See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/284094866

Assessment of Fracture Repair

Article  in  Journal of Orthopaedic Trauma · December 2015

DOI: 10.1097/BOT.0000000000000470

CITATIONS READS

4 26

7 authors, including:

Brent D. Bates Paul Tornetta

Geisel School of Medicine at Dartmouth Boston University
10 PUBLICATIONS   16 CITATIONS    328 PUBLICATIONS   9,760 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Nonunion dynamization and exchanges View project

All content following this page was uploaded by Brent D. Bates on 12 November 2017.

The user has requested enhancement of the downloaded file.

 SUPPLEMENT ARTICLE
Assessment of Fracture Repair
Gillian E. Cook, MHSc,*† Brent D. Bates, BSc,*‡ Paul Tornetta, MD,§
Michael D. McKee, MD, FRCSC,*k Saam Morshed, MD, PhD, MPH,¶** Gerard P. Slobogean, MD,††
and Emil H. Schemitsch, MD, FRCSC*k
Summary: Assessment of fracture union is a critical concept in
clinical orthopaedics; however, there is no established “gold standard”
for fracture healing. This review provides an overview of the problems
related to the assessment of fracture healing, examines currently avail-
able tools to determine union, discusses the role of functional outcomes
in the assessment of fracture healing, and finally evaluates healing
outcome measures as they pertain to fracture trials. Because there is
no universally accepted method to determine fracture healing, ortho-
paedic surgeons must rely on a range of tools that can include: radio-
graphic assessment, mechanical assessment, serologic markers, and
clinical evaluation (including functional outcomes). When used in con-
junction, these tools can help to improve the sensitivity and specificity
of determining fracture union. This is furthermore relevant when con-
ducting fracture healing trials, for which there is little consensus
between surgeons or the Food and Drug Administration as to optimal
study endpoints. Such studies should therefore include a composite
outcome measure consisting of radiographic and functional assess-
ments to increase the quality and consistency of fracture healing trials.
Key Words: fracture union, nonunion, serologic markers, functional
outcomes, fracture healing trials
(J Orthop Trauma 2015;29:S57–S61)
INTRODUCTION
The determination of fracture union is a key concept in
clinical orthopaedics; however, there is no established gold
standard for healing. This review provides an overview of the
lack of consensus with regard to the consistent assessment of
healing, examines currently available tools to determine
Accepted for publication September 18, 2015.
From the *Division of Orthopaedic Surgery, Department of Surgery, St. Mi-
chael’s Hospital, Toronto, ON, Canada; †Institute of Biomaterials and Bio-
medical Engineering, University of Toronto, Toronto, ON, Canada;
‡Institute of Medical Science, Faculty of Medicine, University of Toronto,
Toronto, ON, Canada; §Boston University Medical Center, Boston, MA;
kUniversity of Toronto, Toronto, ON, Canada; ¶Orthopaedic Trauma Insti-
tute, Department of Orthopaedic Surgery, University of California, San
Francisco and San Francisco General Hospital, San Francisco, CA;
**Department of Epidemiology and Biostatistics, University of California,
San Francisco and San Francisco General Hospital, San Francisco, CA; and
††Department of Orthopaedics, University of Maryland School of Medi-
cine, Baltimore, MD.
The authors report no conflict of interest.
The authors alone are responsible for the content and writing of this article.
Reprints: Emil H. Schemitsch, MD, FRCSC, St. Michael’s Hospital, Univer-
sity of Toronto, 55 Queen St East, Suite 800, Toronto, ON M5C 1R6,
Canada (e-mail: schemitsche@smh.ca).
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Orthop Trauma  Volume 29, Number 12 Supplement, December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
union, discusses the role of functional outcomes in the
assessment of fracture healing, and finally evaluates the
assessment of healing as it pertains to fracture trials.
WHAT IS THE PROBLEM AND IS THERE
A CONSENSUS?
There are several problems with the assessment of
fracture union: there is no universally accepted gold standard
for healing, most studies show low rates of interobserver and
intraobserver reliability, and there is considerable variation in
radiographic technique, methods, concepts, and scoring
systems, making the interpretation of data from the literature
difficult and confusing. For example, the subtrochanteric
fracture illustrated in Figure 1 demonstrates a lack of healing
medially with subsequent hardware failure, yet the fracture
consolidates without further deformity and a good clinical
result. Does the healing evident on the lateral cortex in the
first radiograph justify the definition of “union” in this case?
Corrales et al1 examined variability in the assessment of frac-
ture healing in 12 orthopaedic trauma articles and found 11
different radiographic criteria for healing, with only 2 studies
assessing the reliability of the radiographic outcomes; they
noted the “lack of consensus” in this area. Miric et al used
15 sets of plain radiographs and 7 surgeons to examine inter-
observer and intraobserver variability in the radiographic
assessment of scaphoid nonunion healing and found kappa
values in the 0.46 to 0.54 range (fair to moderate agreement).
Their conclusion was that “radiographic assessment was not
reliable or reproducible in this setting.”2
Surgeons have attempted to improve the accuracy of
assessing radiographic healing by adding more advanced
imaging studies. Bhattacharyya et al examined the accuracy
of computed tomography (CT) scanning for the diagnosis of
tibial nonunion in 35 patients with equivocal findings. They
compared evaluations of the scans, by 2 radiologists and 1
surgeon, to the gold standard for union (namely union at the
time of surgery or after 6 months of clinical observation).3
The reported kappa values were in the “excellent” range
(0.89) with a sensitivity of 100% for nonunion. However,
the authors did warn that there were 3 false positives (CT
scan defined “nonunion” in a tibia subsequently found to be
united) decreasing the specificity to only 62%.
Using a common clinical scenario, Whelan et al4 inves-
tigated the reliability of fracture healing in the tibia after
intramedullary fixation using 30 sets of radiographs and 4
orthopaedic surgeons. Interestingly, they found excellent in-
traobserver reliability (kappa values of 0.82–0.83) and
www.jorthotrauma.com | S57
 Cook et al J Orthop Trauma  Volume 29, Number 12 Supplement, December 2015

