TRAUMA

Introduction
In everyday life people of all ages commonly experience traumatic lesions of the skeleton. The
radiologic examination is often pivotal in the diagnosis and management of such injuries. To
neglect to obtain radiographs in cases of trauma may have serious medicolegal ramification. The
first alleged malpractice for failure to take a radiograph in the evaluation of trauma was in April
1896 in Denver, only four months after the discovery of x-rays. (1) when a fracture or dislocation
is identified, key features must be evaluated and reported. (Tables 9.1 and 9.2)
Successful treatment of fractures starts with accurate diagnosis, which requires a well-performed
and accurately interpreted radiographic examination. The minimum examination is considered to
be two radiographs at 90
0
to each other; anything less is considered an incomplete examination.
The standard recommended series for each body part is clearly outlined in the positioning
component of Chapter 1.
The purpose of this chapter is to familiarize the reader with the most common types of fractures
and dislocations. The chapter is organized by body region and includes an introductory section
on descriptive terminology, definitions, and the process of fracture repairs.
Types of Fractures
Terminology
Closed Fracture
A closed fracture doesnt break the skin or communicate with the outside environment. (Fig. 9.
1A) The older term used for this type of fracture was simple.
Open Fracture
An open fracture is one that penetrates the skin over the fracture site. (Fig. 9.1B) The older term
for this type of fracture was compound, which is confusing and generally discarded.
Comminuted Fracture
A comminuted fracture is a fracture from which two or more bony fragments have separated.
(Fig. 9.2A and B) If a triangular cortical fragment is isolated, this is called a butterfly
fragment, which is usually found on the concave side of the injury. (2)
Noncomminuted Fracture
A noncomminuted fracture is one that penetrates completely through the bone, separating the
bone into two fragments. (Fig. 9.2C and D)
Avulsion Fracture
An avulsion fracture exhibits the tearing away of a portion of the bone by a forceful muscular or
ligamentous pulling. (Fig.9.3) Frequent sites are the tuberosities of tubular bones and the lower
cervical spinous processes.
Impaction Fracture
An impaction fracture occurs when a portion of bone is driven into its adjacent segment. Because
of the compressive forces, the radiolucent fracture line is seldom visualized; instead, a subtle
radiopaque white line is seen in the region of impaction. (Fig.9.4) There are two subtypes of
impaction fractures.
Table 9.1. key features to Identifying and Classifying a Fracture
Fracture Type
- Skin penetration
- Comminution
- Mechanism (avulsion, impaction, etc)
- Complete/incomplete
- Pathologic
- Stress
Fracture Orientation
- Oblique
- Transverse
- Spiral
Spatial Relationships
- Aligment
- Apposition
- Rotation
Soft Tissue Involvement

Table 9.2. key Features to Identifying and Classifying Dislocations
Position
- Relative to proximal bone
Type
- Subluxation
- Dislocation
- Diastasis
Associated Fractures

Depressed Fracture. This type of fracture represents an inward bulging of the outer bonne
surface. (1) Two characteristic sites for depressed fractures are the tibial plateau frontal bone.
Compression Fracture. There is decreased size of the involved bone due to trabecular
telescoping, occurring primarily in the spine following a forceful hyperflexion injury. The
vertebral endplates are driven toward each other, creating compression of the intervening spongy
bone. (1)
The mechanism of injury in impaction and compression fractures is similar, with the term
compression fracture used for fractures of the vertebrae and impaction fracture primarily for
those bones of the appendicular skeleton, the most common of which is the femoral neck. (Fig.
9.5A and B)
Incomplete Fracture
Incomplete fractures are broken on only one side of the bone, leaving a buckling or bending of
the bone as the only sign of fracture. (1) Angular deformity is common; however, no
displacement is expected. The following represent various types of incomplete fracture.
Greenstick (Hickory Stick) Fracture. This occurs primarily in infants and children under the
age of 10 because of the relatively greater component of pliable woven bone. The bone bends
applying tension to the convex side, producing a transverse fracture with the concave side
remaining intact. (1) (Fig. 9.6A) Greenstick fractures heal without any complications in most
instance.
Torus (Buckling) Fracture. Due to compression forces the cortex bulges outward. (1) Most
occur in the metaphysic, are very painful and a special variety of greenstick fracture. The term
torus is derived from the Latin root meaning to bulge. (Fig. 9.6B) This has been likened to the
cap at the tip or base of a Greek column or pillar.
