Clinical union: sufficient bone growth across fx, irrespective of radiographic obliteration of fx lucency, to restore original function
Determined clinically: stability on physical exam, absence of pain at site, ability to use fractured extremity in activities of daily living
Radiographic findings play into this determination also
Expected time to fx union varies with patient age and bone involved
Radiographic union: ossified callus bridges fx line, uniting fragments; callus as dense or nearly as dense as normal bone; minimum of 3 of 4 cortices bridged, as seen on AP and lateral radiographs; trabecular pattern restored
Radiographic union often lags clinical union
Radiographic criteria do not correlate well with fx strength and stiffness
Nonunion: fx fragments not bridged by mature bone and healing process has arrested
Delayed union: lack of clinical or radiographic union within expected time frame; in many of these instances, improved immobilization, patient adherence to rehabilitation instructions will lead to ultimate fx union
Pseudarthrosis: false joint that may develop in setting of nonunion, precluding any further healing until intervening synovial tissue is removed
Malunion: fx fragments heal with angulation &/or rotation across fx, improper length, or articular incongruity that is functionally or cosmetically unacceptable
Osteosynthesis: process of augmenting fx healing via surgical fixation, sometimes with bone graft or other accelerants added
IMAGING
General Features
Radiographic Findings
CT Findings
MR Findings
Imaging Recommendations
DIFFERENTIAL DIAGNOSIS
PATHOLOGY
Staging, Grading, & Classification
CLINICAL ISSUES
Demographics
Natural History & Prognosis
Treatment
DIAGNOSTIC CHECKLIST
Image Interpretation Pearls
Reporting Tips
Selected References
Schwarzenberg P et al: Imaging modalities to assess fracture healing. Curr Osteoporos Rep. 18(3):169-79, 2020
Schlickewei CW et al: Current and future concepts for the treatment of impaired fracture healing. Int J Mol Sci. 20(22), 2019
Zura R et al: Epidemiology of fracture nonunion in 18 human bones. JAMA Surg. 151(11):e162775, 2016
Emara KM et al: Recent biological trends in management of fracture non-union. World J Orthop. 6(8):623-8, 2015
Oryan A et al: Bone injury and fracture healing biology. Biomed Environ Sci. 28(1):57-71, 2015
Schaden W et al: Extracorporeal shockwave therapy (ESWT) - first choice treatment of fracture non-unions? Int J Surg. 24(Pt B):179-83, 2015
Tulipan J et al: The effect of osteoporosis on healing of distal radius fragility fractures. Orthop Clin North Am. 46(4):541-9, 2015
Yue B et al: Delayed healing of lower limb fractures with bisphosphonate therapy. Ann R Coll Surg Engl. 97(5):333-8, 2015
Augat P et al: Imaging techniques for the assessment of fracture repair. Injury. 45 Suppl 2:S16-22, 2014
Hak DJ et al: Delayed union and nonunions: epidemiology, clinical issues, and financial aspects. Injury. 45 Suppl 2:S3-7, 2014
Hankenson KD et al: Biological perspectives of delayed fracture healing. Injury. 45 Suppl 2:S8-15, 2014
Pinkas D et al: Management of malunion of the proximal humerus: current concepts. J Am Acad Orthop Surg. 22(8):491-502, 2014
Rao SK et al: A literature review and case series of accelerating fracture healing in postmenopausal osteoporotic working women. J Orthop. 11(3):150-2, 2014
Richard RD et al: Techniques for the surgical treatment of distal tibia fractures. Orthop Clin North Am. 45(3):295-312, 2014
Scolaro JA et al: Cigarette smoking increases complications following fracture: a systematic review. J Bone Joint Surg Am. 96(8):674-81, 2014
Blokhuis TJ et al: Autograft versus BMPs for the treatment of non-unions: what is the evidence? Injury. 44 Suppl 1:S40-2, 2013
Geusens P et al: NSAIDs and fracture healing. Curr Opin Rheumatol. 25(4):524-31, 2013
Hobby B et al: Managing atrophic nonunion in the geriatric population: incidence, distribution, and causes. Orthop Clin North Am. 44(2):251-6, 2013
Balogh ZJ et al: Advances and future directions for management of trauma patients with musculoskeletal injuries. Lancet. 380(9847):1109-19, 2012
