Guideline:Forearm, wrist, & hand (acute & chronic), not including carpal tunnel syndrome. Measure Summary

Work-related injuries of forearm, wrist, and hand (acute and chronic)

Note: Carpal tunnel syndrome is not included.

To offer evidence-based step-by-step decision protocols for the assessment and treatment of workers' compensation conditions

Workers with occupational injuries of the forearm, wrist, and hand (excluding carpal tunnel syndrome)

The following interventions/procedures were considered and recommended as indicated in the original guideline document:

1. Activity restrictions/work
2. Anesthesia, transdermal (for percutaneous trigger finger release)
3. Arteriography/angiography/computed tomographic angiography (CTA)
4. Arthrodesis (fusion)
5. Arthroplasty, finger and/or thumb (joint replacement)
6. Bone-growth stimulators, electrical and ultrasound
7. Casting, fiberglass and plaster
8. Causality (determination)
9. Cold packs
10. Collagenase clostridium histolyticum (Xiaflex)
11. Computed tomography (CT)
12. Continuous passive motion (CPM)
13. Contrast bath therapy
14. De Quervain's tenosynovitis surgery
15. Diagnostic arthroscopy
16. Dupuytren's release (fasciectomy or fasciotomy)
17. Early mobilization (after tendon repair)
18. Electrodiagnostic studies (EDS)/electromyography/nerve conduction studies
19. Exercises
20. Heat therapy
21. Home health services
22. Hospital length of stay (LOS)
23. Hyperbaric oxygen therapy (HBOT) (for diabetic skin ulcers)
24. Lymphedema pumps/vasopneumatic devices/ReidSleeve®
25. Magnetic resonance imaging (MRI)
26. Mallet finger splinting
27. Mallet finger surgery
28. Nonprescription medications: acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs)
29. Occupational therapy/physical therapy
30. Office visits
31. Open reduction internal fixation (ORIF)/radius or ulna fracture surgery
32. Paraffin wax baths
33. Percutaneous release (of trigger finger and/or trigger thumb)
34. Prostheses (artificial limbs)/I-Limb® (bionic hand)/targeted muscle reinnervation
35. Radiography
36. Return to work
37. Splints
38. Static progressive stretch (SPS)
39. Steroid injections for trigger finger
40. Surgery for ganglion cysts
41. Tendon repairs
42. Trapeziectomy
43. Triangular fibrocartilage complex (TFCC) reconstruction/ulnar shortening surgery
44. Ultrasound (diagnostic)
45. Vitamin C
46. Work
47. Work conditioning/work hardening
48. Wound dressings/skin laceration repair
49. Yoga

The following interventions/procedures are under study and are not specifically recommended:

1. Casting versus splinting
2. Ergonomic interventions
3. Iontophoresis
4. Pulsed electromagnetic field

The following interventions/procedures were considered, but are not recommended:

1. Acupuncture
2. Arthroplasty, wrist (joint replacement)
3. Chiropractic (manipulation)
4. Computerized muscle testing
5. Contrast bath therapy
6. Electrical stimulators (E-stim)
7. Fluidotherapy
8. Hardware implant removal (fracture fixation)
9. Immobilization (treatment)/rest
10. Manipulation under anesthesia (MUA)
11. Surgery for broken wrist
12. Transcutaneous electrical neurostimulation (TENS)
13. Traction, arm (skeletal traction treatment)
14. Ultrasound (therapeutic)

Effectiveness of treatments in relieving pain, improving stability, and restoring normal function

Work Loss Data Institute (WLDI) conducted a comprehensive medical literature review (now ongoing) with preference given to high quality systematic reviews, meta-analyses, and clinical trials published since 1993, plus existing nationally recognized treatment guidelines from the leading specialty societies. WLDI primarily searched MEDLINE and the Cochrane Library. In addition, WLDI also reviewed other relevant treatment guidelines, including those in the National Guideline Clearinghouse, as well as state guidelines and proprietary guidelines maintained in the WLDI guideline library. These guidelines were also used to suggest references or search terms that may otherwise have been missed. In addition, WLDI also searched other databases, including MD Consult, eMedicine, CINAHL, and conference proceedings in occupational health (i.e., American College of Occupational and Environmental Medicine [ACOEM]) and disability evaluation (i.e., American Academy of Disability Evaluating Physicians [AADEP], American Board of Independent Medical Examiners [ABIME]). Search terms and questions were diagnosis, treatment, symptom, sign, and/or body-part driven, generated based on new or previously indexed existing evidence, treatment parameters and experience.