Infraction
This type of fracture is actually a form of impaction fracture that is only moderately severe in
nature. (1) It is used to explain a minor localized break in the cortex, leaving minimal bone
deformity.
Chip (Corner) Fracture
This represents a form of avulsion fracture that is usually limited, demonstrating the separation
of a small chip of bone from the corner of a phalanx or other short or long tubular bone. (1) (Fig.
9.7)
Pathologic Fracture
A pathologic fracture is a fracture through a bone that is weakened by a localized or systemic
disease process. The orientation of pathologic fractures are usually transverse and often appear
quite smooth. (1) (Fig.9.8A and B)
Stress (Fatigue) Fracture
A stress fracture is caused by repetitive stress, causing gradual formation of microfractures and,
eventually, an interruption in the bone structure of a grater rate than can be offset by the
reparative process. (Fig.9.9) It represents an actual ffatigue failure of the bone. A stress fracture
through a diseased bone is called an insufficiency fracture. (1,2)
Occult Fracture, Bone Bruise
An occult fracture is one in which the fracture gives clinical signs of its presence without any
radiologic evidence. Often, follow-up radiologic examination, usually within seven to ten days,
reveals resorption of bone at the fracture site or frank displacement. The most common occult
fracture site involves the carpal navicular (scaphoid), with the ribs being the second most
common site. Occult fractures in the spine are very rare.
The phenomenon of bone bruise has only come to light with the application of MR imaging in
traumatic injuries. Its presumed to represent hemorrhage and edema associated with trabecular
microfractures, usually beneath an adjacent joint surface. (3) It appears as an area of high signal
intensity on T2-weighted images and on T1-weighted speckled area of low signal intensity.
(Fig.9.10)
Pseudofracture
A pseudofracture isnt a true fracture. Its thought that it actually represents an insufficiency
fracture or is due to vascular pulsations. (3) Histologically, pseudofractures are discrete regions
of uncalcified osteoid. Radiographically, they appear as linear lucencies on the convex surface of
the bone that are oriented at 90
0
to the long axis of the bone. (Fig. 9.11) They are often multiple
and found in association with bone-softening diseases such as Pagets disease, rickets,
osteomalacia, and fibrous dysplasia. Various synonyms are applied to psuedofractures, including
Loosers line, Milkmans syndrome, increment fractures, and umbauzonen.
Stable and Unstable Fracture
Assessing stability of a fracture may require determination of a number of criteria, depending on
location. In general, a stable fracture is one that doesnt move nor is likely to move during the
healing phase. In the spine the major consideration is the threat to adjacent neurologic structures,
especially the cord. A stable spinal fracture has little probability of producing neurologic
compromise.
Fracture Orientation
Oblique Fracture
The oblique fracture commonly occurs in the shaft of a long tubular bone. (2) Its course is
approximately 45
0
to the long axis of the bone.
Spiral Fracture
Torsion, coupled with axial compression and angulation, creates a spiral fracture. In contrast to
the blunt-ended oblique fracture, the ends of a spiral fracture are pointed like a pen. (2)
Transverse Fracture
A transverse fracture runs at a right angle to the long axis of a bone. This type of fracture is
uncommon through healthy bone, but is frequently seen in diseased bone (pathologic fracture).
An example of this type of fracture is the banana transverse pathologic fracture associated with
Pagets disease of bone. (2) (Fig. 9.8A and B)
Spatial Relationships of Fracture
Alignment
The alignment of a fracture is described as the position of the distal fragment in relation to the
proximal fragment. Fractures are in good alignment when there is no perceptible angulation in
frontal and side views. The relationship of fracture fragments must be accurately described in the
x-ray report, especially when reduction is anticipated. (1)
Apposition
The appositional state of the fracture site concerns the closeness of the bony contact at the
fracture site. Good apposition means near complete surface contact of the fractured area. Partial
apposition refers to partial bony contact. If the fractured ends are pulled apart by muscle force
therapeutic traction, its reffered to as distraction.
Rotation
Twisting forces on a fractured bone along its longitudinal axis produce rotational deformity.
Inclusion of the proximal and distal joints on the film is necessary in determining rotation
malposisition. (1)
Traumatic Articular Lesions
Subluxation
Subluxation occurs when there is a partial loss of contact between the usual articular surface
components of a joint. (Fig.9.12A and B) The joint surfaces are incongruous, but a significant
portion remains apposed. (2)
Dislocation (Luxation)
Dislocation refers to a complete loss of contact between the usual articular components of a joint.