FIGURE 1. A, Anteroposterior radiograph of the hip in a 57-year-old male polytrauma patient who sustained a right sub-
trochanteric fracture. Six months after intramedullary nailing, it is unclear whether the fracture has healed. B, Two months later
the patient developed “squeaking” and slight pain in the hip with fatigue failure of the nail but no fracture displacement apart
from a minor degree of varus collapse. The interpretation of the radiographs was that the lateral aspect of the femur had healed
and the medial side had not, resulting in repetitive cycling of the nail and fatigue failure. The patient elected to have continued
nonoperative treatment. C, An uneventful union of the medial side of the femur with an excellent ensuing clinical result. This case
demonstrates the difficulty of defining union in certain situations.

interobserver reliability (kappa values of 0.70–0.75) in the
surgeons’ ability to agree on the number of cortices bridged
by callus and whether a fracture line was visible or not. They
concluded that the “number of cortices bridged by callus was
a reliable radiographic measure of healing after intramedul-
lary fixation.” In a subsequent study, this same group then
incorporated these findings into a new scoring system, the
radiographic union score for tibial fractures (or RUST).5 By
assigning a numerical grade of 1–3 (depending on fracture
line visibility and the presence or absence of a bridging cal-
lus) to each of the 4 cortices of the tibia visible on standard
anteroposterior and lateral radiographs, they produced
a numerical “score” between 4 and 12. They found that this
RUST score was very consistent, with an “overall agreement”
kappa value of 0.86, and an intraobserver kappa value of
0.88. They proposed that, considering the lack of a gold stan-
dard score, the reliable and reproducible RUST score should
be used and validated in the clinical setting.
In summary, the assessment of fracture healing is of
critical importance to the practicing orthopaedic surgeon and
his or her patient, as many treatment decisions will be made
based on this information. The evaluation of fracture healing
can be optimized using consistent radiographic technique, the
judicious use of advanced imaging, and adherence to
established, reproducible scoring systems.
CURRENT OPTIONS FOR DETERMINING UNION
Determining whether a bone fracture is healed is one of
the most important and fundamental clinical determinations
made in orthopaedics. Recent advancements in imaging
techniques and the introduction of new radiographic scores
have helped decrease the amount of disagreement among
physicians on this topic. Furthermore, a deeper understanding
of the molecular pathways involved in the bone healing
process has led to the emergence of serologic markers as
possible candidates in assessment of fracture union. In addition
to current physician-centered methods, patient-centered ap-
proaches that evaluate quality of life and function are gaining
popularity in the assessment of fracture union. Currently
available tools in the assessment of fracture healing can be
broadly divided into 4 categories: (1) imaging studies; (2)
mechanical assessment; (3) serologic markers; and (4) clinical
examination.
Despite its limitations, radiographic assessment has
remained a crucial tool in determining fracture healing.
Two radiographic scoring systems have been developed that
assess the presence of a bridging callus and the disappearance
of the fracture line; the radiographic union score for hip and
the previously described RUST. The radiographic union score
for hip and RUST increase agreement among surgeons and
radiologists when assessing fracture repair.5–8 It has also been
shown that for patients with diaphyseal tibia fractures, any
cortical bridging on routine postoperative imaging by 4
months is 99% accurate in predicting union.9
CT is superior to plain radiography in the assessment of
union and the visualizing of fracture in the presence of an
abundant callus or overlaying cast,10 or in fractures involving
metaphyseal bone that tend to heal with less callus.11,12 Ultra-
sound is unable to penetrate cortical bone, but there is evi-
dence that it is able to detect callus formation before
radiographic changes are visible.13–16
Mechanical testing measures fracture stiffness and
stability.17,18 With the increased use of internal fixation for