In searching the medical literature, answers to the following questions were sought: (1) If the diagnostic criteria for a given condition have changed since 1993, what are the new diagnostic criteria? (2) What occupational exposures or activities are associated causally with the condition? (3) What are the most effective methods and approaches for the early identification and diagnosis of the condition? (4) What historical information, clinical examination findings or ancillary test results (such as laboratory or x-ray studies) are of value in determining whether a condition was caused by the patient's employment? (5) What are the most effective methods and approaches for treating the condition? (6) What are the specific indications, if any, for surgery as a means of treating the condition? (7) What are the relative benefits and harms of the various surgical and non-surgical interventions that may be used to treat the condition? (8) What is the relationship, if any, between a patient's age, gender, socioeconomic status and/or racial or ethnic grouping and specific treatment outcomes for the condition? (9) What instruments or techniques, if any, accurately assess functional limitations in an individual with the condition? (10) What is the natural history of the disorder? (11) Prior to treatment, what are the typical functional limitations for an individual with the condition? (12) Following treatment, what are the typical functional limitations for an individual with the condition? (13) Following treatment, what are the most cost-effective methods for preventing the recurrence of signs or symptoms of the condition, and how does this vary depending upon patient-specific matters such as underlying health problems?

Criteria for Selecting the Evidence

Preference was given to evidence that met the following criteria: (1) The article was written in the English language, and the article had any of the following attributes: (2) It was a systematic review of the relevant medical literature, or (3) The article reported a controlled trial – randomized or controlled, or (4) The article reports a cohort study, whether prospective or retrospective, or (5) The article reports a case control series involving at least 25 subjects, in which the assessment of outcome was determined by a person or entity independent from the persons or institution that performed the intervention the outcome of which is being assessed.

More information about the selection of evidence is available in the "Methodology Outline" and "Appendix A. ODG Treatment in Workers' Comp. Methodology description using the AGREE instrument" (see "Availability of Companion Documents" field).

Not stated

Ranking by Type of Evidence

1. Systematic Review/Meta-Analysis
2. Controlled Trial-Randomized (RCT) or Controlled
3. Cohort Study-Prospective or Retrospective
4. Case Series
5. Unstructured Review
6. Nationally Recognized Treatment Guideline (from www.guideline.gov )
7. State Treatment Guideline
8. Other Treatment Guideline
9. Textbook
10. Conference Proceedings/Presentation Slides

Ranking by Quality within Type of Evidence

1. High Quality
2. Medium Quality
3. Low Quality

The Work Loss Data Institute (WLDI) reviewed each article that was relevant to answering the question at issue, with priority given to those that met the following criteria: (1) The article was written in the English language, and the article had any of the following attributes: (2) It was a systematic review of the relevant medical literature, or (3) The article reported a controlled trial – randomized or controlled, or (4) The article reported a cohort study, whether prospective or retrospective, or (5) The article reported a case control series involving at least 25 subjects, in which the assessment of outcome was determined by a person or entity independent from the persons or institution that performed the intervention the outcome of which is being assessed.

Especially when articles on a specific topic that met the above criteria were limited in number and quality, WLDI also reviewed other articles that did not meet the above criteria, but all evidence was ranked alphanumerically (see the "Rating Scheme for the Strength of the Evidence" field) so that the quality of evidence could be clearly determined when making decisions about what to recommend in the Guidelines. Articles with a Ranking by Type of Evidence of Case Reports and Case Series were not used in the evidence base for the Guidelines. These articles were not included because of their low quality (i.e., they tend to be anecdotal descriptions of what happened with no attempt to control for variables that might affect outcome). Not all the evidence provided by WLDI was eventually listed in the bibliography of the published Guidelines. Only the higher quality references were listed. The criteria for inclusion was a final ranking of 1a to 4b (the original inclusion criteria suggested the methodology subgroup), or if the Ranking by Type of Evidence was 5 to 10, the quality ranking should be an "a."

