Basic Principles and

Techniques of Internal
Fixation of Fractures
Michael Archdeacon, MD, MSE
Original Author: Dan Horwitz, MD; March 2004
New Author: Michael Archdeacon, MD, MSE; Revised January 2006

Fracture Definitions
Union
Bone restored in terms of mechanical stability

Delayed Union
Fx not consolidated at 3 months, but appears
to be moving in that direction

Non Union
No improvement clinically or radiographically
over 3 month period
A fibrocartilaginous interface
From: OTA Resident Course Russel, T

High Energy vs Low Energy

High Energy"

High
Energy"

Energy imparted into the

bone disrupts the soft
tissue envelope as a very
destructive process

Low Energy
Less energy imparted into
the fracture environment,
thus a less destructive
process

Low
Energy"

Fracture Patterns
Fracture patterns occur based on mode of application,
magnitude and rate of force applied to bone
Bending Load = transverse fx or wedge segment
3-point Bend = Wedge fragment
4-point Bend = Segmental fragment

Torsional Load = oblique or spiral fx

Shear Load = Axial impaction (Plateau, Pilon, ect)

Fracture Patterns
Understanding these patterns and the inherent
stability or instability of each type is important in
choosing the most appropriate method of fixation

Biology of Bone Healing

THESIMPLEVERSION...
Relative
Stability =
20 Bone
Healing

Rigid Fixation
=
10 Bone
Healing
Haversion
Remodeling

High
HighRate
Rateof
ofHealing
Healing

Fibrous Matrix >

Cartilage > Calcified
Cartilage > Woven
Bone > Lamellar
Bone

Spectrum of Healing

Biology of Bone Healing

Primary bone healing
Requires rigid internal
fixation and intimate
cortical contact
Cannot tolerate soft tissue
interposition
Relies on Haversian
remodeling with bridging
of small gaps by osteocytes
Figure from: OTA Resident Course - Russel

Biology of Bone Healing

Secondary Bone Healing
= CALLUS
Divided into stages
Inflammatory Stage
Repair Stage
Soft Callus Stage
Hard Callus Stage
Remodeling Stage 324 mo
Figures from: OTA Resident Course - Russel

Practically speaking...
Plates and screws = Rigid Fixation
IM Rods = Relative Stability
Small Wire / Tension Band =
Relative Stability
Cast = Non-Rigid Fixation

Fixation Stability
Relative Stability
IM nailing
Ex fix
Bridge plating

Absolute Stability
Lag screw/ plate
Compression plate

Fixation Stability
Enders
Nails

IM Nail
Ex Fix

Cast

Unstable

Bridge Plating

Compression
Plating/ Lags

Spectrum of Stability

Stable

Practically speaking.
Most fixation probably involves
components of both types of healing. Even
in situations of excellent rigid internal
fixation one often sees a small degree of
callus formation...

Fixation Stability

Reality

Callus

Unstable

No
callus

Stable

Functions of Internal Fixation

Intrafragmentary
Compression
Lag Screw

Intrafragmentary
Compression & Plates
Dynamic Compression
Plating

Plate Functions

Neutralization
Buttressing
Bridging
Tension Band
Compression

Intramedullary Nails

Indications and Benefits of

Internal Fixation
Displaced intraarticular fracture
Axial or angulatory instability which cannot
be controlled by closed methods
Open fracture
Malreduction/interposed soft tissue
Multiple trauma
Early functional recovery
MULTIPLEREASONSEXISTBEYONDTHESE...

Screws
Cortical screws:
greater surface area of
exposed thread for any given
length
better hold in cortical bone

Cancellous screws:
core diameter is less
the threads are spaced farther
apart
lag effect option with partially
threaded screws
theoretically allows better
fixation in soft
cancellous
bone.

Figure from: Rockwood and Greens, 5th ed.

Lag Screw Fixation

Screw tensioned
across fx =
compression of fx
Terminal threads and
smooth shank
OR
Overdrill near cortex
& engage only far
cortex

Compression Lag Screws

Stability by compression
between bony fragments
Step One: Pilot hole = thread
diameter of screw &
perpendicular to fx
Step Two: Guide sleeve in pilot
hole & drill far cortex = to the
core diameter of the screw

Figure from: Schatzker J, Tile M: The Rationale of

Operative Fracture Care. Springer-Verlag, 1987.

COMPRESSION - LAG SCREWS

Step Three: Screw glides
through the near cortex
& only engages the far
cortex
Step Four: When screw
engages far cortex it
compresses it against the
near cortex
Figurefrom:SchatzkerJ,TileM:TheRationaleof
OperativeFractureCare.SpringerVerlag,1987.

