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UNUNITED FRACTURES WITH SPECIAL REFERENCE TO THE CHEMISTRY OF THE BLOOD

MELVIN S. HENDERSON, THOMAS P. NOBLE and KATHLEEN SANDIFORD J Bone Joint Surg Am. 1926;8:607-617.

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UNUNITED

FRACTURES

607

UNUNITED

FRACTURES

WITH

SPECIAL

REFERENCE

TO

THE
BY MELVIN S.

CHEMISTRY
HENDERSON, on

OF
M.D.,

THE
THOMAS

BLOOD*
P. NOBLE, M.D.,

Section

Orthopaedic and
SANDIFORD,

Surgery,
B.A.,

KATHLEEN

Section

on Clinical

Metabolism, have been investigators

explain it on

Mayo

Clinic,

Rochester,

Minnesota

Many hypotheses in ossification. Some

chemical one, others

evolved to explain maintain that

the basis of the

the processes at work the process is a simple

elective affinity of the

cell, action.
lished

and
in

still
1857

others
by

believe of chemical
Rainey on

it is biochemical changes
the

in origin based
of

and

due

to enzyme puband

Theories

are

on a series
calcium

of papers
carbonate

precipitation

calcium confirmed

phosphate from and amplified the calcium

colloids. by Watt, of the blood

Recently these experiments who, like Wells, accepts exists as a soluble complex : P2O8Ca2H2 : 2 CO2 of the composition

have been the idea of double salt, This, of bone From that action of

Barill#{233} that

tribasic calcium-carbonophosphate he believes, explains the constancy

(COsH)2Ca. of all types

by bringing to it the two salts in exactly this stage onward Watt differs from Wells this salt is taken from the blood and osteoblasts philosophy) concentration istic as formerly while Wells by a change work suggested believes in the of

the proper proportions. in that the former maintains in the bone by the

deposited

by Klotz and by R#{246}hmann (a vitalistic that it is due to a shift in the hydrogen ion carbon Pfaundler, dioxid of content Pauli (a purely and Samec mechanand of

conception). The experimental

Freudenberg and Gyorgy resulted affinity as their bases. Pfaundler cavities up have able calcium the to take of animals was same up thus affinity much and found increased, for calcium. more calcium that

in a number of theories, with elective placed pieces of cartilage in the abdominal their that than power all costal (Kalksalzfanger) varieties cartilage, or tracheal of cartilage for example, cartilage. of taking did not was He but

Epiphyseal

concluded that cell at a certain to assume

Samec demonstrated

a substance was secreted from the stage of development, which caused affinity
that the

bone-cell or the surrounding blood.

a greater

cartilagetissue Pauli
proportion

a specific are

for

the

calcium
fluids that

salts

of the

and the of

tissue

contain

of proteins impregnation

capable of taking of cartilage with put

up more calcium, and lime salts is due to had

they believe that the high content

protein in the cartilaginous in a series of experiments

*

ground-substance. cartilage, which

Orthopaedic Association,

Freudenberg and been previously

Atlanta, Georgia,

Gyorgy treated
April

Read 1926.

before

the

American

26

to

28,

608 with
served first into

M.

S. HENDERSON,

T.

P.

NOBLE,

KATHLEEN

SANDIFORD

a solution
bony a solution

of calcium
changes in the of phosphate

chlorid,
cartilage and

into
then

a solution
into a solution

of phosphate
if they put the of calcium

and
cartilage chlorid,

ob-

; however,

no

bony

change
was

resulted. not purely

From

this

they

concluded reaction

that was

the not

mechanism reversible.

of ossification

chemical,

as the

Robison, in 1923, presented presence of an enzyme in the bones which rapidly phosphate ions. Robison phoric but
is

interesting evidence and ossifying cartilage esters with the been amplified is that cartilage, become the acid) neighborhood phosphoric in the of the

which suggests the of young animals, liberation of and extended free by

hydrolyzes phosphoric This work has recently

and Soames. Their conclusion esterase) is present in ossifying extent

to act

an enzyme (a monophosgrowing bone and teeth, fully grown. esters blood, site This and enzyme liberate (hexosemonoof ossification.

