RADIOACTIVE
ISOTOPES
IN
FRACTURES
G. P.
Many
to the
workers
blood
now
the
intravenously
In 1950
the
over
many
have
supply
most
From
of the
promising
ARDEN,
Heatlzer;vood
some
absorption
Tucker
of nailing
of
method
has
been
that
in
of it appearing
a preliminary
drill
between
of up to 30
could
be regarded
no
effects
from
this
harmful
method
the
method
With
correlation
a normal
in animals
head
which
content
and head.
confirmed
p32
divided
from
the
taking
of the
the
result
that
the
ratio
synovia
and
out
bony
direct
is measured.
phosphorus.
small
samples
The dried
blood
measurements
He
with
bone
sampling
six intertrochanteric
following
months.
all
surviving
for
six
to
twelve
failed to unite (possibly
because
In
the
five
and the ratios
were normal
neck the ratios
were low
of faults
in the
nailing
at the time
be a good
to
that
a ratio
a needle
of P32 with
neck and
up
occurred.
found
on the use
of the femoral
them
that
evidently
in the head.
He found
report on the use of
Arden
and Veall in 1950 reported
cases.
They
studied
sixteen
fractures
trochanteric
fractures
union
occurred
sixteen cases of fracture of the femoral
1 O but
obtained;
the investigation
there
appeared
union.
of
ash
as a ratio
normally
and
to
is given
expressed
of up to 14 was
carrying
follow-up
Up
isotope
was
was
damage
femur.
and trochanter
of radioactive
and
surrounding
ratio
in a few patients,
FEMUR
of detecting
neck
operation
at which
head and trochanter.
a ratio
to thirteen
patients,
a one to two years’
or near-normal
THE
a radioactive
in the femoral
head
report
on the use
one hour
before
from the femoral
were
method
of the
as indicating
a satisfactory
blood
supply
use of P32. Boyd
in 1951 made a preliminary
the
and
femur
OF
Ascot
a reliable
fracture
into
p32
to find
after
of the
applied
this
the fracture.
tried
Hospital,
soon
of these
samples
was measured
for its
between
the P32 contents
of the trochanter
Before
this, animal
experiments
had
head
Orthopaedic
years
NECK
ENGLAND
head
The isotope
was given
intravenously
bone were removed
with a hollow
to the
WINDSOR,
THE
femoral
and the amount
Tucker
published
if all vessels
OF
counter.
in twenty-two
fractures,
patients
with
inter-
(04 to 20).
In nine of the
(1 to 23)
yet three of these
technique).
In 1955 Boyd, Zilversmit and Calandruccio
published a more extensive series of cases in
which the method
had been used firstin dogs and then in patients.
They found that in dogs the p32 level reached a plateau in about one and a half hours,
in both the head and trochanter of the femur.
Even if the blood supply to the head were
damaged
a plateau
was
in the
stillreached
head
in about
the
same
time
but
the
ratio
was
altered by the P32 reading in the head being diminished. They found that in dogs the distribution
of P32 in the normal
femoral
head varied
and that counts
in the posterior
inferior
segment
of
the head were higher than in the posterior
superior
the head had the lowest count.
Autoradiographs
showed
patchy
areas
of radioactivity,
the
segment.
of femoral
unexposed
avascularity. They used the method
in thirty-two patients
the femur and in ten with fresh intertrochanteric
fractures
took readings
from
the weight-bearing
area of the head
The weight-bearing
heads
removed
areas
from
corresponding
with fresh
(controls).
to
fractures
As far
in each case. The
portion
of
patients
zones
of
of the neck of
as possible
they
ratios in the cases
of fracture of the femoral neck varied from 13 to 167 and in the cases of trochanteric
fracture
from 07 to 19. The period of observation was not long enough
to permit a comparison
between the clinical results
and the ratios
of radioactivity.
The results
of these studies
are summarised
in Table
I.
This
of the
VOL.
paper
records
vascularity
42B,
NO.
of the
1,
FEBRUARY
the
results
head
1960
of the
of an extended
femur
after
trial
fracture
of the
of the
use
of P32 for
femoral
the
measurement
neck.
21
22
G.