Compression - Lag Screws

Functional Lag Screw
- note the near cortex
has been drilled to the
outer diameter =
compression

Neutralization Screw note the near cortex

has not been drilled to
the outer diameter =
lack of compression &
fx gap

Compression Lag Screws

Malposition can lead to a loss of reduction
Ideally lag screw should pass perpendicular to fx

Figure from: OTA Resident Course - Olsen

Neutralization Plates
Protect
intrafragmentary
compression (lag
screws) from
large forces
across fxs

The Neutralization Plate

Lag screws provide compression & initial stability
Neutralization plate bridges the fracture & protects
the screws from bending and torsional loads
Protection Plate"

Figure from: Schatzker J, Tile M: The Rationale of

Operative Fracture Care. Springer-Verlag, 1987.

Buttress / Antiglide Plates

Resist shear forces or
bending forces during
axial loading of fx
Stabilize intra-articular
fragments
Plate must be
contoured to fit the
bone
Screws placed to
minimize movement of
plate with tightening

Buttress Concepts
The bottom 3 cortical screws
provide the basis for the buttress
effect.
The top 3 screws are in effect
interfragmentary screws and the 2
top screws are lag screws because
they are only partially threaded.
Underbending the plate can be
advantageous in that it can increase
the force with which the plate
pushes against the proximal
fragment.
NOTE: screws are placed from
distal to proximal maximizing the
buttress action and aiding in
reduction.

Figure from: Schatzker J, Tile M: The Rationale of

Operative Fracture Care. Springer-Verlag, 1987.

Antiglide Concepts
In this model the white plate is secured by three black
screws distal to the red fracture line.
The fracture is oriented such that displacement from
axial loading requires the proximal portion to move
to the left.
The plate acts as a buttress against the
proximal portion, prevents it from sliding
and in effect prevents displacement from
an axial load.
If this concept is applied to an intraarticular
fracture component it is usually referred to as a
buttress plate, and when applied to a diaphyseal
fracture it is usually referred to as an antiglide
plate.

Buttress and Antiglide Plates

The plates on the right are
thin, pliable and often used
as buttress plates in the
distal radius
Those on the are left also
fairly thin and are designed
for subcutaneous antiglide
applications in the distal
tibia & fibula
Figure from: Rockwood and Greens, 5th ed.

Buttress Reconstruction Plates

Both small frag
(3.5mm) and large frag
(4.5mm) sizes
Often used to buttress
acetabular wall
fractures

Figurefrom:RockwoodandGreens,5thed.

Bridging Plates
Bridge comminution
with proximal & distal
fixation, but minimal
fixation in zone of
injury
Maintains length &
axial alignment
Avoids soft tissue
disrutpion @ fracture

Tension Band Plates

Plate counteracts
natural bending
moment seen w/
physiologic loading of
bone
Applied to tension side
to prevent gapping
Examples: Proximal
Femur & Olecranon

Tension Band Theory

The concept here is that a band of fixation at a distance from

the articular surface can provide reduction and compressive
forces at the joint.
The fracture has bending forces applied by the musculature or
load bearing and these forces have a component which is
perpendicular to the joint/cortical surface.
JOINTSURFACE

Tensionband

 Since the tension band prevents distraction at the

cortex the force is converted to compression at the
joint.
The tension band itself essentially functions
like a door hinge, converting displacing forces into
beneficial compressive forces at the joint.
JOINTSURFACE

Tensionband

Classic Tension Band of the Olecranon

2 K-wires up the ulnar shaft
maintain initial reduction
and anchor for the tension
wire
Tension wire brought through
a drill hole in the ulna.
Both sides of the tension wire
tightened to ensure even
compression
Bend down and impact wires
Figure from: Rockwood and Greens, 4th ed.

Compression Plating
Reduce & Compress
transverse or oblique
fxs
Exert compression
across fracture
Pre-bending
External compression
devices (tensioner)
Dynamic compression
w/ oval holes &
eccentric screw
placement in plate

Examples- 3.5 mm Plates

LC-Dynamic
Compression Plate:
stronger
more difficult to contour.
usually used in the treatment
radius and ulna fractures

Semitubular plates:
very pliable
limited strength
most often used in the
treatment of fibula fractures

Figurefrom:RockwoodandGreens,5thed.
Figure from: Rockwood and Greens, 5th ed.