(Fig.9.12C) When found associated with a fracture, its referred to as a fracture dislocation. In
the extremities a dislocated bone is always described in relation to the proximal bone. In the
spine the dislocated segment is described relative to the segment below. (1)
Diastasis
Diastasis represent displacement or frank separation of a slightly movable joint (syndemosis). (1)
The most common locations for this occur are the pubic symphysis, sutures of the skull, or the
distal tibiofibular syndesmosis. (Fig.9.13) A separated suture is a diastatic fracture. (2)
Chondral and Osteochondral Fractures
A fracture through a joint surface may result from shearing, rotary, or tangential impaction
fractures. The fracture fragment may consist of cartilage only (chondral fractures) or cartilage
and underlying bone (osteochondral fractures). (2) The condition of osteochondritis dissecans is
an example of an osteochondral fracture seen to involve convex surfaces of the femoral
condyles, talar dome, and capitulum.
Epiphyseal Fracture
SALTER-HARRIS Classification
A classification system of growth plate injuries based on the radiologic findings was proposed by
Salter and Harris in 1963. (4) this system has gained widespread acceptance in the standard
description and predicting prognosis of epiphyseal injuries. Essentially, the components involved
in the fracture determine its classification type. (Fig.9.14) (Table 9.3)
Salter-Harris Type I
This represent isolated fracture through the growth plate. (Fig 9.15A) Usually, the radiograph
appears normal, with the diagnosis being made clinically because of tenderness over the
epiphyseal plate and soft tissue swelling. This type of fracture can complicate scurvy, rickets,
osteomyelitis, and hormone imbalance, presenting often as a slipped capital femoral epiphysis.
Selter-Harris Type II
This is a fracture through the displaced growth plate, which carries with it a corner of the
metaphysic. (Fig.9.15B) The metaphyseal fragment has been called the Thurston-Hollad sign
(5) This is the most common epiphyseal injury, comprising approximately 75% of cases. (6) The
most common sites are the distal radius (50%), as well as the tibia, fibula, femur, and ulna. (6)
The epiphyseal separation is usually easily reduced and the prognosis is generally favorable. (6)




Table 9.3. Salter-Harris Classification of Epiphyseal Injuries
Fracture Site
Type Growth Plate Metaphysis Ephphysis
I *
II * *
III * *
IV * * *
V Compression

Selter-Harris Type III
The fracture line is directed along the growth plate and then turns toward the epiphysis.
(Fig.9.15C) It results in intraarticular fracture that may require open reduction treatment. The
most frequent site is the distal tibia. (6)
Salter-Harris Type IV
This is an obliquely oriented, vertical fracture that passes through the epiphysis, growth plate,
and metaphysic. (Fig.9.15D) The fracture fragment consists of a portion each of the metaphysic,
growth plate, and epiphysis. The most common sites are the lateral condyle of the distal humerus
in patients under 10 years of age, and the distal tibia in those over the age of 10. Prognosis is
poor without expedient open reduction and internal fixation and may result in permanent
deformity. (4)
Salter-Harris Type V
This injury is the least common of all the Salter-Harris epiphyseal lesions, resulting in a
compressive deformity of the growth plate. Initially, the radiographs are normal, until cessation
of growth creates bone shortening or partial arrest, which leads to progressive angular deformity.
(1) These children should be monitored for at least years following injury to ensure that the
normal growth of bone is occurring at the growth plate. The most common sites are the distal
tibial and distal femoral epiphyseal centers. (6)
Fracture Repair
THREE PHASES OF HEALING
Circulatory of Inflammatory Phase
The initial circulatory of inflammatory phase is conveniently subdivided into three distinct
phases-cellular (with hematoma) vascular, and primary callus-each phase lasting approximately
10 days. (7)
Cellular phase. Trauma sufficient to cause fracture in bone also damages the overlying muscle,
tendon, periosteum, numerous blood vessels, and marrow tissue, resulting in hematoma or clot
information. (8) The injured cells, as well as the hematoma, incite a cellular inflammatory
response that is particularly prominent during the first 5 days of the fracture. Surviving cells in
the area injury, and new cells brought in by the granulation tissue, create a blastema of
undifferentiated mesenchymal cells. This granulation tissue invades and replaces the hematoma.
These cells are ultimately capable of modulating into the mature components of callus.