S58 | www.jorthotrauma.com Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 J Orthop Trauma  Volume 29, Number 12 Supplement, December 2015
fracture treatment, methods such as in vivo biomechanical
testing and vibrational analysis cannot be used. However,
information obtained from CT images or other modalities
may allow for virtual stress testing, whereby a simulation
using multiple loading conditions is developed after subtract-
ing the mechanical contribution of fixation, which enables
prediction of outcomes, such as axial compression, bending,
and the area of tissue failure.19
Given what we know about the early local and systemic
molecular changes after a fracture, serologic biomarkers are
gaining popularity as possible early predictors of fracture
healing.20–24 Current biomarkers under investigation assess
either: (1) local or systemic factors regulating the healing
process (transforming growth factor-beta1, vascular endothe-
lial growth factor); or (2) extracellular matrix components that
are produced or degraded during stages of repair (PIIINP,
CTX). Further investigation is required to validate thresholds
that are predictive of fracture repair failure.
Despite the many advancements in fracture assessment
technologies reviewed above, physical examination remains
one of the mainstays of determining fracture union in the
clinical setting. In a recent international survey of 335
orthopaedic surgeons, 88% of participants agreed that radio-
graphic and clinical data are required for adequate definition
of union; the ability to bear weight being the most common
criteria.25 Because patients are likely to regard the process of
healing very differently from physicians, it is critical to use
tools that evaluate patient-reported outcomes. The currently
available patient-reported functional outcome assessment
tools measure either general physical and psychological
health, as in the Short Form-36, or are disease-specific, as
in the disability of the arm, shoulder, and hand or Western
Ontario McMaster Arthritis Index. In the future, computer-
assisted tests that implement item response theory are likely
to streamline the process of gathering patient-reported out-
comes, as evidenced by the National Institutes of Health
PROMISE initiative.26
Fracture healing is a complex process that requires an
effective combination of clinical information and self-
reported outcomes with imaging and, potentially, serologic
biomarkers for accurate measurement.
WHAT IS THE ROLE FOR
FUNCTIONAL OUTCOMES?
Clinical trials have often tried to mirror orthopaedic
practice by defining fracture healing using a combination of
radiographic and clinical parameters.27 Despite the apparent
real-world generalizability of such an approach, clinical trials
struggle with the added responsibility of trying to minimize bias
within their study design and outcome adjudication. As a result,
recent trials have used independent adjudication committees to
determine radiographic union but still typically require a clinical
assessment from the patient’s treatment team.19
Functional outcome instruments offer a supplemental
method for assessing fracture repair directly from the patient’s
perspective. This approach has potential advantages over clini-
cian assessments as it minimizes investigator bias and measure-
ment variation. Patient-reported outcomes are typically measured
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Fracture Repair Assessment
using well-developed questionnaires with established psycho-
metric properties. The features of these instruments help to quan-
tify the validity, reliability, and responsiveness to change that one
can expect from the results. This establishes the limits of mea-
surement error and thereby identifies true changes in function.
Generic health and disease-specific questionnaires have
successfully been used in fracture healing trials. Analysis of
the study to prospectively evaluate reamed intramedullary
nails in tibial fractures trial data demonstrated that the Short
Form-36 physical component summary (SF-36 PCS) and the
Short Musculoskeletal Function Assessment Disability Index
were able to distinguish between healed and nonhealed tibia
fracture patients at 3, 6, and 12 months postinjury.28 Depend-