METHOD
About
in
one
a sterile
until
hour
before
solution
a guide
of
wire
nailing
sodium
was
P.
ARDEN
OF
INVESTIGATION
200 microcuries
the fracture
phosphate.
in the
correct
The
usual
In the
position.
TABLE
OTHER
Year
Author
1950
Tucker
1953
1955
and
bone
Veall
Boyd,
Zilversmit
and Calandruccio
Arden
were
removed
at this
STUDIES
Method
Since
designed
of
the
1953
therefore
direct
by Veall.
3 millimetres.
tip.
showing
The
fragile
This
The
wall
of
and
the
only
probe
last
Doubtful
ratio
(3:1)
Abnormal
ratio
(4:1 or more)
1
2
16
Direct
sampling
9
2
5
32
Direct
reading
17
4
II
18
Direct
reading
15
1
2
by a Harris
bone
in the counting
been
biopsy
counter
eye
is
is metal
about
has
three
the
head
of the
femur
in the usual
The results
being
obtained
and
way.
were
by dividing
I
at the
a thin
only
to
from
was completed
of one minute.
the”
ratio”
sample.
time
and
in the head.
of operation
with
15 centimetres
long
long
P005
six
n the trochanter
probe
12 millimetres
and
drill
operation
a period
positions
taken
of
of fractures
9
have
needle
Number
sampling
needle
sensitive
out
samples
Direct
per milligram
of bone,
by that for the capital
readings
carried
small
(P32)
Normal ratio
(2:1)
FIG.
Radiographs
cases
12
stage
as counts
per minute
for the trochanteric
twenty-two
intravenously
was
I
from the trochanter (Figs. 1 and 2). The nailing
Counts
were taken
from
the bone
samples
over
expressed
the figure
first
given
procedure
Results:
Number
of
fractures
Arden
1958
ISOTOPE
of P32 were
operative
inch
months.
and
is situated
thick.
A
THE
needle
sterilisable
OF
with
counter
a diameter
6 millimetres
These
JOURNAL
a needle
lead
BONE
AND
from
counters
are
connects
the
JOINT
SURGERY
RADIOACTIVE
enclosed
counts
the
counter
base
of
number
and
The
the needle
of 1 rays
lead
needle
guide
wire
and
along
this
channel
ISOTOPES
IN
counter
picked
can
be sterilised
was
used
then
removed.
were
and
OF
THE
NECK
to a clinical
monitor.
up by the needle
counter
counter
both
FRACTURES
in hot
formaldehyde
as follows:
its position
was
Harris
probe
checked
THE
23
FEMUR
This
apparatus
in thirty
seconds.
automatically
The needle
vapour.
the
The
OF
was
drill
then
was
inserted
passed
into
by radiographs.
The
30
along
the
site
head
a suitable
of the femur
chosen
was
usually
Head
,,..#{149}
20
Trochanrer
to
6
Time
in
of absorption
0
Minutes
2
FiG.
Rate
8
of p32 from blood stream in head
(In this case the fracture
united.)
and trochanter.
about
the centre
of the head.
A reading
was then taken.
Immediately
after
this a further
reading
(Fig.
1) was
taken
from
the trochanteric
region
of the drill hole.
In each case the
procedure
was carried
out three
times
so that an average
of the readings
could
be taken.
In twenty
that
was
cases
the drill
the blood
later found
hole
was
washed
oozing
into this canal
to make
no difference
out
with
saline
TABLE
AGE,
SEX,
IN
SIDE
SIXTY-ONE
The
compared
Average
age
TIME
WITH
each
reading
subsequent
discontinued.
BETWEEN
TROCHANTERIC
INJURY
.
.
.
.
.
.
.
.
.
AND
CERVICAL
AND
.
OPERATION
61
74 years
.
.
.
.
.
50F
I1M
Side
.
.
.
.
.
.
.
37R
24L
operation
the
was
results
clinical
then
of the
injury
and
completed
reading
result
two
were
studied.
years
irrigation
FRACTURES
.
between
suspected
The
II
INTERVAL
.
time
as it was
reading.
Sex
nailing
the
PATIENTS
of patients
whatever
with
AND
Number
Average
fracture
AFFECTED
after
might
increase
the
and was therefore
operation
in
so that
after
24
the
usual
the
way.
results
days
It was
of the
decided
investigation
to nail
could
the
be
operation.