Vascular phase. The cellular phase is promptly followed by the vascular phase. A specialized
circulatory network develops around the fracture. This network consists of dilated tributaries of
major vessels that form around the periphery of the injured area and a central swamplike area of
wide-open capillaries, resulting in formation of a vascular spindle. Following injury, the blood
flow of the entire limb is augmented, with active hyperemia at the edges of the injured area. The
vigorous blood flow in the arteries and arterioles is slowed when it reaches the vascular
swamp, and passive hyperemia or congestion occurs. This passive hyperemia promotes active
secretion of osteoid matrix by the mesenchymal cells that have migrated into the area.
The active hyperemia on the periphery of the vascular spindle, by reason of its high-speed and
well-oxygenated blood flow, induces osteoclastic activity in the cortex surrounding the fracture,
which is easily demonstrable on sequential radiograph. It also activates the vascular bed of the
old growth plate and subchondral plate, producing radiographically identifiable subchondral and
submetaphyseal resorption bands. Augmented circulation to the entire limb also produces
hypertrichosis due to stimulation of hair follicles and tanning of the skin from stimulation of the
melanocytes.
Trauma in the muscle and stripping of the periosteum add to the initial fracture hematoma.
Periosteal cells adjacent to the fracture become activated, reproduce, and secrete a matrix about
themselves that, in effect, elevates the periosteum. Simultaneously, changes take place in the
injured muscle tissue outside the periosteum, with granulation tissue replacing muscle cells.
These cells then give rise to mature callus. As the process continues, a new periosteum forms at
the line of demarcation between the normal muscle and callus. This periosteal callus when
mineralized, may produce a Codmans triangle on radiographs.
Primary Callus Phase. Callus is the plastic exudates and tissue that develops around the ends of,
and ultimately unites, the fracture fragments. (2) The term is derived from the Latin word callum,
meaning hard or thickened.
Once the vascular phase is well established, more and more raw material become available.
Cellular elements arise from injured bone, connective tissue, marrow, and muscle to form
undifferentiated mesenchymal cells. Whether these cells are modulated rhabdomyoblasts,
fibroblasts, or osteoblasts or are new cells arising out of the necrotic tissue has not been resolved;
nevertheless, muscle, connective tissue, and bone marrow are all essential in producing a
blastema that accounts for approximately 70% of the callus in a femur shaft fracture. High-speed
deposition of osteoid occurs in the form of coarsely woven bone, deposited in a more or less
haphazard fashion in the area of the fracture. This osteoid becomes mineralized, and earliest
radiographic visualization occurs after 14 days. Depending on the degree of motion and
vascularization, cartilage is formed within the callus at the same time.
The development of this primitive material in the blastemal zone represents the formation of the
primary callus. The first stage of fracture healing can be summarized as (a) necrosis, hematoma
(approximately ten days), (b) vascular spindle formation (approximately ten days), and (c)
primary callus.
Reparative or Metabolic Phase
This is the second phase of fracture healing and is characterized by a more ordely secretion of
callus and the removal and replacement of coarsely woven osteoid by a more mature form of
bone. The process is one of remodeling, mimicking the generalized remodeling processes that
occur during normal growth and development. The callus can be divided into separate entities,
separated more by nomenclature than by function, and are identifiable as sealing, buttressing,
bridging, and uniting callus. Buttressing callus is adjacent to the outer surface of the cortex and is
formed by the periosteum as well as surrounding skeletal musculature. Sealing callus fills the
medullary cavity and arises from the marrow to seal it from the fracture side. Bridging callus
unites the gap between the two buttress ends and uniting callus joins the cortical of the fracture
bone. Clinical union is achieved when the callus is sufficiently developed to allow weight
bearing or similar stress.
Remodeling or Mechanical Phase
The final phase in fracture repair is the remodeling or mechanical phase, which involves
realignment and remodeling of bone and callus along lines of stress. Extra bone is deposited in
stress line and removed in areas in which stress in not applied (Wolffs law). The final stage of
fracture healing is restoration of the medullary cavity and bone marrow.
The sequence of events in the healing of a fracture, as described previously, has definite practical
consequences in the management of the patient.
Although a hematoma is not essential to the healing of a fracture, the hematoma plays a role in
inducing granulation tissue response. The greater the response, the more cellular the granulation
tissue and the better the ultimate callus. Therefore, the less disturbance of the hematoma, the
better.
Large necrotic bone fragments will have to be removed by phagocytic processes and may impede
callus formation. Sequestered bone fragments may require removal to help the healing process.
Injury induces increased vascularity, which promotes callus. Injured soft tissue should therefore
be left alone. Muscl contributes extensively to formation of callus and is richly vascularized; it
should be minimally disturbed, despite injury. Poor fracture healing usually occurs in bones with
little or no adjacent musculature.