Bishop JA et al: Assessment of compromised fracture healing. J Am Acad Orthop Surg. 20(5):273-82, 2012
Haase SC et al: Management of malunions of the distal radius. Hand Clin. 28(2):207-16, 2012
Taljanovic MS et al: Imaging and treatment of scaphoid fractures and their complications. Semin Musculoskelet Radiol. 16(2):159-73, 2012
Dijkman BG et al: When is a fracture healed? Radiographic and clinical criteria revisited. J Orthop Trauma. 24 Suppl 1:S76-80, 2010
Pape HC et al: Trauma-induced inflammation and fracture healing. J Orthop Trauma. 24(9):522-5, 2010
Lynch JR et al: Femoral nonunion: risk factors and treatment options. J Am Acad Orthop Surg. 16(2):88-97, 2008
Calori GM et al: Risk factors contributing to fracture non-unions. Injury. 38 Suppl 2:S11-8, 2007
Giannoudis P et al: Can we accelerate fracture healing? A critical analysis of the literature. Injury. 38 Suppl 1:S81-9, 2007
Jagodzinski M et al: Effect of mechanical stability on fracture healing--an update. Injury. 38 Suppl 1:S3-10, 2007
Bhattacharyya T et al: The accuracy of computed tomography for the diagnosis of tibial nonunion. J Bone Joint Surg Am. 88(4):692-7, 2006
Blokhuis TJ et al: The reliability of plain radiography in experimental fracture healing. Skeletal Radiol. 30(3):151-6, 2001
Wade R et al: Outcome in fracture healing: a review. Injury. 32(2):109-14, 2001
McKinley DW et al: Follow-up radiographs to detect callus formation after fractures. Arch Fam Med. 9(4):373-4, 2000
Hayda RA et al: Pathophysiology of delayed healing. Clin Orthop Relat Res. S31-40, 1998
Marsh D: Concepts of fracture union, delayed union, and nonunion. Clin Orthop Relat Res. S22-30, 1998
Chew FS: Skeletal Radiology: The Bare Bones. 2nd ed. Williams & Wilkins, 1997
Chapman S: The radiological dating of injuries. Arch Dis Child. 67(9):1063-5, 1992
Hulth A: Current concepts of fracture healing. Clin Orthop Relat Res. 265-84, 1989
Related Anatomy
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Related Differential Diagnoses
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References
Tables
Tables
KEY FACTS
Terminology
Imaging
Diagnostic Checklist
TERMINOLOGY
Abbreviations
Fracture (fx)
Definitions
Clinical union: sufficient bone growth across fx, irrespective of radiographic obliteration of fx lucency, to restore original function
Determined clinically: stability on physical exam, absence of pain at site, ability to use fractured extremity in activities of daily living
Radiographic findings play into this determination also
Expected time to fx union varies with patient age and bone involved
Radiographic union: ossified callus bridges fx line, uniting fragments; callus as dense or nearly as dense as normal bone; minimum of 3 of 4 cortices bridged, as seen on AP and lateral radiographs; trabecular pattern restored
Radiographic union often lags clinical union
Radiographic criteria do not correlate well with fx strength and stiffness
Nonunion: fx fragments not bridged by mature bone and healing process has arrested
Delayed union: lack of clinical or radiographic union within expected time frame; in many of these instances, improved immobilization, patient adherence to rehabilitation instructions will lead to ultimate fx union
Pseudarthrosis: false joint that may develop in setting of nonunion, precluding any further healing until intervening synovial tissue is removed
Malunion: fx fragments heal with angulation &/or rotation across fx, improper length, or articular incongruity that is functionally or cosmetically unacceptable
Osteosynthesis: process of augmenting fx healing via surgical fixation, sometimes with bone graft or other accelerants added
IMAGING
General Features
Radiographic Findings
CT Findings
MR Findings
Imaging Recommendations
DIFFERENTIAL DIAGNOSIS
PATHOLOGY
Staging, Grading, & Classification
CLINICAL ISSUES
Demographics
Natural History & Prognosis
Treatment
DIAGNOSTIC CHECKLIST
Image Interpretation Pearls
Reporting Tips
Selected References
Schwarzenberg P et al: Imaging modalities to assess fracture healing. Curr Osteoporos Rep. 18(3):169-79, 2020
