Injury 51 (2020) 1693–1695
Contents lists available at ScienceDirect
Injury
journal homepage: www.elsevier.com/locate/injury
Editorial
Radiographic Long Bone Fracture Healing Scores: Can they predict
non-union?
Fracture healing is usually uneventful. However, non-union re-
mains the most common post fracture fixation complication with
an incidence of 5-10% of patients [1], adding a significant burden
to society [2], and dramatically decreasing quality of life [3]. The
prerequisite for fracture healing is the close interaction of appro-
priate biology (osteoinduction, osteoconduction, osteogenesis) with
a sound mechanical environment as outlined in the diamond con-
cept [4,5]. There are multiple etiological factors associated with
the development of a non-union [5]. The unique injury charac-
teristics, including fracture locations with tenuous blood supply
such as the femoral neck, open fractures with extensive soft-tissue
damage, presence of compartment syndrome, infection, amounts
of displacement (pre and post-op), amount of comminution and
bone loss are all critical. Patient factors include sex, age, nutri-
tional status, obesity, diabetes and other endocrinopathies includ-
ing vitamin D deficiency, bone mineral density, peripheral vascular
disease, smoking, alcohol, drugs and presence of multiple injuries
[1,6,7]. Surgeon factors addressing biology including respect of the
soft-tissues, adequate debridement, use of bone grafting as well as
optimizing the mechanical environment (method of reduction and
stability) are also of paramount importance [8,9].
Predicting fracture union is challenging [10], and the progress
of healing is usually analyzed by assessing radiological features of
bone repair [11]. As it would be tremendously helpful to be able to
discriminate early the patients that will progress to union versus
the ones that will develop non-union, it would therefore be useful
to examine whether available radiological scoring systems could be
used in this respect (Table 1).
RUST (Radiographic Union Scale for Tibia) Score
The Radiographic Union Scale for Tibia (RUST) was the first
scoring system to be introduced by Whelan et al. in 2010 [10]. It
consists of scoring the anterior, posterior, lateral and medial cor-
tices of a set of orthogonal radiographs by giving a score of 1 if
the fracture line is visible and there is absence of callus, a score
of 2 if the fracture line is visible and there is callus present and a
score of 3 if the fracture line is not visible and callus is present.
The minimum score is 4, whereas the maximum score is 12. Orig-
inally developed for diaphyseal tibial fractures treated with in-
tramedullary nailing (IMN), several studies have shown that RUST
has substantial inter-observer and intra-observer agreement in this
setting [12–15]. Litrenta et al. [16] studied metaphyseal tibial frac-
tures treated with either nail or plate and found that the reliability
https://doi.org/10.1016/j.injury.2020.07.024
0020-1383/© 2020 Elsevier Ltd. All rights reserved.
of the RUST score was substantial for IMN but moderate for plate
fixation. Furthermore, animal studies show that RUST scores cor-
relates with callus volumes [17] and with biomechanical strength
[18]. In a retrospective case-control study of 323 patients, [19], at
6 weeks following IMN of tibial shaft fractures, a RUST score of
more than 10, predicted 100% union, an intermediate score of 6-
9 predicted 75% union, whereas a low RUST score, i.e. less than
6 predicted 69% of nonunion. In 155 tibial fracture patients from
the SPRINT and FLOW randomized trials who had IMN and lack of
radiographic evidence of healing at the 3-month mark [20], com-
pared to a score of greater than 6, scores of 4 and 5-6 were asso-
ciated with a 47% and 23% of absolute risk increase of nonunion in
a greatly heterogenous group of patients.
Modified RUST (mRUST) scores
Litrenta et al. [16] in 2015 modified the RUST score to further
subdivide the RUST when callus is present to either “present” or
“bridging”, i.e. each cortex was scored as follows: 1 = callus absent,
2 = callus present, 3 = callus bridging, 4 = remodeled, with minimal
value of 4 and maximal value of 16. They assessed it in metadia-
physeal fractures (distal femur and proximal tibia) fixed with nails
or plates and showed higher inter-observer agreement than the
standard RUST [11]. However, it has not yet been applied in pre-
dicting nonunions.
RUSH (Radiographic Union Score in Hip Fractures)
The RUSH consists of a checklist resulting in a score ranging
from 10 to 30 [21]. In 250 patients with a femoral neck fracture
treated with cancellous screws or sliding hip screw a RUSH of less
than 18 at the 6 month mark successfully predicted non-union
with a 100% specificity and 100% positive predictive value and a
10-fold increased probability of undergoing a revision surgery [22].