to a less
assumed

after on and and

the

animals

hydrolyze

phosphoric phosphate

acid ions

glycerophosphoric immediate

in the

Consequently, the product of the concentration of the phosphate and calcium ions becomes greater than the solubility product of calcium phosphate, and this is deposited in a solid state. As further evidence, these investigators demonstrated that calcium phosphate is deposited in vitro in bone able taken phosphoric Howland, the from rachitic animals when it is immersed in a solution in his in Harvey of suitLecture form the is referred is based well-known solubilityof, may each salt. soluble of that of silver Unsalts in in an ionic conin to as in experishowed some by be stated on esters. in his discussion pathogenesis of theories of Wells for a full exposition

of bone-formation rickets, puts on ossification, of the subject.

of 1923 on physicochemical to their the law The papers fact that of mass

more concrete and the reader The theory follows the the so-called conditions

the precipitation action and can which law

of salts in solution be predicted from from, the most but simple

product as follows: univalent

constant solubility-product

is different under

characteristic

in sufficiently salt the product

dilute solutions saturated of the concentrations

with a slightly of the ion species

salt is constant. silver and chlorin chlorid is a constant fortunately pure water exceedingly

For example, the product of the ionic concentrations divided by the concentration of the molecular which cannot be exceeded without precipitation. dealing valence with simple in solution variations univalent equilibrium in the

in the blood we are not but with salts of higher complex solvent.

Furthermore,

centrations of calcium and phosphorus in the serum clinical work and hence a true solubility constant In spite of these difficulties, Howland believes that the the Inents that carbonate clinician serum. carried can factors He out is formed based be deduced the total the from possible with largely the hydrogen a rough value Marriott ion product approximate concentration

cannot be measured cannot be determined. information of value obtained and a product Kramer. phosphate by upon They with is increased using phosphorus

of calcium of such and

in conjunction consisting when

a precipitate

of tricalcium

concentration

UNUNITED

FRACTURES

609 serum, if the product of

reducing

the

carbon

dioxid

tension

in an

artificial

the concentration 100 c.c.) exceeds tion

solution account

of calcium and phosphate 40. Howland visualized :

present (in milligrams for each the mechanism of bone formaand

water is some

as

follows
in of much the

Serum higher CO2

contains
concentration tension.

calcium
than There

inorganic
would evidence

phosphorus
hold to them, show that

in
on

high

part protein total

roughly

of the calcium
the

calcium

is bound is poorly

to protein. ionized
of

If it is assumed would
and protein

that the

this

calciumthe
to our

compound
same

this

be equivalent fluid
is much

to reducing tissues
according apparently

concentration.
amount as the serum, but of

Intercellular
calcium the cellular

of

contains
about that the

phosphorus, less, But

determinations,

1 per CO2

cent., tension

as contrasted
high on

with
account

7-9 per the tissue

cent.,

in the

serum. or dead,

The
supposing

CO2 tension conditions are CO2

is relatively

activity.

is low

because

is inactive and the that one

then

are favorable both inactive tension

for precipitation. Cartilage tissues and it is in them it is in them of the factors

explains

trabeculae of bone would expect the place. and

the

low and This view

calcification,

that that
the

precipitation takes control calcification

normal process and

of the
failure

mechanin rickets

ism

of

and tion planes to

tetany of children in dead or inactive of the muscles be a hyaline

importance,

and the tissues in myositis

it explains

rickets of animals. such as tuberculous ossificans, of the

the

It also lesions where the tissue.

of composition

explains calcificaand in the fascial first change What phosphorus do not

of the

seems is further
bones

transformation species in which serum

connective and have

of much

constancy

of all animal centrations greatly the from Putting

the

calcium as they

inorganic been found healing studied that

was

condiffer when place or

of the

so far

those of man. this theory to the was above 40 either did not have usually present; present. in the 1924, applying calcium and

test,

Howland

in rickets taking

product

demonstrable

the patient rickets was was invariably

rickets; that with products and that when the product the work phosphorus

between was below

30 and 40 30 rickets

Petersen, rickets, studied

of Howland in the serum

and Kramer on in cases of un-

united fracture and used He studied nine normal

his index of ability to unite,

normally healing cases and nine

the same value

fractures cases of
of the

to control his results. nonunion, and used, as

product which Howland

had

found

indicative

of

the

presence

or

absence

of

rickets

in

children.