ing on the time from injury, comparisons between patient
groups showed that healed patients had mean scores 4–8
points higher with the SF-36 PCS and 7–14 points higher
with the Short Musculoskeletal Function Assessment Disabil-
ity Index. These differences were clinically significant and
consistent with the psychometrics of the instruments.
Although the study to prospectively evaluate reamed
intramedullary nails in tibial fractures trial demonstrated
significant differences between the patient-reported outcome
scores of healed and nonhealed tibia fracture patients, using
this information in a clinical trial to define fracture healing
would require an a priori score threshold. The obvious
problem is that a low score would not be specific for
nonunion and would therefore need to be combined with
radiographic determination as well. For example, a nonunion
event could be defined as an SF-36 PCS score less than 45
and evidence of a persistent fracture line on the radiograph. In
an attempt to achieve the psychometric benefits of a functional
outcome questionnaire and the specificity of a focused clinical
assessment for fracture healing, Bhandari et al29 have devel-
oped the Functional IndeX for Trauma. This clinician-based
tool has explicit criteria and grading to assess lower extremity
fracture healing based on weight bearing and pain. To date,
a threshold score defining nonunion has not been published;
however, the instrument has established its validity and inter-
rater reliability, which is a great advancement over indepen-
dent clinician assessments that can vary significantly.
In summary, a reliable and valid method to assess
fracture healing is essential to minimizing bias in clinical
trials and facilitating communication among surgeons. Func-
tional outcomes have several advantages over previous
clinical assessments and offer a potential alternative to
increase the rigor of defining fracture union.
ARE FRACTURE HEALING TRIALS A THING OF
THE PAST: THE CHALLENGE OF FDA
Accelerating fracture repair and achieving higher rates
of union are 2 major concerns among orthopaedic surgeons.
These clinical outcomes, however, are not commonly differ-
entiated in fracture healing trials. Furthermore, the Food and
Drug Administration (FDA) lacks guidelines for successful
fracture healing, resulting in low-quality evidence and incon-
sistencies throughout the literature. To conduct research
leading to higher-level evidence, guidelines for fracture
healing trials must be established.
www.jorthotrauma.com | S59
 Cook et al J Orthop Trauma  Volume 29, Number 12 Supplement, December 2015
Study endpoints must be appropriately selected to allow
for high-level evidence to be obtained from clinical trials. Time
to union is a commonly reported endpoint; however, a specific
time to union is difficult to define, as this measure is limited by
the continuous nature of fracture healing, infrequent follow-up
intervals, and the associated subjective assessment by surgeons
and radiologists. For radiographs of tibial fractures treated with
intramedullary nailing, Whelan et al4 reported sufficient agree-
ment among orthopaedic surgeons on various parameters of
fracture healing (k = 0.57–0.75). However, when compared with
musculoskeletal radiologists, orthopaedic surgeons reported ear-
lier healing (10%–12% earlier),30,31 and a greater number of
patients having achieved union at 12 months (90% vs. 75% with
union, as reported by orthopaedic surgeons and musculoskeletal
radiologists, respectively).32 Percent united might provide a better
measure of fracture repair, as specific time points for assessment
can be standardized. Thus for fracture trials, better endpoints and
more consistent assessment of radiographs by standard sets of
reviewers are required to increase consistency and comparability
across studies, and minimize interrater variability.
Although radiographs provide a noninvasive assessment
of bone formation, functional strength and stability are the
ultimate endpoints for clinical fracture healing. However,
despite the critical importance of positive functional outcomes,
surrogates for fracture healing, such as radiographs, CT, and
ultrasound are often used and reported as primary outcomes in
fracture trials. In a study by Hammer et al,33 127 tibia fractures
