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Fracture Healing
Kirkland W. Davis, MD, FACR; Corrie M. Yablon, MD
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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

                                1. Schwarzenberg P et al: Imaging modalities to assess fracture healing. Curr Osteoporos Rep. 18(3):169-79, 2020
                                2. Schlickewei CW et al: Current and future concepts for the treatment of impaired fracture healing. Int J Mol Sci. 20(22), 2019
                                3. Zura R et al: Epidemiology of fracture nonunion in 18 human bones. JAMA Surg. 151(11):e162775, 2016
                                4. Alkhawashki HM: Shock wave therapy of fracture nonunion. Injury. 46(11):2248-52, 2015
                                5. Emara KM et al: Recent biological trends in management of fracture non-union. World J Orthop. 6(8):623-8, 2015
                                6. Oryan A et al: Bone injury and fracture healing biology. Biomed Environ Sci. 28(1):57-71, 2015
                                7. Schaden W et al: Extracorporeal shockwave therapy (ESWT) - first choice treatment of fracture non-unions? Int J Surg. 24(Pt B):179-83, 2015
                                8. Tulipan J et al: The effect of osteoporosis on healing of distal radius fragility fractures. Orthop Clin North Am. 46(4):541-9, 2015
                                9. Yue B et al: Delayed healing of lower limb fractures with bisphosphonate therapy. Ann R Coll Surg Engl. 97(5):333-8, 2015
                                10. Augat P et al: Imaging techniques for the assessment of fracture repair. Injury. 45 Suppl 2:S16-22, 2014
                                11. Hak DJ et al: Delayed union and nonunions: epidemiology, clinical issues, and financial aspects. Injury. 45 Suppl 2:S3-7, 2014
                                12. Hankenson KD et al: Biological perspectives of delayed fracture healing. Injury. 45 Suppl 2:S8-15, 2014
                                13. Pinkas D et al: Management of malunion of the proximal humerus: current concepts. J Am Acad Orthop Surg. 22(8):491-502, 2014
                                14. 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
                                15. Richard RD et al: Techniques for the surgical treatment of distal tibia fractures. Orthop Clin North Am. 45(3):295-312, 2014
                                16. Scolaro JA et al: Cigarette smoking increases complications following fracture: a systematic review. J Bone Joint Surg Am. 96(8):674-81, 2014
                                17. Blokhuis TJ et al: Autograft versus BMPs for the treatment of non-unions: what is the evidence? Injury. 44 Suppl 1:S40-2, 2013
                                18. Geusens P et al: NSAIDs and fracture healing. Curr Opin Rheumatol. 25(4):524-31, 2013
                                19. Hobby B et al: Managing atrophic nonunion in the geriatric population: incidence, distribution, and causes. Orthop Clin North Am. 44(2):251-6, 2013
                                20. Balogh ZJ et al: Advances and future directions for management of trauma patients with musculoskeletal injuries. Lancet. 380(9847):1109-19, 2012
                                21. Bishop JA et al: Assessment of compromised fracture healing. J Am Acad Orthop Surg. 20(5):273-82, 2012
                                22. Haase SC et al: Management of malunions of the distal radius. Hand Clin. 28(2):207-16, 2012
                                23. Taljanovic MS et al: Imaging and treatment of scaphoid fractures and their complications. Semin Musculoskelet Radiol. 16(2):159-73, 2012
                                24. Dijkman BG et al: When is a fracture healed? Radiographic and clinical criteria revisited. J Orthop Trauma. 24 Suppl 1:S76-80, 2010
                                25. Pape HC et al: Trauma-induced inflammation and fracture healing. J Orthop Trauma. 24(9):522-5, 2010
                                26. Lynch JR et al: Femoral nonunion: risk factors and treatment options. J Am Acad Orthop Surg. 16(2):88-97, 2008
                                27. Calori GM et al: Risk factors contributing to fracture non-unions. Injury. 38 Suppl 2:S11-8, 2007
                                28. Giannoudis P et al: Can we accelerate fracture healing? A critical analysis of the literature. Injury. 38 Suppl 1:S81-9, 2007
                                29. Jagodzinski M et al: Effect of mechanical stability on fracture healing--an update. Injury. 38 Suppl 1:S3-10, 2007
                                30. 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
                                31. Blokhuis TJ et al: The reliability of plain radiography in experimental fracture healing. Skeletal Radiol. 30(3):151-6, 2001
                                32. Wade R et al: Outcome in fracture healing: a review. Injury. 32(2):109-14, 2001
                                33. McKinley DW et al: Follow-up radiographs to detect callus formation after fractures. Arch Fam Med. 9(4):373-4, 2000
                                34. Hayda RA et al: Pathophysiology of delayed healing. Clin Orthop Relat Res. S31-40, 1998
                                35. Marsh D: Concepts of fracture union, delayed union, and nonunion. Clin Orthop Relat Res. S22-30, 1998
                                36. Chew FS: Skeletal Radiology: The Bare Bones. 2nd ed. Williams & Wilkins, 1997
                                37. Chapman S: The radiological dating of injuries. Arch Dis Child. 67(9):1063-5, 1992
                                38. Rogers LF: Radiology of Skeletal Trauma. 2nd ed. Churchill Livingstone, 1992
                                39. 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

                                                              1. Schwarzenberg P et al: Imaging modalities to assess fracture healing. Curr Osteoporos Rep. 18(3):169-79, 2020
                                                              2. Schlickewei CW et al: Current and future concepts for the treatment of impaired fracture healing. Int J Mol Sci. 20(22), 2019
                                                              3. Zura R et al: Epidemiology of fracture nonunion in 18 human bones. JAMA Surg. 151(11):e162775, 2016