However, the RUSH score has only fair levels of inter-observer re-
liability, which is improved if the time radiographs are taken is
known, instead of evaluation at an unknown point in time. Notably,
6 out of 7 radiographs taken within 2 weeks after surgery had
been initially been judged as healed fractures, which is impossible
[21]. A recent large multicentre study of 734 patients [23] showed
for a RUSH score at 3-months and 6-months post femoral neck
fracture was predictive of re-operation within 24-months for a
variety of causes, including infection, non-union, delayed healing,
avascular necrosis and implant failure. At 3-months, a lower RUSH
1694 Editorial / Injury 51 (2020) 1693–1695
Table 1
Radiographic Scores for Predicting Nonunions.
Non-union prediction
RUST [15] Score at 6 weeks [19]:
> 10 100% union, 6–9: 75% union,
<6 31% union
mRUST [16] Unknown
RUSH [21] At 6 months: Score<18 predicts
non-union [22]
RUST for diaphyseal At 12-weeks: RHUM <7 predicts
humeral fractures nonunion whereas RHUM >8 predicts
(RHUM/RUSHU) [25–28] union [26]
At 6-weeks: RUSH <8 predicts nonunion
with 80% specificity and 75% sensitivity
[27]
RUSS [29] Unknown (all fractures united) [29]
score predicted increased probability of reoperation and for every
1 unit, 2 units and 5 units decrease in RUSH score, the probabil-
ity increased by 8%, 16% and 45% respectively. Similarly, for the 6-
month mark, for every 1, 2 and 5 units the increased probability
of reoperation was 2%, 5% and 14%. In both cases, these were inde-
pendent of fracture displacement or age. The RUSH score has been
applied to intertrochanteric fractures [24] and there was increased
inter-observer agreement between orthopedic surgeons and radiol-
ogists. However, no prediction thresholds were reported.
RUST score for diaphyseal humerus fractures: Also known as
RHUM [25,26] or RUSHU [27]
The RUST score has been applied to diaphyseal humerus frac-
tures treated conservatively [25–28], and has also been named
“RHUM” [25,26] or “RUSHU” [27] score, with a substantial to near-
perfect interobserver and intraobserver agreements [25,27,28]. A
RHUM score of 10 had an excellent probability for any observer
to consider the fracture healed [25]. In 36 patients with humeral
shaft fractures treated conservatively, chosen at a 3:1 ratio of
union/nonunion, matched for age and gender, a RHUM score at 12
weeks of less than 7 predicted nonunion in all cases. Intermedi-
ate scores of 7-8 had a 43% chance of healing, whereas all patients
with RHUM scores higher than 8 healed. Another study showed
that at 6 weeks, there was substantial to near-perfect intra- and
inter-observer agreement and using ROC curves they showed that
a cut-off of <8 showed a specificity of 0.80 and sensitivity of 0.75
for predicting union [27].
RUSS (Radius Union Scoring System)
Looking at distal radius fractures non-union, treated conserva-
tively versus volar plating, Patel and al. [29] developed the RUSS
score which is the sum of 4 cortical scores obtained through AP
and lateral radiographs. For each cortex: A score of zero indicates
a visible fracture line and no callus; 1 point if there is callus but
the fracture line is visible, and 2 points if there is bridging callus
and no fracture line visible. Therefore, the minimum score is 0 and
the maximum is 8. There was substantial intra-observer reliabil-
ity, however the inter-observer reliability was substantial and mod-
erate for non-operative and operative fractures respectively and
hardware obscuring the cortices was interfering with the scoring.
It can be argued that the distal radius is not a common site of
Advantages Limitations
Substantial inter-/intra-observer reliability Further studies needed to validate
[12–15] prediction scores
Prediction limited to tibial fractures
treated with IMN.
Metaphyseal tibial fractures treated with
plate have moderate
inter-/intra-observer reliability [16]
Higher inter-/intra-observer reliability No prediction data available
than RUST [16]
Applies to both femoral neck [21,22] and Fair inter-observer reliability [21]
intertrochanteric fractures [24]
No threshold to predict nonunion earlier
than 6 months.
Substantial to near-perfect Applies only to fractures treated
inter-/intra-observer reliability conservatively [25–28]
[25,27,28]
Substantial inter-/intra-observer reliability Superimposed hardware interferes with
[29] scoring [29]
nonunion and all fractures in this cohort were considered “healed”
after 100 days. Therefore, it is questionable if such a system may
be useful in terms of predicting nonunion, but rather, it may be
rather used for objectively following fracture healing and for re-
search purposes.
Conclusion
Historically, the radiographic determination of bone healing has
been problematic. The advent of radiographic scoring systems is
certainly an important advancement which shows promise. Most
of them have substantial inter- and intra-observer reliabilities.