Petersens was not would

evidence is confirmatory likely to occur if the product occur if it was between 30 and

of the idea that union was less than 30, that 35, and that active was of the disturbance

of a fracture little healing would be opinion that causing a below normal, and drugs. on animals

healing

more frequent if it were between in cases of ununited fracture there reduction of the concentration and that the normal concentration Later in the same year he published

35 and 40. He is a constitutional of calcium and

phosphorus

can be restored by diet the results of experiments

610 and and

factors

M.

S.

HENDERSON,

T.

P.

NOBLE,

KATHLEEN

SANDIFORD

drew Harris,
at

the
the

same on
site

conclusions other
of fracture.

as in his study hand, had

They

on fractures more
that,

in man. on local
adult, only

Tisdall metabolic
when

the

laid
found

stress
in the

bone reach young.

is being formed as the result the level maintained during Recent studies
of the in or plasma The milligrams ; whether serum

of a fracture the period of the

and and in health

does the of normal blood

phosphorus bone-growth produced

content in the many

These are

on
content

the
of the

chemistry
of calcium calcium serum

have
phosphate. for makes

estimations expressed serum difference.

inorganic phosphorus is used is is

each little constant

100

c.c.
in

of
all

or plasma

practical

calcium

singularly

mammals,
usually

including
accepted figure

man,
for

but
serum

shows
calcium

slight

variations
10 mg. for

with
each

age. 100 c.c.

The plus

or minus 1 mg. with a tendency, land, for it to run between 10 and showed that presumably calcium calcium obtained ourselves The plasma the child part of the in combination under calcium with similar

as shown by Kramer, Tisdall 11 mg. in children. Rona and of serum protein. conditions

and HowTakahashi of

was nondiffusible and, therefore, From the solubility constant they 2.2 mg. studies, present calculated Brinkman however, in the that the ionized Dam limit and van we must serum.

carbonate

in serum would not a similar figure. to a knowledge

be far from For clinical total

of the

calcium

inorganic phosphate (expressed is not as constant as the calcium and the adult. Tisdall and

as phosphorus) and varies relatively Harris found,

in the serum or more between from the

in children

fourth month to the eighteenth year, an average of 5.4 mg. of phosphorus in 100 c.c. of serum, and in adults from twenty to forty-four years, 3.8 mg. Anderson gives an average of 4.8 mg. for children up to twelve years and 3.3 for adults. for children and In our 3.4 mg. series of examination The because too long by we found estimation an average of inorganic of 4.2 mg. phosphate blood concomfor adults.

is somewhat tricky partly has been allowed to stand siderably increased, probably

the amount obtained, after the in contact with the clot, is usually hydrolysis or organic phosphorus

pounds diffusing out from the corpuscles. It is, therefore, necessary to standardize the time between the taking of the blood and the estimations. Maitland and Robison found that after the blood had been laked with distilled water, the amount of inorganic phosphate in whole blood increased rapidly, as much as 10 per cent. in five minutes and 50 per cent. in two hours at room temperature. At 37#{176} the increase C. In the presence of 1 per cent. of trichloracetic all in two investigators reported
five hours

was considerably acid no increase

greater. occurred at

hours at found by
at

37#{176} C. In unlaked blood at room temperature, these only a slight increase in six hours, but experiments blood is kept in the plasma we
six

Kay
370

and Robison show that when unlaked C. the amount of inorganic phosphate 20 per that was cent. In a control during stand series the first in contact the increase allowed to

for is like

increased

about

have
hours

found,
was

Howland and Kramer, even when the serum

slight

with

the

clot;

if,

UNUNITED

FRACTURES

611 hours
of reaction the the and serum is,

however, amount
Alterations produced
of

under obtained
in in several

the was
the

latter from
calcium ways.

