Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Skeletal Radiology
Published in: Skeletal Radiology 3/2019

01-03-2019 | Review Article

Radiologic evaluation of fracture healing

Authors: Jessica S. Fisher, J. Jacob Kazam, Duretti Fufa, Roger J. Bartolotta

Published in: Skeletal Radiology | Issue 3/2019

Login to get access

Abstract

While assessment of fracture healing is a common task for both orthopedic surgeons and radiologists, it remains challenging due to a lack of consensus on imaging and clinical criteria as well as the lack of a true gold standard. Further complicating this evaluation are the wide variations between patients, specific fracture sites, and fracture patterns. Research into the mechanical properties of bone and the process of bone healing has helped to guide the evaluation of fracture union. Development of standardized scoring systems and identification of specific radiologic signs have further clarified the radiologist’s role in this process. This article reviews these scoring systems and signs with regard to the biomechanical basis of fracture healing. We present the utility and limitations of current techniques used to assess fracture union as well as newer methods and potential future directions for this field.
Literature
1.
Vortkamp A, Pathi S, Peretti GM, Caruso EM, Zaleske DJ, Tabin CJ. Recapitulation of signals regulating embryonic bone formation during postnatal growth and in fracture repair. Mech Dev. 1998;71(1–2):65–76.CrossRef
2.
Ferguson C, Alpern E, Miclau T, Helms JA. Does adult fracture repair recapitulate embryonic skeletal formation? Mech Dev. 1999;87(1–2):57–66.CrossRef
3.
Bruder SP, Fink DJ, Caplan AI. Mesenchymal stem cells in bone development, bone repair, and skeletal regeneration therapy. J Cell Biochem. 1994;56(3):283–94.CrossRef
4.
Karsenty G, Wagner EF. Reaching a genetic and molecular understanding of skeletal development. Dev Cell. 2002;2(4):389–406.CrossRef
5.
Provot S, Schipani E. Molecular mechanisms of endochondral bone development. Biochem Biophys Res Commun. 2005;328(3):658–65.CrossRef
6.
Du X, Xie Y, Xian CJ, Chen L. Role of FGFs/FGFRs in skeletal development and bone regeneration. J Cell Physiol. 2012;227(12):3731–43.CrossRef
7.
Phillips AM. Overview of the fracture healing cascade. Injury. 2005;36(Suppl 3):S5–7.CrossRef
8.
Lee TC, Staines A, Taylor D. Bone adaptation to load: microdamage as a stimulus for bone remodelling. J Anat. 2002;201(6):437–46.CrossRef
9.
Einhorn TA. The cell and molecular biology of fracture healing. Clin Orthop Relat Res. 1998(355 Suppl):S7–21.
10.
Einhorn TA, Gerstenfeld LC. Fracture healing: mechanisms and interventions. Nat Rev Rheumatol. 2015;11(1):45–54.CrossRef
11.
Watanabe Y, Nishizawa Y, Takenaka N, Kobayashi M, Matsushita T. Ability and limitation of radiographic assessment of fracture healing in rats. Clin Orthop Relat Res. 2009;467(8):1981–5.CrossRef
12.
Marsh D. Concepts of fracture union, delayed union, and nonunion. Clin Orthop Relat Res. 1998;355(Suppl):S22–30.CrossRef
13.
Mills L, Tsang J, Hopper G, Keenan G, Simpson AH. The multifactorial aetiology of fracture nonunion and the importance of searching for latent infection. Bone Joint Res. 2016;5(10):512–9.CrossRef
14.
Morshed S, Corrales L, Genant H, Miclau T. Outcome assessment in clinical trials of fracture-healing. J Bone Joint Surg Am. 2008;90(Suppl 1):62–7.CrossRef
15.
Morshed S. Current options for determining fracture union. Adv Med. 2014;2014:708574.CrossRef
16.
Calori GM, Albisetti W, Agus A, Iori S, Tagliabue L. Risk factors contributing to fracture non-unions. Injury. 2007;38(2):S11–8.CrossRef
17.
Donovan A, Schweitzer ME, editors. Imaging musculoskeletal trauma: interpretation and reporting. Chichester, West Sussex: Wiley-Blackwell; 2012.