However, there are still significant challenges (Table 1). There are
very few studies that have established thresholds to predict future
nonunion, and these are not provided for all scoring systems devel-
oped to date. Further research, with large cohorts is needed to con-
firm them and establish newer thresholds at different time-points.
Most studies look at one method of fixation and reliabilities have
not been established for other fixation methods. Some studies look
at heterogenous patient populations and therefore results may be
prone to bias and conclusions may be difficult to extract for a par-
ticular group of patients, secondary to those limitations. Future en-
deavors may be directed towards developing scores for other com-
monly encountered fractures, particularly areas that are notorious
for their tenuous blood supply including the scaphoid, talus, nav-
icular, and proximal fifth metatarsal. Finally, as far as predicting
non-union, the above systems should be further investigated and
validated and their use in that respect should be cautious and be
supplemented by clinical judgement and laboratory data on a case-
by-case basis.
Declaration of Competing Interest
No benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the sub-
ject of this article.
George D. Chloros, MD
Academic Department of Trauma and Orthopaedics,
School of Medicine, University of Leeds, United Kingdom
 Editorial / Injury 51 (2020) 1693–1695
Anthony Howard, MRCS, PhD
Academic Department of Trauma and Orthopaedics,
School of Medicine, University of Leeds, United Kingdom
NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital,
Leeds, United Kingdom
Vincenzo Giordano, MD PhD FBCS
Hospital Municipal Miguel Couto, Serviço de Ortopedia e
Traumatologia Prof. Nova Monteiro - Rio de Janeiro - RJ - Brasil
Peter V. Giannoudis, BSc, MD, FACS, FRCS∗
Academic Department of Trauma and Orthopaedics,
School of Medicine, University of Leeds, United Kingdom
NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital,
Leeds, United Kingdom
∗ Corresponding
author. Academic Department of Trauma &
Orthopaedic Surgery, School of Medicine, University of Leeds,
Clarendon Wing, Floor D, Great George Street, Leeds General
Infirmary, LS1 3EX, Leeds, UK. Tel.: 0044 113 3922750.
E-mail address: pgiannoudi@aol.com (P.V. Giannoudis)
References
[1] Santolini E, West RM, Giannoudis PV. Leeds-Genoa Non-Union Index: a clini-
cal tool for asessing the need for early intervention after long bone fracture
fixation. International orthopaedics 2020;44:161–72.
[2] Kanakaris NK, Giannoudis PV. The health economics of the treatment of
long-bone non-unions. Injury 2007;38(Suppl 2):S77–84.
[3] Brinker MR, Hanus BD, Sen M, O’Connor DP. The devastating effects of
tibial nonunion on health-related quality of life. J Bone Joint Surg Am
2013;95:2170–6.
[4] Giannoudis PV, Einhorn TA, Marsh D. Fracture healing: the diamond concept.
Injury 2007;38(Suppl 4):S3–6.
[5] Andrzejowski P, Giannoudis PV. The ’diamond concept’ for long bone non-u-
nion management. J Orthop Traumatol 2019;20:21.
[6] Calori GM, Mazza EL, Mazzola S, Colombo A, Giardina F, Romanò F,
et al. Non-unions. Clin Cases Miner Bone Metab 2017;14:186–8.
[7] El Fatayri B, Bulaïd Y, Djebara AE, Havet E, Mertl P, Dehl M. A compari-
son of bone union and complication rates between locking and non-lock-
ing plates in distal fibular fracture: Retrospective study of 106 cases. Injury
2019;50:2324–31.
[8] Santolini E, West R, Giannoudis PV. Risk factors for long bone fracture non-u-
nion: a stratification approach based on the level of the existing scientific evi-
dence. Injury 2015;46(Suppl 8):S8–19.
[9] Pankaj P, Xie S. The risk of loosening of extramedullary fracture fixation de-
vices. Injury 2019;50(Suppl 1):S66–72.
[10] Nicholson JA, Oliver WM, LizHang J, MacGillivray T, Perks F, Robinson CM,
et al. Sonographic bridging callus: An early predictor of fracture union. Injury
2019;50:2196–202.
[11] Chakrabarti D, Thokur N, Ajnin S. Cable plate fixation for Vancouver Type-B1
periprosthetic femoral fractures-Our experience and identification of a subset
at risk of non-union. Injury 2019;50:2301–5.
1695
[12] Ali S, Singh A, Agarwal A, Parihar A, Mahdi AA, Srivastava RN. Reliability Of The
RUST Score For The Assessment Of Union In Simple Diaphyseal Tibial Fractures.
International Journal of Biomedical Research 2014;5:333–5.
[13] Azevedo Filho FASd, Cotias RB, Azi ML, Teixeira AAdA. Reliability of the radio-
graphic union scale in tibial fractures (RUST). Rev Bras Ortop 2016;52:35–9.