Not applicable

The guideline developers reviewed published cost analyses.

Prior to publication, select organizations and individuals making up a cross-section of medical specialties and typical end-users externally reviewed the guideline.

Note from the Work Loss Data Institute (WLDI) and the National Guideline Clearinghouse (NGC): The following recommendations were current as of February 21, 2011. However, because the Work Loss Data Institute updates their guidelines frequently, users may wish to consult the Work Loss Data Web site  for the most current version available.

Initial Diagnosis

1. Determine the type of injury or contributing factors (direct trauma, fall, repetitive motion, twisting incident, animal bite, etc.)
2. Determine whether the problem is acute, subacute, chronic, or of insidious onset.
3. Record the severity and specific anatomic location of the pain asserted.
4. Assess the ability of the patient to use the fingers, forearm, wrist, or hand, from no to full ability.
5. Search for any evidence of an open or penetrating wound.
6. Search for any evidence of deformity (anterior/posterior or lateral/medial) of the wrist or phalanges.
7. Test the range-of-motion of the joint (normal, mild restriction, severe restriction, or complete restriction).
8. Record any present medication.
9. Elicit any previous medical history, history of systemic disease, or previous wrist or hand injury or disability.

Presumptive Diagnosis

Fracture or dislocation (see original guideline document for International Classification of Diseases, Ninth Revision [ICD-9] codes for this and other diagnoses)

• Sprain, sprain-fracture or contusion, excluding carpal tunnel syndrome (see separate chapter)
• Laceration
• Tenosynovitis
• Hand tendon injuries
• Superficial injury

Fracture or Dislocation of Wrist

1. Definitive Evaluation
   • Record a history of the cause of injury.
   • Search for any evidence of an open wound in the vicinity of the injury.
   • Perform a clinical examination for deformity, tenderness, or ecchymosis, or associated nerve, neurovascular, or tendon injury.
   • Check for snuff box tenderness.
   • Search for any evidence of dislocation or arterial vascular compromise (cold, dusky hand with loss of sensation). If found, an immediate reduction should take place (prior to x-rays, if necessary, or proper consultations).
   • Perform an evaluation for an associated injury of the wrist or fingers.
   • X-ray the wrist. Include a scaphoid view.
   • Consider the easily missed scapholunate dissociation, or scaphoid fracture.

2. Initial Therapy
   1. Simple, undisplaced, stable fractures of the wrist can be treated by the primary care physician.
      1. Place the wrist in a plaster or sugar tong splint for seven to ten days, and then change to a short arm cast.
      2. Ice prior to application of cast, if applicable, and elevate for 4 to 7 days to prevent or reduce swelling (Hand Higher than Heart - HHH).
      3. Give the patient instructions to prevent tight cast problems.
      4. Analgesics and/or nonsteroidal anti-inflammatory drugs for up to two weeks may be appropriate.
      5. Recheck at seven days and then at two-week intervals until healed. Repeat x-rays at seven days and at two weeks to assure that the fracture has not slipped. X-ray again at five weeks; in most cases, the cast can be removed at that time.
      6. Estimate a return-to-work date for temporary transitional and regular work at each visit.
      7. Prescribe temporary transitional and job modifications at each visit.
   2. Undisplaced scaphoid fractures can be treated by the primary care physician. The average time for a fracture of the waist of the scaphoid of a bone that is not displaced is three months in a cast. A careful discussion with an orthopedic surgeon may result in a decision to operate and stabilize the bone with a special screw. These patients usually are allowed out of a cast within three weeks to begin flexibility exercises.
      1. With a negative x-ray but clinical suspicion of a scaphoid fracture (i.e., localized pain at snuff box following fall/trauma), a short arm thumb spica cast is used for seven to ten days. Then a repeat x-ray out of plaster is obtained to clarify the diagnosis. Rarely is a bone scan useful to confirm a suspected diagnosis of scaphoid fracture.
      2. Confirmed scaphoid fractures should be immobilized in a short arm thumb spica cast for 10 to 12 weeks until healed by x-ray examination.
      3. Analgesics and/or nonsteroidal anti-inflammatory drugs for up to two weeks may be appropriate.
      4. Recheck at seven days and then at two-week intervals until healed. Treatment may be as long as 12 to 36 weeks.
      5. Wrist x-rays should be taken at four to six weeks. It is often necessary to remove the cast to obtain the quality of x-rays necessary to determine healing status. Persistent fracture line on the x-ray and continued clinical tenderness over the scaphoid suggest delayed union that should prompt referral.
      6. Estimate a return-to-work date for temporary transitional and regular work at each visit.
      7. Prescribe temporary transitional and job modifications at each visit, and maybe a brace to prevent re-injury.
   3. Minimally displaced fractures can be reduced and treated by a primary care physician with proper training.
      1. Patients with minimally displaced fractures and no loss of length can have local anesthesia injected into the fracture; then the physician can perform a reduction. Parenteral analgesic will facilitate the reduction.
      2. Ice prior to application of cast, if applicable, and elevate for up to seven days is appropriate to prevent or reduce swelling.
      3. Apply a sugar tong splint with an ace bandage. Replace with a short arm cast after seven days or when swelling has subsided.
      4. Give the patient instructions to prevent tight cast problems.
      5. Analgesics and/or nonsteroidal anti-inflammatory drugs for up to two weeks may be appropriate.
      6. Recheck at seven days and then at two-week intervals until healed.
      7. Obtain x-rays after reduction, seven to ten days, and at four weeks.
      8. Physical therapy (three to four visits) to teach patient range-of-motion and muscle-strengthening exercises is appropriate following removal of cast.
      9. Estimate a return-to-work date for temporary transitional and regular work at each visit.
      10. Prescribe temporary transitional and job modifications at each visit.