18.
Dijkman BG, Sprague S, Schemitsch EH, Bhandari M. When is a fracture healed? Radiographic and clinical criteria revisited. J Orthop Trauma. 2010;24(Suppl 1):S76–80.CrossRef
19.
Beaton DE, Schemitsch E. Measures of health-related quality of life and physical function. Clin Orthop Relat Res. 2003;413:90–105.CrossRef
20.
Axelrad TW, Einhorn TA. Use of clinical assessment tools in the evaluation of fracture healing. Injury. 2011;42(3):301–5.CrossRef
21.
Bhandari M, Guyatt GH, Swiontkowski MF, Tornetta P, Sprague S, Schemitsch EH. A lack of consensus in the assessment of fracture healing among orthopaedic surgeons. J Orthop Trauma. 2002;16(8):562–6.CrossRef
22.
Corrales LA, Morshed S, Bhandari M, Miclau T. Variability in the assessment of fracture-healing in orthopaedic trauma studies. J Bone Joint Surg Am. 2008;90(9):1862–8.CrossRef
23.
Dijkman BG, Busse JW, Walter SD, Bhandari M, Investigators T. The impact of clinical data on the evaluation of tibial fracture healing. Trials. 2011;12:237.CrossRef
24.
Webb J, Herling G, Gardner T, Kenwright J, Simpson AH. Manual assessment of fracture stiffness. Injury. 1996;27(5):319–20.CrossRef
25.
Hammer R, Norrbom H. Evaluation of fracture stability. A mechanical simulator for assessment of clinical judgement. Acta Orthop Scand. 1984;55(3):330–3.CrossRef
26.
Leow JM, Clement ND, Tawonsawatruk T, Simpson CJ, Simpson AH. The radiographic union scale in tibial (RUST) fractures: reliability of the outcome measure at an independent centre. Bone Joint Res. 2016;5(4):116–21.CrossRef
27.
Bohl DD, Lese AB, Patterson JT, Grauer JN, Dodds SD. Routine imaging after operatively repaired distal radius and scaphoid fractures: a survey of hand surgeons. J Wrist Surg. 2014;3(4):239–44.CrossRef
28.
Eastaugh-Waring SJ, Joslin CC, Hardy JR, Cunningham JL. Quantification of fracture healing from radiographs using the maximum callus index. Clin Orthop Relat Res. 2009;467(8):1986–91.CrossRef
29.
Panjabi MM, Walter SD, Karuda M, White AA, Lawson JP. Correlations of radiographic analysis of healing fractures with strength: a statistical analysis of experimental osteotomies. J Orthop Res. 1985;3(2):212–8.CrossRef
30.
Sano H, Uhthoff HK, Backman DS, Yeadon A. Correlation of radiographic measurements with biomechanical test results. Clin Orthop Relat Res. 1999;368:271–8.CrossRef
31.
Hammer RR, Hammerby S, Lindholm B. Accuracy of radiologic assessment of tibial shaft fracture union in humans. Clin Orthop Relat Res. 1985;199:233–8.
32.
Kooistra BW, Dijkman BG, Busse JW, Sprague S, Schemitsch EH, Bhandari M. The radiographic union scale in tibial fractures: reliability and validity. J Orthop Trauma. 2010;24(Suppl 1):S81–6.CrossRef
33.
Whelan DB, Bhandari M, McKee MD, Guyatt GH, Kreder HJ, Stephen D, et al. Interobserver and intraobserver variation in the assessment of the healing of tibial fractures after intramedullary fixation. J Bone Joint Surg (Br). 2002;84(1):15–8.CrossRef
34.
Whelan DB, Bhandari M, Stephen D, Kreder H, McKee MD, Zdero R, et al. Development of the radiographic union score for tibial fractures for the assessment of tibial fracture healing after intramedullary fixation. J Trauma. 2010;68(3):629–32.CrossRef
35.
Tawonsawatruk T, Hamilton DF, Simpson AH. Validation of the use of radiographic fracture-healing scores in a small animal model. J Orthop Res. 2014;32(9):1117–9.CrossRef
36.
Bhandari M, Chiavaras M, Ayeni O, Chakraverrty R, Parasu N, Choudur H, et al. Assessment of radiographic fracture healing in patients with operatively treated femoral neck fractures. J Orthop Trauma. 2013;27(9):e213–9.CrossRef
37.