were assessed by 7 radiologists for stability and the stage of
radiographic union. Radiologic assessment did not correlate
well with the measured stability, as 44% of the mechanically
stable fractures were determined to have not achieved union,
whereas 55% of the unstable fractures were read as united.
More recently, a systematic review and meta-analysis by Busse
et al34 identified 13 trials investigating the use of low-intensity
pulsed ultrasound for fracture repair. Although pooled study
data suggested a moderate improvement in time to radio-
graphic union, only 5 studies directly measured functional out-
comes, of which a single study demonstrated improved
function. Radiographic imaging is an important clinical tool
for evaluating fracture healing progression; however, radio-
graphs alone cannot accurately ascertain functional repair.
Because functional recovery is the ultimate goal in fracture
healing, a composite measure consisting of comparable radio-
graphic and functional outcomes is fundamental for the success
of clinical trials involving bone fractures.
Fracture healing trials are critical to the improvement of
patient care, yet they are often limited by insufficient or
inappropriate endpoints and outcome measures. Consensus
among orthopaedic surgeons and the FDA is lacking, and
guidelines for fracture healing and trial design are limited. To
increase the quality and consistency of fracture healing trials,
with the ultimate goal of successfully enhancing orthopaedic
practice, surgeon investigators along with the FDA must
establish and implement consistent metrics for fracture healing.
CONCLUSIONS
There is currently no singular method to reliably
determine fracture healing. A number of scoring systems
S60 | www.jorthotrauma.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
for radiographic assessment have been developed to aid in the
consistent assessment of union. However, to ensure fracture
healing from the perspective of both the clinician and the
patient, radiographic assessment must be combined with
functional outcomes measured using well-developed ques-
tionnaires. This combined approach must furthermore be
applied to the development of fracture healing trials, for
which establishment of clear study endpoints is critical to the
design of high-quality, reliable trials.
REFERENCES
1. Corrales LA, Morshed S, Bhandari M, et al. Variability in the assessment
of fracture-healing in orthopaedic trauma studies. J Bone Joint Surg.
2008;90:1862–1868.
 ÐorCevic Z. Radiographic signs of scaphoid union
2. Miric D, Vuckovic C,
after bone grafting: the analysis of inter-observer agreement and intra-
observer reproducibility. Srp Arh Celok Lek. 2005;133:142–145.
3. Bhattacharyya T, Bouchard KA, Phadke A, et al. The accuracy of com-
puted tomography for the diagnosis of tibial nonunion. J Bone Joint
Surg. 2006;88:692–697.
4. Whelan D, Bhandari M, McKee M, et al. Interobserver and intraobserver
variation in the assessment of the healing of tibial fractures after intra-
medullary fixation. J Bone Joint Surg Br. 2002;84:15–18.
5. Whelan DB, Bhandari M, Stephen D, et al. Development of the radio-
graphic union score for tibial fractures for the assessment of tibial frac-
ture healing after intramedullary fixation. J Trauma Acute Care Surg.
2010;68:629–632.
6. Bhandari M, Chiavaras MM, Parasu N, et al. Radiographic union score
for hip substantially improves agreement between surgeons and radiol-
ogists. BMC Musculoskelet Disord. 2013;14:70.
7. Kooistra BW, Dijkman BG, Busse JW, et al. The radiographic union
scale in tibial fractures: reliability and validity. J Orthop Trauma. 2010;
24:S81–S86.
8. Chiavaras MM, Bains S, Choudur H, 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. Skel-
etal Radiol. 2013;42:1079–1088.
9. Lack WD, Starman JS, Seymour R, et al. Any cortical bridging predicts
healing of tibial shaft fractures. J Bone Joint Surg Am. 2014;96:
1066–1072.
10. Braunstein EM, Goldstein SA, Ku J, et al. Computed tomography and
plain radiography in experimental fracture healing. Skeletal Radiol. 1986;
15:27–31.
11. Schnarkowski P, Rédei J, Peterfy CG, et al. Tibial shaft fractures: assess-
ment of fracture healing with computed tomography. J Comput Assist
Tomogr. 1995;19:777–781.