   Wrist fractures with any question of non-union and all other wrist fractures not described above should be referred to an orthopedic surgeon for care.

   Evaluate for delayed union, malalignment, or signs of associated tendon or nerve injury.

   Promptly refer to an orthopedic surgeon if one of these conditions is found, otherwise continue therapy.

Other Diagnoses

Record a history including the onset of symptoms, limitations of present activity, and history of previous episodes, including type of treatment and results.

The history should include the nature of symptoms (numbness, pain, tingling), the time of day symptoms are experienced, and how the pain is relieved.

Separate cases of true nerve root impairment from those that mimic carpal tunnel syndrome (CTS). These include sprains, tenosynovitis, contusions, and hand arm vibration syndrome (HAV).

X-rays are not usually needed, unless local pathology or referred pain in the wrist from cervical spine pathology is suspected or the case is persistent. In such cases, wrist or cervical spine x-rays are appropriate.

Order laboratory studies including glycohemoglobin, sedimentation rate, thyroid-stimulating hormone (TSH), and a Rheumatoid Factor, if appropriate.

• The initial evaluation of the wrist needs to include a careful history for type of injury and the possibility of both repetitive and vibration type injuries. It is extremely important to make sure that any painful injury of the wrist does not have its origin in the upper extremity or the neck. It is also important to evaluate the patient's history for avocational activities that may be the cause of or be aggravating the problem, as it is necessary to have the patient modify these activities if one is to successfully treat the problem.
• The presumptive diagnosis is used to classify the type of problem prior to a thorough evaluation. Subsequent to a thorough evaluation, the diagnosis may change (e.g., if the physician classifies a patient with a sprain and the x-rays subsequently show a fracture). In such a case, therapy should follow the subsequent rather than the initial diagnosis.
• An open wound in the vicinity of a fracture makes it a compound fracture, even if no clear connection to the fracture site is apparent. All compound fractures should be referred to an orthopedic surgeon for care.
• Snuff box tenderness is often a sign of injury to the scaphoid bone. If symptoms persist for seven days or longer, repeated scaphoid view x-rays should be taken.
• Trans-scaphoid perilunar dislocation is a rare, severe injury which should be referred to an orthopedic surgeon.
• Scapholunate dissociation is the most frequent serious ligamentous injury of the wrist and is diagnosed by the "Terry Thomas sign" on wrist x-rays. There is a widening of the space between the lunate and the scaphoid on the anteroposterior view.
• Magnetic resonance imaging (MRI) of the wrist shows:
  • 82% of triangular fibrocartilage (TFC) tears, as confirmed by arthroscopy (Injuries to the triangular fibrocartilage complex are a frequent cause of ulnar-sided wrist pain. The TFC is a complex structure that involves the central fibrocartilage articular disc, merging with the volar edge of the ulnocarpal ligaments and, at its dorsal edge, with the floors of the extensor carpi ulnaris and extensor digiti minimi.)
  • 50% of scapholunate ligament tears
  • 40% of intercarpal dorsal ligament tears
• Arthroscopy is thought to be superior to arthrograms in delineating ligament tears.
• Fluoroscopy exam is helpful in diagnosing tears and abnormal motion.
• Undisplaced scaphoid fractures can be treated by the primary care physician. Those scaphoid fractures that are displaced or have a wide gap between the fragments should be immediately referred to an orthopedic surgeon, as they have a significant increased incidence of nonunion.
• Wrist sprains are common industrial injuries, and must be differentiated from carpal tunnel syndrome and tendonitis.
• Tendon injuries are not common with sprains, but it is important to check for such injuries as they require different therapy than a simple sprain.