                                                              4. Alkhawashki HM: Shock wave therapy of fracture nonunion. Injury. 46(11):2248-52, 2015
                                                              5. Emara KM et al: Recent biological trends in management of fracture non-union. World J Orthop. 6(8):623-8, 2015
                                                              6. Oryan A et al: Bone injury and fracture healing biology. Biomed Environ Sci. 28(1):57-71, 2015
                                                              7. Schaden W et al: Extracorporeal shockwave therapy (ESWT) - first choice treatment of fracture non-unions? Int J Surg. 24(Pt B):179-83, 2015
                                                              8. Tulipan J et al: The effect of osteoporosis on healing of distal radius fragility fractures. Orthop Clin North Am. 46(4):541-9, 2015
                                                              9. Yue B et al: Delayed healing of lower limb fractures with bisphosphonate therapy. Ann R Coll Surg Engl. 97(5):333-8, 2015
                                                              10. Augat P et al: Imaging techniques for the assessment of fracture repair. Injury. 45 Suppl 2:S16-22, 2014
                                                              11. Hak DJ et al: Delayed union and nonunions: epidemiology, clinical issues, and financial aspects. Injury. 45 Suppl 2:S3-7, 2014
                                                              12. Hankenson KD et al: Biological perspectives of delayed fracture healing. Injury. 45 Suppl 2:S8-15, 2014
                                                              13. Pinkas D et al: Management of malunion of the proximal humerus: current concepts. J Am Acad Orthop Surg. 22(8):491-502, 2014
                                                              14. 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
                                                              15. Richard RD et al: Techniques for the surgical treatment of distal tibia fractures. Orthop Clin North Am. 45(3):295-312, 2014
                                                              16. Scolaro JA et al: Cigarette smoking increases complications following fracture: a systematic review. J Bone Joint Surg Am. 96(8):674-81, 2014
                                                              17. Blokhuis TJ et al: Autograft versus BMPs for the treatment of non-unions: what is the evidence? Injury. 44 Suppl 1:S40-2, 2013
                                                              18. Geusens P et al: NSAIDs and fracture healing. Curr Opin Rheumatol. 25(4):524-31, 2013
                                                              19. Hobby B et al: Managing atrophic nonunion in the geriatric population: incidence, distribution, and causes. Orthop Clin North Am. 44(2):251-6, 2013
                                                              20. Balogh ZJ et al: Advances and future directions for management of trauma patients with musculoskeletal injuries. Lancet. 380(9847):1109-19, 2012
                                                              21. Bishop JA et al: Assessment of compromised fracture healing. J Am Acad Orthop Surg. 20(5):273-82, 2012
                                                              22. Haase SC et al: Management of malunions of the distal radius. Hand Clin. 28(2):207-16, 2012
                                                              23. Taljanovic MS et al: Imaging and treatment of scaphoid fractures and their complications. Semin Musculoskelet Radiol. 16(2):159-73, 2012
                                                              24. Dijkman BG et al: When is a fracture healed? Radiographic and clinical criteria revisited. J Orthop Trauma. 24 Suppl 1:S76-80, 2010
                                                              25. Pape HC et al: Trauma-induced inflammation and fracture healing. J Orthop Trauma. 24(9):522-5, 2010
                                                              26. Lynch JR et al: Femoral nonunion: risk factors and treatment options. J Am Acad Orthop Surg. 16(2):88-97, 2008
                                                              27. Calori GM et al: Risk factors contributing to fracture non-unions. Injury. 38 Suppl 2:S11-8, 2007
                                                              28. Giannoudis P et al: Can we accelerate fracture healing? A critical analysis of the literature. Injury. 38 Suppl 1:S81-9, 2007
                                                              29. Jagodzinski M et al: Effect of mechanical stability on fracture healing--an update. Injury. 38 Suppl 1:S3-10, 2007
                                                              30. 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
                                                              31. Blokhuis TJ et al: The reliability of plain radiography in experimental fracture healing. Skeletal Radiol. 30(3):151-6, 2001
                                                              32. Wade R et al: Outcome in fracture healing: a review. Injury. 32(2):109-14, 2001
                                                              33. McKinley DW et al: Follow-up radiographs to detect callus formation after fractures. Arch Fam Med. 9(4):373-4, 2000
                                                              34. Hayda RA et al: Pathophysiology of delayed healing. Clin Orthop Relat Res. S31-40, 1998
                                                              35. Marsh D: Concepts of fracture union, delayed union, and nonunion. Clin Orthop Relat Res. S22-30, 1998
                                                              36. Chew FS: Skeletal Radiology: The Bare Bones. 2nd ed. Williams & Wilkins, 1997
                                                              37. Chapman S: The radiological dating of injuries. Arch Dis Child. 67(9):1063-5, 1992
                                                              38. Rogers LF: Radiology of Skeletal Trauma. 2nd ed. Churchill Livingstone, 1992
                                                              39. Hulth A: Current concepts of fracture healing. Clin Orthop Relat Res. 265-84, 1989