MATERIAL
One
hundred
patients
of technical
faults-faults
monitor
and
electrical
discarded
because,
for
VOL.
42 B,
NO.
1,
FEBRUARY
In fifteen
in the counter,
false
disturbances
from
the
reasons
to be discussed
1960
the
readings
mains
later,
investigation
was
abandoned
because
from
the cable,
faults
in the clinical
supply.
Seventeen
more
cases
were
the readings
were
considered
to be
24
G.
unreliable.
cases
of the
was
In the
for
femur
not
sixty-eight
analysis.
less
remaining
Of these,
and
forty
twenty-one
than
two
had
years
P.
patients
there
had
displaced
patients
trochanteric
in any
ARDEN
were
seven
deaths,
(disimpacted)
fractures
(Table
leaving
sixty-one
fractures
II).
The
period
of the
neck
of observation
case.
RESULTS
No
toxic
effect
patients blood
from
counts
the P32 was
were
done
found
in any
TABLE
ANALYSIS
OF
CLINICAL
AND
RESULT
FORTY
of the
intervals
at weekly
IN
hundred
after
patients.
operation
In the first
but
no
unusual
twenty
changes
III
TWENTY-ONE
FRACTURES
OF
TROCHANTERiC
THE
FEMORAL
FRACTURES
NECK
Results
Type
of fracture
Intertrochanteric
Number of
fractures
.
.
Fractured neck of femur
were
seen.
Examination
of the
patients
United
21
21
40
25
with
reading
These
been
by some
caused
and the other two,
discrepancies were
technical
fault
in the
RATIos
Intertrochanteric
counter
series
CLINICAL
6 to 25
was
showed
a marked
that
discrepancy
in the head
that
they
and
must
in the
have
Result
All
d
t
I
uni e
28
232 avascular
united
3 non-union
7#{216}0/
,norma1
neck
operation
RESULTS
20
#{149}6
t 25 I
of femur
after
there
Number
30
Fractured
8
IV
TO
Ratio
(controls)
7
apparatus.
RELATED
of fracture
Type
-
either
in the head alone
or both
so large that it was considered
TABLE
p32
Non-union
-
a Geiger
all had excreted
nearly
all the P32 in forty-eight
hours.
In each of the seventeen
cases omitted
from
the
between
one
trochanter.
Avascular
26 to 35
(borderline)
4
1
(10%)
1
36 t 300
,a 1,norma,
,1200/
8
necrosis
united I
1 united
43 non-union
avascular
necrosis
/o)
All the trochanteric fractures united. Twenty-five
of the fractures
of the femoral
neck
united; in seven there was evidence of avascular necrosis and eight went on to non-union
(Table III).
Comparison
trochanteric
In
forty
the
of clinical
result
with ratio
of radioactivity (Table IV)-In
twenty
fractures the ratio of radioactivity between
the trochanter
and head
remaining
patients
patient
with
fractures
the
ratio
of the
was
femoral
30.
All
neck
these
can
fractures
be analysed
THE
JOURNAL
united.
The
patients
was below
results
with
25.
in the
as follows.
OF
BONE
AND
JOINT
SURGERY
RADIOACTIVE
Of the
three
twenty-eight
went
1.
on
to
Subcapiial
with
Subcapitalfracture-P32
Subcapital
eighteen
ratio
segmental
necrosis
patients
one
Suheapital
with
failed
necrosis
to
Transcervical
Transcervical
renailed.
and
ratios
unite
two
and
nailing-nail
extruded-renailed
nailing-nail
extruded-
Fair
portion
reduction
Non-union.
union-but
of head
and
after
occurred.
nailing-united-but
at one
year
patients
ratio
one
in this
fracture
group
united,
went
two
on to bony
developed
union.
avascular
28.
Good
3O.
80
reduction
per
and
cent
nailing-united.
reduction-good
nailing-developed
years.
ratio
avascular
developed
patients
Union-P32
33.
ratio
Non-union-P32
The
in
on
Good
reduction
and
necrosis
at nine
months.