Bhandari M, Chiavaras MM, Parasu N, Choudur H, Ayeni O, Chakravertty R, et al. Radiographic union score for hip substantially improves agreement between surgeons and radiologists. BMC Musculoskelet Disord. 2013;14:70.CrossRef
38.
Chiavaras MM, Bains S, Choudur H, Parasu N, Jacobson J, Ayeni O, et al. The radiographic union score for hip (RUSH): the use of a checklist to evaluate hip fracture healing improves agreement between radiologists and orthopedic surgeons. Skelet Radiol. 2013;42(8):1079–88.CrossRef
39.
Frank T, Osterhoff G, Sprague S, Garibaldi A, Bhandari M, Slobogean GP, et al. The radiographic union score for hip (RUSH) identifies radiographic nonunion of femoral neck fractures. Clin Orthop Relat Res. 2016;474(6):1396–404.CrossRef
40.
Patel SP, Anthony SG, Zurakowski D, Didolkar MM, Kim PS, Wu JS, et al. Radiographic scoring system to evaluate union of distal radius fractures. J Hand Surg [Am]. 2014;39(8):1471–9.CrossRef
41.
Salih S, Blakey C, Chan D, McGregor-Riley JC, Royston SL, Gowlett S, et al. The callus fracture sign: a radiological predictor of progression to hypertrophic non-union in diaphyseal tibial fractures. Strategies Trauma Limb Reconstr. 2015;10(3):149–53.CrossRef
42.
Lujan TJ, Madey SM, Fitzpatrick DC, Byrd GD, Sanderson JM. Bottlang M. A computational technique to measure fracture callus in radiographs. J Biomech. 2010;43(4):792–5.CrossRef
43.
Yee AJ, Bae HW, Friess D, Robbin M, Johnstone B, Yoo JU. Accuracy and interobserver agreement for determinations of rabbit posterolateral spinal fusion. Spine (Phila Pa 1976). 2004;29(12):1308–13.CrossRef
44.
Markel MD, Morin RL, Wikenheiser MA, Lewallen DG, Chao EY. Quantitative CT for the evaluation of bone healing. Calcif Tissue Int. 1991;49(6):427–32.CrossRef
45.
Grigoryan M, Lynch JA, Fierlinger AL, Guermazi A, Fan B, MacLean DB, et al. Quantitative and qualitative assessment of closed fracture healing using computed tomography and conventional radiography. Acad Radiol. 2003;10(11):1267–73.CrossRef
46.
Krestan CR, Noske H, Vasilevska V, Weber M, Schueller G, Imhof H, et al. MDCT versus digital radiography in the evaluation of bone healing in orthopedic patients. AJR Am J Roentgenol. 2006;186(6):1754–60.CrossRef
47.
Kuhlman JE, Fishman EK, Magid D, Scott WW, Brooker AF, Siegelman SS. Fracture nonunion: CT assessment with multiplanar reconstruction. Radiology. 1988;167(2):483–8.CrossRef
48.
Bhattacharyya T, Bouchard KA, Phadke A, Meigs JB, Kassarjian A, Salamipour H. The accuracy of computed tomography for the diagnosis of tibial nonunion. J Bone Joint Surg Am. 2006;88(4):692–7.PubMed
49.
Braunstein EM, Goldstein SA, Ku J, Smith P, Matthews LS. Computed tomography and plain radiography in experimental fracture healing. Skelet Radiol. 1986;15(1):27–31.CrossRef
50.
Firoozabadi R, Morshed S, Engelke K, Prevrhal S, Fierlinger A, Miclau T, et al. Qualitative and quantitative assessment of bone fragility and fracture healing using conventional radiography and advanced imaging technologies--focus on wrist fracture. J Orthop Trauma. 2008;22(8 Suppl):S83–90.CrossRef
51.
den Boer FC, Bramer JA, Patka P, Bakker FC, Barentsen RH, Feilzer AJ, et al. Quantification of fracture healing with three-dimensional computed tomography. Arch Orthop Trauma Surg. 1998;117(6–7):345–50.CrossRef
52.
Sigurdsen U, Reikeras O, Hoiseth A, Utvag SE. Correlations between strength and quantitative computed tomography measurement of callus mineralization in experimental tibial fractures. Clin Biomech (Bristol, Avon). 2011;26(1):95–100.CrossRef
53.
Lynch JA, Grigoryan M, Fierlinger A, Guermazi A, Zaim S, MacLean DB, et al. Measurement of changes in trabecular bone at fracture sites using X-ray CT and automated image registration and processing. J Orthop Res. 2004;22(2):362–7.CrossRef