• Grade III sprains involve tears of the carpal ligaments and are impairing injuries. Clinically they have significant swelling, ecchymosis, and an unstable joint. These are the sprains that are more likely to have associated injury of tendons or nerves. Injuries to the triangular fibrocartilage complex (TFCC) may have pain and stiffness as the only relevant findings. These injuries should be referred to an orthopedic surgeon or hand surgeon for evaluation and treatment.
• A wrist splint or short arm cast is sometimes necessary for the initial treatment of sprains which are very tender, swollen, and painful with motion. Splinting is continued until symptoms abate. An early nonresisted exercise program is indicated.
• The Terry Thomas sign refers to the x-ray appearance of a widening gap between the two carpal bones of the wrist in patients with scapholunate dissociation. (Terry Thomas's teeth were apart when he smiled).
• Imaging procedures are appropriate for sprains that have been treated for six weeks with little or no improvement in the patient's complaints or physical findings. Repeat x-rays with scaphoid views are indicated, since routine anteroposterior and lateral x-rays generally fail to demonstrate scaphoid fractures. Additionally, an arthrogram may be of value to demonstrate carpal ligament tears and help determine the necessity of surgical therapy, but should be obtained only after a consultation with an orthopedic surgeon.
• A laceration produced by crush injury needs an x-ray to rule out any underlying fracture and to answer any question of penetration of the joint or a foreign body in the wound.
• Neurovascular and tendon function need evaluation with any laceration around a joint. No anesthesia should be used in the wound until the sensation has been checked distal to the laceration and the function of the tendons has been identified as intact.
• Antibiotic therapy for contaminated lacerations should include both anti-staphylococcal and broad-spectrum coverage.
• Tenosynovitis is a common enthesopathy of the tendon of the wrist. It is most important to rule out infection, for this is an emergent problem that requires prompt referral. Infectious tenosynovitis will usually demonstrate marked tenderness and more pain than noninfectious tenosynovitis. The patient with septic tenosynovitis will frequently have an elevated temperature, lymphangitis, erythematous swelling, and severe pain with attempted motion along with an elevated white blood count.
• Ganglions of the wrist are benign synovial cysts and usually do not require treatment. An initial aspiration with injection of corticosteroids is acceptable. There is a 50% recurrence rate. With an accurate diagnosis, no further treatment is necessary. Surgery, though commonly done, has a significant recurrence rate and is only indicated in unusually symptomatic wrists.
• Placing the wrist in a splint post injection for a short time is often helpful.
• Hand arm vibration syndrome (HAV) is a relatively common industrial injury in workers whose job involves work with frequent and sustained vibrations. Sensory impairment of the fingers and Raynaud's phenomenon are the common complaints. It must be differentiated from carpal tunnel syndrome, as the treatment is never surgical for HAV. The treatment is primarily reduction of vibration exposure and taking a slow release calcium channel blocker (e.g., nifedipine).
• Acute CTS occasionally occurs with acute trauma to the wrist, most commonly with severe sprains. It can occur in fractures and with a direct blow to the volar aspect of the wrist. There is rapid and intense development of symptoms with paresthesias, pain, and numbness in the distribution of the median nerve. This is an urgent (four to eight hours) surgical problem. It can be differentiated from other problems by the measurement of the pressure in the carpal tunnel.
• Acute episodes of traumatic arthritis frequently follow minor wrist fractures and severe sprains. One of the common sites of traumatic arthritis of the wrist is the trapeziometacarpal joint at the base of the first metacarpal. Persistent and increasing impairment of this joint from arthritis often requires surgical treatment.