Clinical healing will preced anatomic reconstitution. Extensive remodeling will proceed for years
after the fracture; therefore, realignment of fracture should emphasize maintained viable bone
and all fragments within the field of the vascular spindle. Anatomic reconstitution will usually
occur as a consequence of extensive remodeling and does not require exact replacement of
fracture fragments.
RADIOLOGIC FEATURES OF FRACTURE HEALING
Within the first five days following fracture, resorption of the fracture line occurs, creating an
increase in width of the actual fracture line. (Fig.9.16A and B) In the following 10 to 30 days a
veil of new bone formation occurs adjacent to the fracture site (callus). (Fig.9.16C) Gradually,
the callus formation is remodeled, filling in the previous area of cortical disruption. (Fig.9.16D)
This entire healing process takes 4 to 6 weeks in the young patient and 6 to 1 weeks in the
geriatric patient.
COMPLICATIONS OF FRACTURE
Complications of fractures are multiple. (Table 9.4) These may arise at different times following
injury and be conveniently divided into immediate, intermediate, and delayed complications. (2)












Table 9.4. Complications of Fracture
Immediate complications
Arterial injury
Compartment syndrome
Gas gangrene
Fat embolism syndrome
Thromboembolism
Intermediate complications
Osteomyelitis
Hardware failure
Reflex sympathetic dystrophy syndrome
Posttraumatic osteolysis
Refracture
Myositis ossificans
Synostosis
Delayed union
Delayed complications
Osteonecrosis
Degenerative joint disease
Lead arthrophy and toxicity
Osteoporosis
Aneurysmal bone cyst
Nonunion
Malunion


IMMEDIATE COMPLICATIONS
Arterial Injury
Vascular injury may accompany fractures, especially open and comminuted injuries. The
popliteal artery is the most common artery injured following fractures of the distal femur or
proximal tibia or knee dislocation. The second most common site is the superficial femoral artery
at the adductor canal. Other less frequent sites include the brachial artery in supracondylar
fractures of the humerus or elbow dislocation, aortic arch in sternal fractures, iliac arteries in
pelvic fractures, and axillary artery in shoulder dislocation or upper rib fractures.
Compartment Syndrome
A continuing rise in pressure within a closed compartment due to edema and hemorrhage may
compromise perfusion of contained muscules, resulting in permanent necrosis. The anterior tibial
compartment of the leg and anterior forearm (Volkmanns contracture) are the most frequent
regions of invelovement.

Gas Gangrene
Any injury that penetrates the skin or intestine and compromises the blood supply can precipitate
clostridium perfringens infection. This can occur within 1 to 3 days, with the buttocks and thighs
the most frequent sites. The appearance of him linear, parallel, streaks within muscle planes is
characteristic.
Fat Embolism Syndrome
Fracture of a major bone may be associated with pulmonary fat embolism for one ti five days
after. Following fracture the cumulative effects of vasoactive substance and fat hydrolysis within
the marrow act to mobilize emboli. (,9) More than 50% have multiple fractures including the
femur; 30% involve the femur alone; 10% involve the tibia; 5% involve the pelvis and the
remainder of smaller bones. (10)
Tromboembolism
Injuries that result in immobilization and bed rest can precipitate deep vein thrombosis, which
can become a potentially lethal source of pulmonary emboli. Fractures of the hip, pelvis, and
lower extremity are particularly prone to this complication.
INTERMEDIATE COMPLICATIONS
Osteomyelitis
Approximately 15% of open fractures, and those requiring internal fixation with plates and
screws, go on to develop osteomyelitis. (11,12) It is a rare complication of closed fractures. The
most common organism is Staphylococcus aureus, occurring in 60 to 70% of cases. (11) The
most likely sites for secondary osteomyletis are the femur and tibia. Most cases manifest within a
month of occurrence of open fracture or open surgical reduction. (2) The dominant symptom is
pain, and the radiologic features are destructive mont-eaten lesions, sequestra formation, and
periosteal response near the fracture site. (Fig.9.17C)
Hardware Failure
Failure of hardware applied to fractures can be due to loosening, breakage, bending, or
migration. Loosening can be detected by widening of the metal-bone interface and movement.