conditions, 60 to 100
and Binger into

twenty-four per cent.

that right caused

elapsed,
blood can injection in amounts calcium according

the
be

greater.
content the intravenous

phosphorus showed dogs at the weight,

orthophosphates 150 tetany. mg. for The each

of sodium kilogram

of

of body state caused

to to

drop
of

from

10 to 6 mg.
tetanic

for each

100 c.c. and

by

was
the

accompanied
phosphate

by a condition with the Salveson,

found or ion are due two conto a one

Binger, degree
Hastings, that days,

not dependent of alkalinity

and large doses McIntosh, of

on the drop in calcium of the solution used.

in a recent phosphate, tetany extensive administered independently

alone but also varies On the other hand

study over of of the a period the hydrogen subject, of

produced

marked

centration
of tetany, decrease

of the
produced in blood

solution
by calcium. the

used
oral

; they

concluded

that

the

clinical

symptoms

administration

of phosphate,

The variable. a decrease in the diet lum, and low

results Some

of

feeding

calcium find an

in

excess

to

animals plasma

are

somewhat but

investigators

increase

in the

calcium,

in the plasma phosphorus. raises the concentration Shipley and to Park rats, in protein is fed

In like of phosphorus found that absorption

manner, excess phosphorus in the plasma. McColwhen a diet high in calcium and of calcium is improved

Simmons,

that of phosphorus impaired. on this diet, observed that

raised and that of inorganic

Howland and the concentration

phosphorus lowered.

Kramer, also studying rats of calcium in the serum is

Salvesen, Hastings, and

McIntosh salt. The dermically,

considered administration may correct

that

calcium of calcium deficiency

chlorid salts

given to

orally man, but

is the by

most materially

effective or hyporaise of lime either

mouth

in calcium

cannot

the calcium content salts in a normal

above normal. There diet. If hypocalcemia

is never a deficiency exists, the cause must

operate in the gastro-intestinal excessive elimination in the which facilitates absorption deficiency presence that the is hampered salts appear ent on the the blood. in maintaining and phosphorus. roid extract by repeated substance of some is essential absorption by diet to exist hydrogen

tract to prevent absorption, or depend on urine or feces, on some condition in the tissues of calcium from the blood stream, or on the in of blood and the blood calcium. from stream Orr has the whose shown

hormone (parathyroid) for a normal content of both which in the ion calcium

phosphorus

intestine Calcium is dependtension of

increases the alkalinity of the stools. blood in a saturated solution and this concentration and the carbon dioxid

It has been shown that cod-liver oil and ultra-violet rays assist the proper concentration and utilization of both calcium Collip has demonstrated that by the use of the parathyprepared by him the blood calcium subcutaneous injections at short that will materially increase the blood can be more than doubled intervals; this is the only calcium above normal.

612 We
phosphorus

M.

S.

HENDERON,

T.

P.

NOBLE,

KATHLEEN

SANDIFORD

have
in

carried
the blood

out
of

quantitative
a considerable

estimations*
number of

of the
patients

calcium
with

and
un-

united surgical
of typical

fracture. service
ununited

For many reasons to follow up the case In addition

fracture

it is not and compile incomplete

one blood

always possible in a busy sufficient readings suitable data after we have

examination

for publication. before The and the eighteen operation accompanying

to this
in which

twenty
was

cases
made

and

at least tables give

two the

determinations percentages

operation and

(Table
phosphorus

1).

of calcium

products of the cases of chronic

figures. eczema

As controls we have listed a series of (Table 2), in each of which at least two mg., mg., phosphorus readings for phosphorus made within

similar tests were made ; the averages were for calcium 10.3 3.1 mg., and the product 31.9. The average preoperative the 3.3 twenty cases mg., product of ununited 33.7. The fracture were postoperative : calcium 10.2 determinations 3.6, product calcium 10.0 were
that

thirty vations
3.4, phorus

days were: calcium 9.8 mg., phosphorus between thirty and sixty days were: product
3.1 and