None provided

During the comprehensive medical literature review, preference was given to high quality systematic reviews, meta-analyses, and clinical trials over the past ten years, plus existing nationally recognized treatment guidelines from the leading specialty societies.

The heart of each Work Loss Data Institute guideline is the Procedure Summary (see the original guideline document), which provides a concise synopsis of effectiveness, if any, of each treatment method based on existing medical evidence. Each summary and subsequent recommendation is hyper-linked into the studies on which they are based, in abstract form, which have been ranked, highlighted and indexed.

These guidelines unite evidence-based protocols for medical treatment with normative expectations for disability duration. They also bridge the interests of the many professional groups involved in diagnosing and treating work-related injuries of the forearm, wrist, and hand.

Contraindications to arthroplasty of the finger and/or thumb (joint replacement) include:

• Lack of stability (e.g., as a result of rheumatoid arthritis or destruction of the ligaments caused by an accident)
• Nonreconstructable extensor tendons
• Florid or chronic infection
• Lack of patient compliance

The Treatment Planning section is not designed to be a rule, and therefore should not be used as a basis for Utilization Review. The Treatment Planning section outlines the most common pathways to recovery, but there is no single approach that is right for every patient and these protocols do not mention every treatment that may be recommended. See the Procedure Summaries (in the original guideline document) for complete lists of the various options that may be available, along with links to the medical evidence. The Procedure Summaries are the most important section of Official Disability Guidelines (ODG) Treatment, and that section, not the Treatment Planning section, should be used as a basis for Utilization Review.

An implementation strategy was not provided.

Not applicable: The guideline was not adapted from another source.

Not stated

Not stated

Editor-in-Chief, Philip L. Denniston, Jr. and Senior Medical Editor, Charles W. Kennedy, Jr., MD, together pilot the group of approximately 80 members. See the ODG Treatment in Workers Comp Editorial Advisory Board .

There are no conflicts of interest among the guideline development members.

This is the current release of the guideline.

This guideline updates a previous version: Work Loss Data Institute. Forearm, wrist, & hand (acute & chronic), not including carpal tunnel syndrome. Corpus Christi (TX): Work Loss Data Institute; 2008. 128 p.

The Official Disability Guidelines product line, including ODG Treatment in Workers Comp, is updated annually, as it has been since the first release in 1996.

Electronic copies: Available to subscribers from the Work Loss Data Institute Web site .

Print copies: Available from the Work Loss Data Institute, 169 Saxony Road, Suite 210, Encinitas, CA 92024; Phone: 800-488-5548, 760-753-9992, Fax: 760-753-9995; www.worklossdata.com .

The following are available:

• Methodology outline is available from the Work Loss Data Institute (WLDI) Web site .
• Appendix A. Official Disability Guidelines (ODG) Treatment in Workers' Comp. Methodology description using the AGREE instrument. Available from the WLDI Web site .
• ODG for eReader. Treatment and disability duration guidelines are available for purchase from the WLDI Web site .

The following is available:

• Appendix C. ODG Treatment in Workers' Comp. Patient information resources. Electronic copies: Available to subscribers from the Work Loss Data Institute Web site .

Print copies: Available from the Work Loss Data Institute, 169 Saxony Road, Suite 210, Encinitas, CA 92024; Phone: 800-488-5548, 760-753-9992, Fax: 760-753-9995; www.worklossdata.com .

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

This NGC summary was completed by ECRI on April 4, 2005. This NGC summary was updated by ECRI on January 18, 2006, April 11, 2006, November 9, 2006, March 29, 2007, and August 17, 2007. This summary was updated by ECRI Institute on December 19, 2008. This summary was updated by ECRI Institute on May 25, 2011.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.