Current Options for Determining Fracture Union

Abstract

Determining whether a bone fracture is healed is one of the most important and fundamental clinical determinations made in orthopaedics. However, there are currently no standardized methods of assessing fracture union, which in turn has created significant disagreement among orthopaedic surgeons in both clinical and research settings. An extensive amount of research has been dedicated to finding novel and reliable ways of determining healing with some promising results. Recent advancements in imaging techniques and introduction of new radiographic scores have helped decrease the amount of disagreement on this topic among physicians. The knowledge gained from biomechanical studies of bone healing has helped us refine our tools and create more efficient and practical research instruments. Additionally, a deeper understanding of the molecular pathways involved in the bone healing process has led to emergence of serologic markers as possible candidates in assessment of fracture union. In addition to our current physician centered methods, patient-centered approaches assessing quality of life and function are gaining popularity in assessment of fracture union. Despite these advances, assessment of union remains an imperfect practice in the clinical setting. Therefore, clinicians need to draw on multiple modalities that directly and indirectly measure or correlate with bone healing when counseling patients.

Figure 1

((a) and (b)) Radiographs of a hypertrophic tibial nonunion in a 35-year-old man ten months status after medullary fixation of an open tibial shaft fracture with persistent pain and inability to weight bare. Note abundant callus formation but persistent fracture line.

Figure 2

((a) and (b)) Radiographs of an atrophic nonunion of the tibia with hardware failure one year after motorcycle collision resulting in an open tibial fracture. In this patient, little or no callus is evident.

Figure 3

Assignment of the RUST in a patient with distal tibial shaft fracture at 3 months postoperatively. Overall RUST = 7.

Figure 4

Assignment of the RUSH in a patient with an acute intertrochanteric fracture at 6 weeks postoperatively. The overall score in this patient is 22. As evident, the RUSH checklist incorporates cortical and trabecular bridging and fracture line disappearance in its scoring system.

Figure 5

Figure 6

Distribution of general and region-specific instrument usage over time from 2000 to 2006 showing an increase in use of regional questionnaires between 2000 and 2005.