35.3; the obsermg., phosphorus 10.2 mg.,

of the

34.0

and

those
31.6.

over

sixty
be

days
noted

: calcium
the average

phosearly

product

It will

postoperative phosphorus in phosphorus

tions, however,

calcium

determinations

was

slightly

lower

and

of

the

slightly higher than the preoperative, resulted in a slightly higher product.

are within the experimental error

and that the The individual

of the method and

increase variaare no

greater In

than one

those case

found of fracture

in our

control tibia,

series. with a persistently high reading When the readings for phosphorus slowly, and it was evident that twenty it did will equal cases not, probably in which presented, and three occur union high are union still without failed, side decrease product. of the after to above end of the

of the

for phosphorus, were persistently metabolism occurred under further both the in

union was very rapid. low, union progressed was after in In the and sluggish. operation, one of two calcium which cases were In one resulting in the fifteen

of bone observation, difficulty. phosphorus

Of the in two union of either

nonunion,

to or on the

of the average below normal In the other phosphorus, operation. the original year.
* The phosphate

before operation. in the phosphorus, there was a decrease resulting Six level months but in a slightly later, there

case there was a slight in a slightly lowered calcium with an elevation product product drop had toward immediately returned the

decreased the a subsequent

however, was

calcium by the
of the

was determined Bell and Doisy

by the method.

tion of serum
the calcium

calcium

frequently
used

arise
in boiling

Kramer and Tisdall method and the inorganic In clinical laboratories errors in the calcula from contamination of the syringe or tube with
or cleaning; therefore, the blood was collected

water

in a syringe which had been boiled in double distilled water had been previously washed with hot cleaning solution,
distilled water, and then dried in hot air. fuging and the calcium precipitated directly immediately precipitated by trichloracetic

and was placed in tubes which rinsed with distilled and re-

The serum was obtained at once by centrias calcium oxalate. The serum protein was acid and the filtrate thus obtained was used

for the determination

and the proper correction

of the inorganic
determined;

phosphate.
phosphorus

Daily
blanks

blanks
were

for calcium
run at frequent

were made
intervals

and found

negjigible.

UNUNITED

FRACTJRES

613

0 .

i2 C

0 0 00

0 0 0

0 0

.-0 000

C
#{149}

#{149}

0 0
0

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0

0 0
0

0 0
0

0 0
0

.0
...

0 0
0

0 0
0

0 0 0

00

00

00

0 0 0

0 0

0.00 0

C 0c

c.

cOc
C C ? 01

a
0 0

.-

.0
-

__x-.
C

0ON
NC

N010X#{149}
0C

0
CC

E
C C -o CCC xxoe CCC x 00CC CCtt. nON

.,

a
.0l3

-----C0t. :-01*.0-

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1C1010

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01

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CO

X o
01

01

000

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ccnt.Onco
0101 0cC cOOl

o
CO

CO

CoXcX N CO N

CO

co N

CO CO

C 0

00 0.0

cC CO

C CO

CO

t CO

cC

C
NN C ON

-.
CO

CN

-1 CO
CO

CO CO

CO

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CO CO N

C) .0 S C

E
C cCcC.c CC

x-n
CON

C) N CO C C CO 0 N N

CC

Cc

CCCCo --cO-

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00000

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0
C)

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C
0.0 C C C 0 -..

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C
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CE
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a
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zzzzzz ..c
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.
C)

CC CC 00

C C 0

zzzz
N Cl

C C 0

C C 0

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zzz
C CO
CO 0 0 N

C C 0

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*

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614 Although

M.

S.