Schlickewei CW et al: Current and future concepts for the treatment of impaired fracture healing. Int J Mol Sci. 20(22), 2019
Zura R et al: Epidemiology of fracture nonunion in 18 human bones. JAMA Surg. 151(11):e162775, 2016
Emara KM et al: Recent biological trends in management of fracture non-union. World J Orthop. 6(8):623-8, 2015
Oryan A et al: Bone injury and fracture healing biology. Biomed Environ Sci. 28(1):57-71, 2015
Schaden W et al: Extracorporeal shockwave therapy (ESWT) - first choice treatment of fracture non-unions? Int J Surg. 24(Pt B):179-83, 2015
Tulipan J et al: The effect of osteoporosis on healing of distal radius fragility fractures. Orthop Clin North Am. 46(4):541-9, 2015
Yue B et al: Delayed healing of lower limb fractures with bisphosphonate therapy. Ann R Coll Surg Engl. 97(5):333-8, 2015
Augat P et al: Imaging techniques for the assessment of fracture repair. Injury. 45 Suppl 2:S16-22, 2014
Hak DJ et al: Delayed union and nonunions: epidemiology, clinical issues, and financial aspects. Injury. 45 Suppl 2:S3-7, 2014
Hankenson KD et al: Biological perspectives of delayed fracture healing. Injury. 45 Suppl 2:S8-15, 2014
Pinkas D et al: Management of malunion of the proximal humerus: current concepts. J Am Acad Orthop Surg. 22(8):491-502, 2014
Rao SK et al: A literature review and case series of accelerating fracture healing in postmenopausal osteoporotic working women. J Orthop. 11(3):150-2, 2014
Richard RD et al: Techniques for the surgical treatment of distal tibia fractures. Orthop Clin North Am. 45(3):295-312, 2014
Scolaro JA et al: Cigarette smoking increases complications following fracture: a systematic review. J Bone Joint Surg Am. 96(8):674-81, 2014
Blokhuis TJ et al: Autograft versus BMPs for the treatment of non-unions: what is the evidence? Injury. 44 Suppl 1:S40-2, 2013
Geusens P et al: NSAIDs and fracture healing. Curr Opin Rheumatol. 25(4):524-31, 2013
Hobby B et al: Managing atrophic nonunion in the geriatric population: incidence, distribution, and causes. Orthop Clin North Am. 44(2):251-6, 2013
Balogh ZJ et al: Advances and future directions for management of trauma patients with musculoskeletal injuries. Lancet. 380(9847):1109-19, 2012
Bishop JA et al: Assessment of compromised fracture healing. J Am Acad Orthop Surg. 20(5):273-82, 2012
Haase SC et al: Management of malunions of the distal radius. Hand Clin. 28(2):207-16, 2012
Taljanovic MS et al: Imaging and treatment of scaphoid fractures and their complications. Semin Musculoskelet Radiol. 16(2):159-73, 2012
Dijkman BG et al: When is a fracture healed? Radiographic and clinical criteria revisited. J Orthop Trauma. 24 Suppl 1:S76-80, 2010
Pape HC et al: Trauma-induced inflammation and fracture healing. J Orthop Trauma. 24(9):522-5, 2010
Lynch JR et al: Femoral nonunion: risk factors and treatment options. J Am Acad Orthop Surg. 16(2):88-97, 2008
Calori GM et al: Risk factors contributing to fracture non-unions. Injury. 38 Suppl 2:S11-8, 2007
Giannoudis P et al: Can we accelerate fracture healing? A critical analysis of the literature. Injury. 38 Suppl 1:S81-9, 2007
Jagodzinski M et al: Effect of mechanical stability on fracture healing--an update. Injury. 38 Suppl 1:S3-10, 2007
Bhattacharyya T et al: The accuracy of computed tomography for the diagnosis of tibial nonunion. J Bone Joint Surg Am. 88(4):692-7, 2006
Blokhuis TJ et al: The reliability of plain radiography in experimental fracture healing. Skeletal Radiol. 30(3):151-6, 2001
Wade R et al: Outcome in fracture healing: a review. Injury. 32(2):109-14, 2001
McKinley DW et al: Follow-up radiographs to detect callus formation after fractures. Arch Fam Med. 9(4):373-4, 2000
Hayda RA et al: Pathophysiology of delayed healing. Clin Orthop Relat Res. S31-40, 1998
Marsh D: Concepts of fracture union, delayed union, and nonunion. Clin Orthop Relat Res. S22-30, 1998
Chew FS: Skeletal Radiology: The Bare Bones. 2nd ed. Williams & Wilkins, 1997
Chapman S: The radiological dating of injuries. Arch Dis Child. 67(9):1063-5, 1992