Invited Commentary related to: When Is a Fracture Not “Fresh”? Aligning Reimbursement With Patient Outcome After Treatment With Low-Intensity Pulsed Ultrasound

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Fracture healing is a biological process that occurs at various rates over time depending on several factors including, among others, the bone involved, the location within the bone, the patient's age, and the patient's medical condition. The orthopaedic community has had a great deal of difficulty and frustration in defining when a fracture is healed, and indeed this determination often remains a clinical one with only supportive objective evidence.
In an attempt to enhance the natural fracture repair process, in the 1980s, we studied the effects of low-intensity ultrasound on the healing of tibial shaft fractures treated in a cast.1 We conducted the first randomized clinical trial of this modality, and it demonstrated a modestly positive effect. In designing the study, 2 features were essential: (1) controlling for as many variables as possible and (2) distinguishing this noninvasive method from electrostimulation which had been popularized earlier in that decade for the treatment of fracture nonunions (fractures which certainly were not “fresh” and had no potential to heal without further intervention).
To meet the first criterion of controlling variables, it was necessary to select patients who had sustained their tibial fracture within a very narrow window of time (7 days) so that the relatively small study groups would be comparable. Thus, all these study patients had fresh fractures, but that inclusion criterion was never intended to mean that someone with a fracture which is more than seven days old does not also have a fresh fracture. This current elegant study clearly reinforces that point as fractures that were 7 weeks or more along still responded well to the ultrasound therapy.
To meet the second criterion of distinguishing ultrasound from electrostimulation, we selected the term fresh to contrast the fractures we treated from established nonunions. We never defined fresh in the published article, using it only in a very generic sense, and we never intended more for this term than for it to provide a soft distinction from an ununited fracture.
To use the term “fresh fracture” as only descriptive of a fracture that is less than 8 days old is incorrect, inappropriate, and unnecessarily restrictive. Most importantly, such an interpretation should never be used to restrict patient care. The authors should be congratulated on bringing this important distinction to our attention.

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