Good
reduction
and
29.
nailing-nail
fair
extruded-
nailing-nail
cut
out-
300
moment
from
the
chart
(Fig.
was
an
almost
7.0,
united,
and
nailing
three
were
developed
good
avascular
in all
these
cases.
recorded,
whereas
from
give
rate
sampling
were taken
than examination
head
of P32,
a better
of rise
the
the
of injection
equal
300.
by direct
readings
2) might
100.
200,
examined
were
cases
resultant
67,
120,
measurements
lower reading
two
intervals
fracture
as follows:
ratios
I10,
cases
as
In
one
Reduction
4l.
ratios
high
ratio
non-union.
were
necrosis-P32
which
direct
to give a much
as
an abnormal
to
in them
twenty-two
110.
with
went
ratio
3.
in the
ratio
fracture-P32
obtained
A vascular
there
necrosis
as follows:
but
four
2.
ratios
avascular
follows:
reduction-poor
twenty-three
fracture-P32
In the eight
was
25
FEMUR
Non-union.
necrosis
tended
as
and
weight-bearing
1 .3
ratio
at
renailed-united
cases
THE
developed
are
reduction
OF
Imperfect
reduction
and nailing.
Good
reduction
and nailing-good
.
a borderline
fracture-P32
avascular
.
two
cases
Good
of
in the remaining
four
and
1 7.
2 1
necrosis
Transcervicalfracture-P32
The
NECK
necrosis.
fractures
In the
4.
THE
P32 ratio
five
Good
08.
ratio
avascular
The
3.
a normal
25.
ratio
ratio
Transcervicalfracture-P32
2.
OF
of these
ratio
fracture-P32
months
developed
I
with
Details
fracture-P32
3.
.
FRACTURES
Non-union.
4.
1
IN
Non-union.
Subeapital
renailed.
5.
patients
non-union.
fracture-P32
a plate.
2.
ISOTOPES
in the
highest
and
as
idea
compared
fairly
well
with
the
forty-six
except
that
sampling
of a damaged
head
with the needle counter.
With sampling,
it was
of the
counts,
recorded
with
trochanter
were
thought
that
vascularity
yet
union
of
the
needle
taken
at
counter
two-minute
the
rate
the
head.
In
both
cases
in one
case
and
failed
occurred
of
climb
on
the
other.
DISCUSSION
In 82 per
cent
of
the
cases
in
which
a low
P32 ratio
seemed
to
prognosis
the clinical
result
was good.
On the other
hand
union
with a borderline
count
(28)
and in one with a definitely
abnormal
five
patients
who
should
have
done
well,
as judged
by the
indicate
a favourable
occurred
count
P32 counts,
in one patient
(4l).
Further,
developed
non-union
or avascular
necrosis.
The discrepancy
between
expected
and actual
results
could
errors inherent in the method
of investigation
or to technical
faults
in the method
be due to
of internal
fixation.
Sources
of error
in the method
of investigation-As
Boyd
and Calandruccio
1955) have pointed
out, the amount
factors
apart from the circulation of blood through
and
common
to all cases and cannot
anyway
be readily
excluded.
measuring
the radioactivity
and, by inference,
the vascularity
subject
to many
and serious
limitations.
Firstly,
most of the
VOL.
42 B,
NO.
1,
FEBRUARY
1960
his
colleagues
(Boyd,
Zilversmit
of P32 in the bone depends
on many
the bone.
These
factors
however
are
The efficiency
of the femoral
rays
picked
of the
head
up
by
probe
in
is clearly
the
probe
26
G.
P.
ARDEN
emanate
from
a relatively
small
area.
If the distribution
patchy,
misleading
readings
would
assuredly
be obtained.
have
shown
that
the distribution
of P32 in the head
of P32 in the femoral
head
were
In fact, Boyd and his colleagues
after
fracture
of the neck
is often
patchy.
In cases ofnon-union
where removal
ofthe
head was necessary
I gave P32 intravenously
one hour before
operation
and took samples
from various
sites in the excised
head.
Readings
were taken
from
the trochanter
at the time
of operation.