HENDERSON,

T. P.

NOBLE,

KATHLEEN

SANDIFORD

our

data

lend

no

support

to

the the

clinical

value treatment we wish theory

of

blood

calcium and layed union, out One and that they formation

phosphorus determinations in as seen in a general orthopaedic do not least thereby in part in this amount invalidate dependent the on

routine clinic, yet

of deto point that bone-

underlying a physicochemical

is at

mechanism. are all in adults is less than in ; therewill

factor to remember that normally the

connection is that our of phosphorus in the different that conditions the clinical in children in adults the limits nothing
2
OF

cases serum

children and also varies under fore, one can hardly anticipate have With of the

to a lesser degree solubility-product

the same significant values as found this decrease in maximal variability may determination well decrease themselves, to within to say
TABLE
CALCIUM AND INORGANIC CASES

suffering from rickets. the possible significant of the experimental in the errors solubility errors

variations

of the

PHOSPHATE OF CHRONIC

THE

BLOOD

IN

EIGHTEEN

ECZEMA . Inorganic

Case 1.

Age 17

Calcium 10.4 11.1

Inorganic phphate 2.9

PrOduct 30.2

Case

Age

Calcium 10.8

phosphate 2.3 2.5

Product 24.8 24.3

10.

56

3.0 3.0
2.9

33.3
32.4 31.9 11.

9.7 59 10.6
10.9 12.

2.

24

10.8
11.0

3.4
3.6

36.0
39.2

3.

25

10.8

10.0
4. 29 9.9

3.7 3.7
3.1

40.0 37.0
30.7

59

10.7 10.2 10.5 10.7 10.4 9.7 10.1 10.1 10.4 10.0 10.0 10.3 10.3 10.4 10.0 10.5

2.9 3.1 3.1 3.0 3.0 3.5 3.7 3.0 2.8 3.6 3.6 3.1 3.7 2.7 3.7 3.0 3.0
2.3 product
=

31.0 31.6 32.6 32.1 31.2 34.0 37.4 30.3 29.1 36.0 36.0 31.9 38.1 28.1 37.0 31.5 30.0
22.1

10.9 5. 41 10.0
10.3

3.2 2.5
2.7

34.9 25.0
27.8

13.

62

14.

63

6.

47

10.6 10.0 10.8 10.1 10.6

10.6

2.8 3.3 3.4 3.4 3.6

2.8

29.7 33.0 36.7 34.3 38.2

29.7

15.

63

7.

50

16.

66

8.

52

10.8 9.7 9. 55 9.8 9.7 10.6

3.0 3.1 2.8 3.2 3.2

32.4 30.1 27.4 31.0 33.9

17.

72

______ ______ __________ _

Average calcium
=

18.

78

10.0 9.6
Average

10.3

Average

inorganic

phosphate

= 3.1

31.9

UNUNITED

FRACTURES

615 of these substances.

constant

obtained

by

using

the

total

concentration

As Howland pointed out, it was in regard to the etiology of rickets a deficiency that forth. chemistry. an important cells work its positive surgeons,
come to

finally possible to harmonize the views of those who believed the disease due to in the diet and such of those as a question of Haldane whether who thought and of physical to or not deny the so factors the cells sunlight,

of some due We role

particular that

vitamin bone-formation with

it was

solely unlikely are too to the

to environmental imbued bone-forming

It seems

is solely philosophy themselves;

by the production demonstration we must

our attention.

of a specific enzyme is immaterial although may be anticipated. However, as orthopaedic manner the ununited fractures that case to as they in con-

treat

in a practical

demonstrate certainly

can

the do

While we may not be able in a given value of calcium and cod-liver oil, nevertheless, no harm, we must use them on theoretic grounds well-balanced light must
to operative

junction with shine as well

cases that prove

an otherwise as artificial
obstinate

also

nourishing not be

diet ; the use of sunneglected especially in

As surgeons we cannot

treatment.

fail to be impressed with the importance fragments by surgical procedures when cause as little local injury as possible.
SUMMARY

of a proper approximation necessary and by methods

of the which

The in certain Investigation tional surgical blood, in the clinical tures more

failure of a fracture to unite is difficult to explain. instances be due to constitutional causes is hardly to determine of treatment Study this factor is to be commended should be of the calcium used as a routine and phosphorus standpoint, may it rarely leads to average run

That it may to be doubted. and constituin addition to content of the prove of value information of frac-

methods methods.

if carried out from the investigative future although in routine work value. is in the frequently Successful great on majority correct as yet treatment of cases surgical unknown
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