Migration of pins to distant sites by vascular transport can rarely occur to the heart, aorta, and
great vessels. (13)
Reflex Sympathetic Dystrophy Syndrome
Severe and painful regional osteoporosis following rather trivial trauma is referred to as reflex
sympathetic dystrophy syndrome (RSDS) or Sudecks atrophy. This is a relatively rare
complication of trauma to a limb. A more detailed discussion of this entity is found in Chapter
14.
Posttraumatic Osteolysis
Dissolution of bone following trauma is a poorly understoon disorder peculiar to the distal
calvicle and pubic bones. Posttraumatic osteolysis of the clavicle (PTOC) is themost common
site and follows fracture of the clavicle, acromioclavicular joint trauma, or overuse syndromes of
the sholder especially in athletes. (14,15) This is discussed in more detail later in the chapter.
Refracture
Disruption of the bone at the site of the original fracture is usually secondary to inappropriate
immobilization, noncompliant patient, underlying tumor or infection, or through bone weakened
by surgery such as pin site.
Myositis Ossificans
Heterotopic bone formation at a site trauma can occur alone or in combination with a fracture. It
is recognizable as an increasingly confluent ossification in muscle tissue most commonly at the
thigh or anterior arm. This is discussed in more detail later in this chapter.
Synostosis
Bony fusion between two adjacent bones is most frequent between bones closely opposed, such
as the radius ulna, tibia fibula, and the small bones of the hands and feet. Such a complication
may create significant functional loss of motion.
Delayed Union
Slow bony union across a fracture site may follow inappropriate immobilization, intrinsically
poor vascularity, disease state (diabetes, malignancy, infection, malnutrition) and advancing age.
A number of sites such as the scaphoid, proximal femur and tibia are known to often exhibit
delayed union.
DELAYED COMPLICATIONS
Osteonecrosis
When bone is deprived of its blood spply,it will undergo necrosis. Synonyms for this condition
include avascular necrosis, ischemic necrosis, aseptic necrosis, and osteonecrosis. The crucial
factors in the development of posttraumatic osteonecrosis are the location of the fracture, the
intrinsic vascularity of the bone, and appropriate early treatment. The most common sites in
order of frequenscy for post fracture avascular necrosis are the femoral head, humeral head,
scaphoid, and talus.these and other are discussed in chapter 13.
Degenerative Joint Disease
If a fracture is intraarticular, damage to the articular cartilage can occur. This is seen most
commontly in weight-bearing joints such as the hip, knee, or ankle. Additionally, if the fracture
changes the weight-bearing axis the joint and the alters the distribution of forces across the joint,
degenerative changes may be initiated. The constellation of subsequent arthritic changes
represent secondary degenerative joint disease (posttraumatic arthritis).
Lead Arthorathy and Toxicity
Gunshot wounds may not only produce comminueted fractures, but retention of lead can produce
secondary toxic local and systemic effects. Lead within a joint precipitates a degenerative
arthropathy. Systemic lead intoxication can follow lead pellet breakdown, especially when
located near joint due to the acidity of the fluid and mechanical effects to fragment the metal.(16)
Osteoporosis
Following fracture healing there may be delayed return to full function due to pain, altered
function, nerve palsy, or failure to mobilize. The return of bone density may subsequently be
incomplete.
Aneurysmal Bone Cyst
Although uncommon, aneurysmal bone cyst has been documented to follow a traumatic event.
(17,18) Conversion of subperiosteal hematoma to expansile tumor is the likely mechanism.
Nonunion
Nonunion is a failure to complete osseous fusion across the fracture site. Contributing factors of
nonunion include distraction, inadequate immobilization, infection, or impaired circulation. The
most cmmon site for nonunion are the midclavicle, ulna, and tibia. The radiographyc signs of
nonunion take number af months to develop and include fracture rounding, lack of callus,
sclerosis, and pseudoarthrosis. (Fig. 9.17A and B) (Table 9.5)
Pseudoathrosis is precipitated by inadequate immobilization where motion between the fractured
bony ends constantly shears the small vessels the grow into the fracture site in an attempt to heal.
The callus produced is poorly vascularized and tends to produce cartilage instead of bone.
Continued motion results in myxoid degeneration and liquefaction of yhe cartilage, eith the
formation of a pseudo-joint cavity. This pseudoarthrosis, one established, can be healed only by
refracture, removal of the cartilaginous component, and the reestablishment of a vascular spindle
with newcallus formation.
Malunion
Union is poor anatomic position can produce severe loss of fuctional capacity, especially if joint
mechanics are altered. Shortening of a limb can also result, which may create distant secondary
compensations and stresses such as pelvic unleveling, spinal scoliosis, and altered gait
mechanics.