Compression
Fundamental concept critical for primary bone
healing
Compressing bone fragments decreases the gap
the bone must bridge creating stability by
preventing fracture components from moving in
relation to each other.
Achieved through lag screw or plating
techniques.

Plate Pre-Bending Compression

Prebent plate
As plate is compressed,
prebend forces opposite
cortex into compression
Near cortex is compressed via
standard methods

Plate Pre-Bending Compression

Screw Driven Compression Device

Requires a separate drill/screw
hole beyond the plate
Replaced by the use of DCP
plates.
Concept of anatomic reduction
with added to stability by
compression to promote primary
bone healing has not changed
Currently used with indirect
fracture reduction techniques
Figure from: Schatzker J, Tile M: The Rationale of
Operative Fracture Care. Springer-Verlag, 1987.

DynamicCompressionPlates
Note the screw holes in the
plate have a slope built into
one side.
The drill hole can be purposely
placed eccentrically so that when
the head of the screw engages the
plate the screw and the bone
beneath are driven or compressed
towards the fracture site one
millimeter.

Figure from: Schatzker J, Tile M: The Rationale of

Operative Fracture Care. Springer-Verlag, 1987.

This maneuver can be

performed twice before
compression is maximized.

Dynamic Compression Plating

Compression applied
via oval holes and
eccentric drilling
Plate forces bone to
move as screw
tightened =
compression
DCP is a misnomer =
static compression is
applied once the screw
is tightened

Combined Plating and

Lag Screw
Compression can
be achieved and
rigidity obtained all
with one construct.

Figure from: Rockwood and Greens, 5th ed.

Intramedullary Nails
Relative stability
achieved via
intramedullary splint
Allows axial loading
of fracture
Healing primarily by
secondary bone
healing

Intramedullary Fixation
Generally utilizes closed or minimally open
reduction techniques
Greater preservation of soft tissues as
compared to ORIF
IM reaming has been shown to stimulate
fracture healing
Expanded indications i.e. Reamed IM nail is
acceptable in many open fractures

Intramedullary Fixation
Rotational and axial stability
provided by interlocking
screws
Reduction can be technically
difficult in segmental,
comminuted fractures
Fractures in close proximity to
metaphyseal flare may be
difficult to control

 Open segmental
tibia fracture treated
with a reamed,
locked IM Nail.
Note the use of
multiple proximal
interlocks where
angulatory control is
more difficult to
maintain due to the
metaphyseal
flare.

 Subtrochfracture
treatedwithclosed
IMNail.
Thegoalhereisto

restorealignment
androtation,notto
achieveanatomic
reduction.

Withoutextensive
exposurethis
fractureformed
abundantcallous
by6weeks.

Valgus is restored...

Reduction Techniquessome of
the options

Traction
Direct external force i.e. push on it
Percutaneous clamps - INDIRECT METHOD
Percutaneous K wires - INDIRECT METHOD
Minimal incision, debridement of hematoma
Incision and direct fracture exposure and
reduction- DIRECT METHOD

Reduction Techniques
Over the last 25 years the biggest change
regarding ORIF of fractures has probably
been the increased respect for soft tissues.
Whatever reduction or fixation technique is
chosen, the surgeon should attempt to
minimize periosteal stripping and soft tissue
damage.
EXAMPLE: supraperiosteal plating techniques

Reduction Technique
The use of a pointed reduction clamps to reduce a complex
distal femur fracture pattern.
Excellent access to the fracture to place lag screws with
the clamp in place
Can be done open or percutaneously, as long as the
neurovascular structures are respected.

Reduction Technique - Clamp and Plate

Place clamp over bone and the plate
Maintain fracture reduction
Ensure appropriate plate position proximally and distally with
respect to the bone, adjacent joints, and neurovascular structures
Ensure that the clamp does not scratch the plate, otherwise the
created stress riser will weaken the plate

Figure from: Rockwood and Greens, 5th ed.

Percutaneous Plating
ORIF Through
Modified Incisions
Nondisplaced Or
Minimally Displaced
Fxs
Indirect Reductions
Limited Hardware
Lag Screws

Failure to Apply Concepts

Classic example of
inadequate fixation &
stability
Narrow, weak plate
Insufficient cortices engaged
Gaps left at the fx site

Unavoidable result =
Nonunion
Figure from: Schatzker J, Tile M: The Rationale of
Operative Fracture Care. Springer-Verlag, 1987.

Summary
Respect soft tissues
Choose appropriate fixation method
Achieve stability, length, and rotational
control to permit motion as soon as possible
Understand the limitations and requirements
of methods of internal fixation
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