The ratio
was normal
near the
ligamentum
may often
misleading
The
in this
teres and became
abnormal
near the fracture
be a difference
in the radioactivity
of different
result
question
study
can be given ifthe
is raised
whether
is the
correct
one.
line (Fig. 3). It is clear that there
parts of the femoral
head and that a
eye ofthe
probe happens
to lie in a patch
the position
of the probe
in the centre
Trueta
and
Harrison
(1953)
showed
of good vascularity.
of the head as used
that
the
superior
weight-
bearing
part of the head,
supplied
by the superior
epiphysial
artery,
is particularly
liable to be
deprived of itsblood supply after a fracture of the neck. Boyd and his colleagues
have suggested
that,
because
of the liability
of this part of the femoral
head
to avascular
necrosis,
counts
should
be taken
from
it rather
than
from
the
centre
of femur
resulting
excised
three months
in non-union.
Radioactivity
ratio.
lie in the
p32
The
use
Purser
1957).
after
cause
operation
of failure.
fracture
in which
solution
of nail
to the problem
plates
and lag
Too
little
is known
a poor
unlikely
that
the
much
faults
were
faults
result
of the
screws
of the role
on a fracture
of the
Lastly,
it is possible
drill may determine
failure.
Trueta
the introduction
of a nail is unlikely
therefore
one
hour
at different sites in the excised
to that in the trochanter.
Technical faults in internal
fixation-Technical
and inadequate
internal
fixation.
These
of subcapital
after fracture
given
32
was
of femoral
before
fragment
compared
in operation
may be imperfect
in fact obvious
in only one
associated
of post-operative
with
an
would
reduction
of the cases
apparently
nail which
(Charnley,
treatment
neck to allow
damage
caused
and Claffey
(1957)
to cause
damage
drill
neck
operation.
apparently
well-placed
of the Charnley
type
femoral
that the
smaller
head.
3
FIG.
Head
of the
favourable
slides out
Blockey
in determining
valid
comment
on
by the introduction
failure
this possible
of a hollow
have produced
evidence
to show
to the blood
supply
of the head.
inflict
significant
may
and
that
It is
damage.
SUMMARY
1.
A method
is described
for
measuring
blood
flow
to the
head
of the
femur
after
fracture
of the femoral
neck,
by estimation
of the rate of uptake
of radioactive
phosphorus.
2. Of one hundred
cases investigated
the readings
in fifteen
were incomplete,
and in seventeen
were unreliable.
Reasons
are given for discarding
the latter
seventeen
cases.
After
two years
seven patients had died, leaving sixty-one available for analysis.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
RADIOACTIVE
3. The
analysed.
by direct
4. The
p32
ISOTOPES
IN
FRACTURES
OF
THE
NECK
OF
THE
27
FEMUR
results
in sixty-one
surviving
patients
with a follow-up
of not less than two years
are
In twenty
of these
radioactivity
was measured
by bone sampling
and in forty-one
readings
with a needle
counter.
twenty-one
intertrochanteric
fractures
studied
were used as controls.
In these
the
ratio
varied
from
04
to 30.
necrosis.
5.
Of the forty
patients
with
low P32 ratio.
In twenty-three
Union
occurred
displaced
of these
in all patients
and
fractures
of the femoral
(82 per cent) the fracture
6. Twelve
patients
with fractures
of the
ratio.
In ten of these there was subsequent
none
developed
avascular
neck twenty-eight
united.
femoral
neck showed
avascular
necrosis
a borderline
or non-union.
showed
a
or abnormal
P32
The possible
reasons
for the discrepancy
between
expected
and actual
results
are discussed.
8. Almost
40 per cent of the cases investigated
had to be abandoned
because
of technical
faults and in one-fifth of the remaining
cases
the expected
results
failed
to agree
with the
7.
clinical results. The method
present
time.
Improvements
and more
of investigation
in apparatus
and
is therefore
technique
not
might
of much
practical
make the method
value at the
more reliable
useful.
I am indebted
to Mr N. Veall for his constant
to my colleagues,
Mr W.
Editor of the Postgraduate
Herschell
Medical
and
Mr
Journal
help and advice
in this investigation.
My
R. H. Maudsley,
for their cooperation.
for permission
to publish
Figure 3.
thanks are also due
I am grateful
to the
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(Section of Orthopaedics),
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H. B. (1951):
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