54.
Mallinson PI, Coupal TM, McLaughlin PD, Nicolaou S, Munk PL, Ouellette HA. Dual-energy CT for the musculoskeletal system. Radiology. 2016;281(3):690–707.CrossRef
55.
Augat P, Morgan EF, Lujan TJ, MacGillivray TJ, Cheung WH. Imaging techniques for the assessment of fracture repair. Injury. 2014;45(Suppl 2):S16–22.CrossRef
56.
Moed BR, Subramanian S, van Holsbeeck M, Watson JT, Cramer KE, Karges DE, et al. Ultrasound for the early diagnosis of tibial fracture healing after static interlocked nailing without reaming: clinical results. J Orthop Trauma. 1998;12(3):206–13.CrossRef
57.
Moed BR, Watson JT, Goldschmidt P, van Holsbeeck M. Ultrasound for the early diagnosis of fracture healing after interlocking nailing of the tibia without reaming. Clin Orthop Relat Res. 1995;310:137–44.
58.
Wawrzyk M, Sokal J, Andrzejewska E, Przewratil P. The role of ultrasound imaging of callus formation in the treatment of long bone fractures in children. Pol J Radiol. 2015;80:473–8.CrossRef
59.
Risselada M, Kramer M, Saunders JH, Verleyen P, Van Bree H. Power Doppler assessment of the neovascularization during uncomplicated fracture healing of long bones in dogs and cats. Vet Radiol Ultrasound. 2006;47(3):301–6.CrossRef
60.
Rawool NM, Goldberg BB, Forsberg F, Winder AA, Hume E. Power Doppler assessment of vascular changes during fracture treatment with low-intensity ultrasound. J Ultrasound Med. 2003;22(2):145–53.CrossRef
61.
Niikura T, Lee SY, Sakai Y, Nishida K, Kuroda R, Kurosaka M. Comparison of radiographic appearance and bone scintigraphy in fracture nonunions. Orthopedics. 2014;37(1):e44–50.CrossRef
62.
Piert M, Zittel TT, Becker GA, Jahn M, Stahlschmidt A, Maier G, et al. Assessment of porcine bone metabolism by dynamic. J Nucl Med. 2001;42(7):1091–100.PubMed
63.
Messa C, Goodman WG, Hoh CK, Choi Y, Nissenson AR, Salusky IB, et al. Bone metabolic activity measured with positron emission tomography and [18F]fluoride ion in renal osteodystrophy: correlation with bone histomorphometry. J Clin Endocrinol Metab. 1993;77(4):949–55.PubMed
64.
Narita N, Kato K, Nakagaki H, Ohno N, Kameyama Y, Weatherell JA. Distribution of fluoride concentration in the rat's bone. Calcif Tissue Int. 1990;46(3):200–4.CrossRef
65.
Hsu WK, Feeley BT, Krenek L, Stout DB, Chatziioannou AF, Lieberman JR. The use of 18F-fluoride and 18F-FDG PET scans to assess fracture healing in a rat femur model. Eur J Nucl Med Mol Imaging. 2007;34(8):1291–301.CrossRef
Metadata
Title
Radiologic evaluation of fracture healing
Authors
Jessica S. Fisher
J. Jacob Kazam
Duretti Fufa
Roger J. Bartolotta
Publication date
01-03-2019
Publisher
Springer Berlin Heidelberg
Published in
Skeletal Radiology / Issue 3/2019
Print ISSN: 0364-2348
Electronic ISSN: 1432-2161
DOI
https://doi.org/10.1007/s00256-018-3051-0

Other articles of this Issue 3/2019

Skeletal Radiology 3/2019 Go to the issue

Abstracts

Annual Meeting Abstracts of the Society of Skeletal Radiology (SSR) 2019, Scottsdale, Arizona, USA

Case Report

Sequelae of bilateral luxatio erecta in the acute post-reduction period demonstrated by MRI: a case report and literature review

Review Article

Current perspectives in conventional and advanced imaging of the distal radioulnar joint dysfunction: review for the musculoskeletal radiologist

Scientific Article

The pattern of idiopathic isolated teres minor atrophy with regard to its two-bundle anatomy

Scientific Article

Preliminary investigation of brown adipose tissue assessed by PET/CT and cancer activity

Scientific Article

Reliability of patellotrochlear index in patellar height assessment on MRI—correction for variation due to change in knee flexion