (10.2106/00004623-198971090-00023)
  • [L4] The implant has a very low revision rate and union was seen in most fractures by 6 months. (10.1111/j.1758-5740.2011.00144.x)
  • [L4] However, patients with bridge plates often require a second surgery for removal and experience high rates of general complications because of the complexity of their condition. (10.1016/j.jse.2024.03.013)
  • [Paper] The paper is a collection of German abstracts summarizing pathophysiological mechanisms, clinical incidence, and consequences of fat embolism and the fat embolism syndrome, noting that early fracture stabilization may reduce recurrence. (10.1016/j.injury.2006.08.044)
  • [L4] However, considering an early postoperative complication rate of 25% and a 100% rate of secondary surgery due to removal of the CC screw does not seem to justify this technique anymore. (10.1186/s12891-017-1398-3)
  • [L3] The incidence of refracture following implant removal after bone union is underestimated, and severe comminute fractures and unsatisfactory reduction during primary surgery are risk factors. (10.1186/s12891-023-06391-0)
  • [L3] Screw fixation was associated with a significantly lower rate of recurrences, but greater reoperations due to irritation or pain after surgery. (10.1177/17585732241227206)
  • [L4] The rate of infection was 6 per cent, delayed union 16 per cent, and malunion 4 per cent. (10.2106/00004623-198365070-00001)
  • [L3] Stable osteosynthesis of simple distal meta or diaphyseal tibia fractures leads to faster radiologic fracture healing without an increase in complications or number of revisions compared to bridge plating. (10.1016/j.injury.2017.03.005)
  • [L4] The technique is safe and reliable, with a predictably high rate of union and low incidence of complications. (10.2106/00004623-198668040-00030)
  • [Paper] After adjusting for confounding factors, there was no difference in general complications or infection rates between patients treated with C-clamp/external fixation and those without, although the adjusted odds of death were 32% lower in the C-clamp/external fixation group. (10.1016/j.injury.2019.08.039)
  • [L4] This sequential protocol for treatment, which involved a short period of external fixation and thus minimized colonization of the pin tracks, yielded excellent results and a low rate of infection. (10.2106/00004623-199072050-00013)
  • [L1] However, the results of this metaanalysis are limited by problems inherent in the primary studies, including poor reporting of randomization protocols, as well as possible attrition bias and reporting bias. (10.1016/j.jse.2016.05.014)
  • [L1] Methodological flaws remain to be addressed in future meta-analyses in order to continue increasing the quality of the orthopaedic literature. (10.1302/0301-620x.100b10.bjj-2017-1142.r2)

See Also

References

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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.

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