12. Grigoryan M, Lynch JA, Fierlinger AL, et al. Quantitative and qualitative
assessment of closed fracture healing using computed tomography and
conventional radiography 1. Acad Radiol. 2003;10:1267–1273.
13. Craig JG, Jacobson JA, Moed BR. Ultrasound of fracture and bone
healing. Radiol Clin North Am. 1999;37:737–751.
14. Moed BR, Watson JT, Goldschmidt P, et al. Ultrasound for the early
diagnosis of fracture healing after interlocking nailing of the tibia without
reaming. Clin Orthop Relat Res. 1995;310:137–144.
15. Moed BR, Kim EC, van Holsbeeck M, et al. Ultrasound for the early
diagnosis of tibial fracture healing after static interlocked nailing without
reaming: histologic correlation using a canine model. J Orthopaedic
Trauma. 1998;12:200–205.
16. Moed BR, Subramanian S, van Holsbeeck M, et al. Ultrasound for the
early diagnosis of tibial fracture healing after static interlocked nailing
without reaming: clinical results. J Orthop Trauma. 1998;12:206–213.
17. Chehade MJ, Pohl AP, Pearcy MJ, et al. Clinical implications of stiffness
and strength changes in fracture healing. J Bone Joint Surg Br. 1997;79:
9–12.
18. Richardson J, Cunningham J, Goodship A, et al. Measuring stiffness can
define healing of tibial fractures. J Bone Joint Surg Br. 1994;76:389–394.
19. FAITH Investigators. Fixation using alternative implants for the treat-
ment of hip fractures (FAITH): design and rationale for a multi-centre
randomized trial comparing sliding hip screws and cancellous screws on
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
 J Orthop Trauma  Volume 29, Number 12 Supplement, December 2015
revision surgery rates and quality of life in the treatment of femoral neck
fractures. BMC Musculoskelet Disord. 2014;15:219.
20. Bostrom MP. Expression of bone morphogenetic proteins in fracture
healing. Clin Orthop Relat Res. 1998;355:S116–S123.
21. Cox G, Einhorn T, Tzioupis C, et al. Bone-turnover markers in fracture
healing. J Bone Joint Surg Br. 2010;92:329–334.
22. Einhorn TA. The cell and molecular biology of fracture healing. Clin
Orthop Relat Res. 1998;355:S7–S21.
23. Moghaddam A, Müller U, Roth H, et al. Tracp 5b and ctx as osteological
markers of delayed fracture healing. Injury. 2011;42:758–764.
24. Zimmermann G, Henle P, Küsswetter M, et al. Tgf-b1 as a marker of
delayed fracture healing. Bone. 2005;36:779–785.
25. Bhandari M, Fong K, Sprague S, et al. Variability in the definition and
perceived causes of delayed unions and nonunions. J Bone Joint Surg
Am. 2012;94:e109.
26. Promis: Dynamic Tools to Measure Health Outcomes from the Patient
Perspective. Available at: http://www.nihpromis.org. Accessed Decem-
ber 3, 2013.
27. Morshed S, Corrales L, Genant H, et al. Outcome assessment in clinical
trials of fracture-healing. J Bone Joint Surg Am. 2008;90(suppl 1):62–67.
28. Busse JW, Bhandari M, Guyatt GH, et al. Use of both short musculo-
skeletal function assessment questionnaire and short form-36 among
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
View publication stats
Fracture Repair Assessment
tibial-fracture patients was redundant. J Clin Epidemiol. 2009;62:
1210–1217.
29. Bhandari M, Wasserman SM, Yurgin N, et al. Development and pre-
liminary validation of a function index for trauma (fix-it). Can J Surg.
2013;56:E114.
30. Emami A, Larsson A, Petrén-Mallmin M, et al. Serum bone markers after
intramedullary fixed tibial fractures. Clin Orthop Relat Res. 1999;368:
220–229.
31. Kristiansen TK, Ryaby JP, McCabe J, et al. Accelerated healing of distal
radial fractures with the use of specific, low-intensity ultrasound. A
multicenter, prospective, randomized, double-blind, placebo-controlled
study*. J Bone Joint Surg Am. 1997;79:961–973.
32. Jones AL, Bucholz RW, Bosse MJ, et al. Recombinant human bmp-2 and
allograft compared with autogenous bone graft for reconstruction of
diaphyseal tibial fractures with cortical defects. J Bone Joint Surg Am.
2006;88:1431–1441.
33. Hammer RR, Hammerby S, Lindholm B. Accuracy of radiologic assess-
ment of tibial shaft fracture union in humans. Clin Orthop Relat Res.
1985;199:233–238.
34. Busse JW, Kaur J, Mollon B, et al. Low intensity pulsed ultrasonography
for fractures: systematic review of randomised controlled trials. BMJ.
2009;338:b351.
www.jorthotrauma.com | S61