[14] Leow JM, Clement ND, Tawonsawatruk T, Simpson CJ, Simpson AH. The radio-
graphic union scale in tibial (RUST) fractures: Reliability of the outcome mea-
sure at an independent centre. Bone Joint Res 2016;5:116–21.
[15] Whelan DB, Bhandari M, Stephen D, Kreder H, McKee MD, Zdero R, et al. De-
velopment of the Radiographic Union Score for Tibial Fractures for the Assess-
ment of Tibial Fracture Healing After Intramedullary Fixation. J Trauma-Injury
Infect Crit Care 2010;68:629–32.
[16] Litrenta J, Tornetta P 3rd, Mehta S, Jones C, OʼToole RV, Bhandari M, et al. De-
termination of Radiographic Healing: An Assessment of Consistency Using
RUST and Modified RUST in Metadiaphyseal Fractures. J Orthop Trauma
2015;29:516–20.
[17] Fiset S, Godbout C, Crookshank MC, Zdero R, Nauth A, Schemitsch EH. Experi-
mental Validation of the Radiographic Union Score for Tibial Fractures (RUST)
Using Micro-Computed Tomography Scanning and Biomechanical Testing in an
in-Vivo Rat Model. J Bone Joint Surg Am 2018;100:1871–8.
[18] Litrenta J, Tornetta P 3rd, Ricci W, Sanders RW, OʼToole RV, Nascone JW,
et al. In Vivo Correlation of Radiographic Scoring (Radiographic Union Scale
for Tibia Fractures) and Biomechanical Data in a Sheep Osteotomy Model: Can
We Define Union Radiographically? J Orthop Trauma. 2017;31:127–30.
[19] Ross KA, O’Halloran K, Castillo RC, Coale M, Fowler J, Nascone JW, et al. Pre-
diction of tibial nonunion at the 6-week time point. Injury 2018;49:2075–82.
[20] Mundi R, Axelrod D, Chaudhry H, Sahota N, Heels-Ansdell D, Sprague S,
et al. Association of Three-Month Radiographic Union Score for Tibia Fractures
(RUST) with Nonunion in Tibial Shaft Fracture Patients. Cureus 2020;12:12.
[21] Bhandari M, Chiavaras M, Ayeni O, Chakraverrty R, Parasu N, Choudur H,
et al. Assessment of radiographic fracture healing in patients with operatively
treated femoral neck fractures. J Orthop Trauma 2013;27:e213–19.
[22] Frank T, Osterhoff G, Sprague S, Garibaldi A, Bhandari M, Slobogean G,
et al. The Radiographic Union Score for Hip (RUSH) Identifies Radiographic
Nonunion of Femoral Neck Fractures. Clinical Orthopaedics and Related Re-
search 2016;474:1396–404.
[23] Bernaus M, Slobogean GP, Bzovsky S, Heels-Ansdell D, Zhou Q, Bhandari M,
et al. Early Radiographic Union Score for Hip Is Predictive of Femoral
Neck Fracture Complications Within 2 Years. Journal of orthopaedic trauma
2020;34:e195–202.
[24] Chiavaras MM, Bains S, Choudur H, Parasu N, Jacobson J, Ayeni O, 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. Skeletal Radiol 2013;42:1079–88.
[25] Christiano AV, Goch AM, Burke CJ, Leucht P, Konda SR, Egol KA. Radiographic
Humerus Union Measurement (RHUM) Demonstrates High Inter- and Intraob-
server Reliability in Assessing Humeral Shaft Fracture Healing. HSS Journal ®
2019.
[26] Christiano AV, Pean CA, Leucht P, Konda SR, Egol KA. Scoring of radiographic
cortical healing with the radiographic humerus union measurement predicts
union in humeral shaft fractures. European journal of orthopaedic surgery &
traumatology: orthopedie traumatologie 2020.
[27] Oliver WM, Smith TJ, Nicholson JA, Molyneux SG, White TO, Clement ND,
et al. The Radiographic Union Score for HUmeral fractures (RUSHU) predicts
humeral shaft nonunion. Bone Joint J 2019 101-b:1300-6.
[28] Schneble CA, Li DT, Kahan J, Brand J, Socci A, Haims A, et al. Reliability of
Radiographic Union Scoring in Humeral Shaft Fractures. J Orthop Trauma 2020.
[29] Patel SP, Anthony SG, Zurakowski D, Didolkar MM, Kim PS, Wu JS, et al. Radio-
graphic Scoring System to Evaluate Union of Distal Radius Fractures. Journal of
Hand Surgery 2014;39:1471–9.