Strategies in Trauma and Limb Reconstruction

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VOLUME 10 , ISSUE 3 ( November, 2015 ) > List of Articles

Original Article

The callus fracture sign: a radiological predictor of progression to hypertrophic non-union in diaphyseal tibial fractures

Saif Salih, C. Blakey, D. Chan, J. C. McGregor-Riley, S. L. Royston, S. Gowlett, D. Moore, Mick Dennison

Keywords : Ilizarov technique, Tibial fracture, Fracture healing, Radiography, X-ray, Hypertrophic non-union

Citation Information : Salih S, Blakey C, Chan D, McGregor-Riley JC, Royston SL, Gowlett S, Moore D, Dennison M. The callus fracture sign: a radiological predictor of progression to hypertrophic non-union in diaphyseal tibial fractures. 2015; 10 (3):149-153.

DOI: 10.1007/s11751-015-0238-y

License: CC BY-NC-SA 4.0

Published Online: 01-12-2013

Copyright Statement:  Copyright © 2015; The Author(s).


We report a radiological sign which predicts progression to hypertrophic non-union for fractures of the tibial diaphysis. Radiographs of 46 tibial fractures were reviewed independently by four orthopaedic trauma surgeons and two musculoskeletal radiologists. Patients were identified from a database of tibial fractures managed with Ilizarov frame fixation. There were 23 fractures that progressed to non-union requiring further surgery. The controls were 23 fractures that had united without need for further surgery at 1-year follow-up. Radiographs selected were the first images taken following frame removal. All radiographs were anonymised and randomized prior to review. Presence of the callus fracture sign was identified in 16 radiographs of the fractures that progressed to non-union, and 7 of the united fracture group. Sensitivity is 69.6 %. Specificity is 91.4 %. Positive and negative predictive values are 88.9 and 75.0 %, respectively. These results compare favourably with computerised tomography for predicting non-union. Intra- and inter-observer reliability was good (κ = 0.68), and moderate (κ = 0.57), respectively. The callus fracture sign is a useful radiological predictor of progression to non-union and may represent insufficient mechanical stability at the fracture site.

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  1. Perren SM (2002) Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br 84:1093-1110
  2. Bucholz RW (2005) Rockwood and green's fractures in adults. Lippincott Williams and Wilkins, Philadelphia
  3. Whelan DB et al (2002) Interobserver and intraobserver variation in the assessment of the healing of tibial fractures after intramedullary fixation. J Bone Joint Surg Br 84:15-18
  4. Panjabi MM, Walter SD, Karuda M, White AA, Lawson JP (1985) Correlations of radiographic analysis of healing fractures with strength: a statistical analysis of experimental osteotomies. J Orthop Res 3:212-218
  5. Fleiss JL (1971) Measuring nominal scale agreement among many raters. Psychol Bull 76:378
  6. Hubert L (1977) Kappa revisited. Psychol Bull 84:289-297
  7. Iwakura T et al (2009) Human hypertrophic nonunion tissue contains mesenchymal progenitor cells with multilineage capacity in vitro. J Orthop Res 27:208-215
  8. Saleh M, Royston S (1996) Management of nonunion of fractures by distraction with correction of angulation and shortening. J Bone Joint Surg Br 78:105-109
  9. Sarmiento A, Sobol P (1984) Prefabricated functional braces for the treatment of fractures of the tibial diaphysis. J Bone Joint Surg Am 66:1328-1339
  10. Hammer RR, Hammerby S, Lindholm B (1985) Accuracy of radiologic assessment of tibial shaft fracture union in humans. Clin Orthop Relat Res (199):233-238
  11. Eastaugh-Waring SJ, Joslin CC, Hardy JRW, Cunningham JL (2009) Quantification of fracture healing from radiographs using the maximum callus index. Clin Orthop 467:1986-1991
  12. Kooistra BW et al (2010) The radiographic union scale in tibial fractures: reliability and validity. J Orthop Trauma 24(Suppl 1):S81-S86
  13. Whelan DB et al (2010) Development of the radiographic union score for tibial fractures for the assessment of tibial fracture healing after intramedullary fixation. J Trauma 68:629-632
  14. Bhattacharyya T et al (2006) The accuracy of computed tomography for the diagnosis of tibial nonunion. J Bone Joint Surg Am 88:692-697
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