Basic Principles and

Techniques of Internal
Fixation of Fractures

Brett D. Crist, MD
Original Author: Dan Horwitz, MD; March 2004
Revision Author: Michael Archdeacon, MD, MSE; January 2006
New Author: Brett D. Crist, MD; October 2009
Common Definitions of Fracture Healing
Union
Bones mechanical stability restored to withstand normal
loads
Clinically: no pain at fracture site
Radiographically: 3 out of 4 cortices with bridging callus
Delayed Union
Fx not consolidated at 3 months, but progressive callus
Non Union
No improvement clinically or radiographically over 3
consecutive months
A fibrocartilaginous interface
From: OTA Resident Course Russel, T
 High Energy vs. Low Energy
High Energy"
Direct axial load or bending force High
Fall from height/Motor vehicle crash Energy"
Soft tissue envelope significantly
damaged
Comminuted fracture patterns
Open fractures
Low Energy
Twisting mechanism or direct load on
weak bone
Fall from standing Low
Less soft tissue injury Energy"
Simple fracture pattern
 Fracture Patterns
Fracture patterns occur based on mode, magnitude
and rate of force application to bone
Bending Load transverse fx with wedge segment
3-point Bend Wedge fragment
4-point Bend Segmental fragment
Torsional Load oblique or spiral fx
Axial Load Articular impaction (Plateau, Pilon, etc.)
 Fracture Patterns
Understanding these patterns and the inherent
stability of each type is important in choosing the
most appropriate method of fixation and surgical
approach
 Biology of Bone Healing
THE SIMPLE VERSION...
Absolute Stability = Relative Stability =
10 Bone Healing 20 Bone Healing
Haversian Fibrous Matrix >
Remodeling Cartilage > Calcified
Cartilage > Woven
High Rate of Healing Bone > Lamellar Bone

Minimal Callus
Callus
Spectrum of Healing
Biology of Bone Healing
Direct/Primary bone healing
Requires rigid internal fixation
and intimate cortical contact
absolute stability
Minimal callus formation
Cannot tolerate fracture gap
Interfragmental compression will
minimize fracture motion
Relies on Haversian remodeling
with bridging of small gaps by
osteocytes (cutting cones)
Figure from: OTA Resident Course - Russel
Biology of Bone Healing
Indirect/Secondary Bone
Healing = CALLUS
Divided into stages
Inflammatory Stage
Repair Stage
Soft Callus Stage
Hard Callus Stage
Remodeling Stage
3-24 mo
Relative stability
Figures from: OTA Resident Course - Russel
 Practically speaking...
Primary/Direct Bone Secondary/Indirect Bone
Healing Healing
Simple fracture patterns Complex fracture patterns
See the fx during surgery Dont directly see the
and directly reduce and fracture during surgery
fix with: (use fluoro)
Lag screws Indirectly reduce the fx and
Plates and screws fix with:
IM Rods
Bridge plate fixation
External fixation
Cast
 Fixation Stability
Relative Stability
IM nailing
Ex fix
Bridge plating
Cast

Absolute Stability
Lag screw/ plate
Compression plate
 Spectrum of Stability

IM Nail

Ex Fix

Cast Bridge Plating Compression

Plating/ Lag
screw

Relative Absolute
(Flexible) (Rigid)
 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 No
callus
Absolute Relative
(Flexible) (Rigid)
 Functions of Fixation
Interfragmentary Intramedullary Nails
Compression Internal splint
Lag Screw Bridge plate fixation
Plate Functions Internal splint
Neutralization External fixation
Buttress
External splint
Bridge
Cast
Tension Band
External splint
Compression
Locking *Not internal fixation
 Indications for Internal Fixation
Displaced intra-articular fracture
Axial, angular, or rotational instability that
cannot be controlled by closed methods
Open fracture
Polytrauma
Associated neurovascular injury
MULTIPLE REASONS EXIST
BEYOND THESE...
 Benefits of Internal Fixation
Earlier functional recovery

More predictable fracture alignment

Potentially faster time to healing

 Screws
Cortical screws:
Greater number of threads
Threads spaced closer together (pitch is
(smaller pitch)
Outer thread diameter to core
diameter ratio is less
Better hold in cortical bone
Cancellous screws:
Larger thread to core diameter ratio
Threads are spaced farther apart (pitch is
greater)
Lag effect with partially-threaded screws
Theoretically allows better fixation in
cancellous bone
Figure from: Rockwood and Greens, 5th ed.
 Lag Screw Fixation
Screw compresses both
sides of fx together
Best form of compression
Poor shear, bending, and
rotational force resistance
Partially-threaded screw
(lag by design)
Fully-threaded screw (lag
by technique)
 Lag Screws
Lag by technique
Using fully-threaded
1
screw
Step One: Gliding hole =
drill outer thread diameter of 2
screw & perpendicular to fx
Step Two: Pilot hole= Guide
sleeve in gliding hole & drill
far cortex = to the core Figure from: Schatzker J, Tile M: The Rationale of
Operative Fracture Care. Springer-Verlag, 1987.
diameter of the screw
 Lag Screws
Step Three: counter sink near
cortex so screw head will sit
flush
Step Four: screw inserted and
glides through the near cortex
& engages the far cortex which Figure from: Schatzker J, Tile M: The
Rationale of Operative Fracture Care.
compresses the fx when the Springer-Verlag, 1987.

screw head engages the near

cortex
 Lag Screws
Functional Lag Screw Position Screw - note
- note the near cortex the near cortex has not
has been drilled to the been drilled to the
outer diameter = outer diameter = lack
compression of compression & fx
gap maintained
 Lag Screws

Malposition of screw, or neglecting to

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

Figure from: OTA Resident Course - Olsen

 Neutralization Plates
Neutralizes/protects
lag screws from
shear, bending, and
torsional forces
across fx
Protection Plate"

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

Operative Fracture Care. Springer-Verlag, 1987.
 Buttress / Antiglide Plates
Hold the bone up
Resist shear forces during
axial loading
Used in metaphyseal
areas to support intra-
articular fragments
Plate must match contour
of bone to truly provide
buttress effect
 Buttress Concepts
Order of fixation:
Articular surface compressed with
bone forceps and provisionally fixed
with k-wires
1. Bottom 3 cortical screws placed
Provide buttress effect
2. Top 2 partially-threaded cancellous
screws placed
Lag articular surface together
3. Third screw placed either in lag or
normal fashion since articular Figure from: Schatzker J, Tile M: The Rationale of
surface already compressed Operative Fracture Care. Springer-Verlag, 1987.
 Antiglide/Buttress Concepts
Plate is secured by three black screws distal to
the red fracture line
Axial loading causes proximal fragment to
move distal and to the left along fracture line
Plate buttresses the proximal fragment
Prevents it from sliding
Buttress Plate
When applied to an intra-articular fractures
Antiglide Plate
When applied to diaphyseal fractures
 Bridge Plates
Bridge/bypass
comminution
Proximal & distal fixation
Goal:
Maintain length, rotation, &
axial alignment
Avoids soft tissue
disruption at fx = maintain
fx blood supply
 Tension Band Plates
Plate counteracts natural
bending moment seen w/
physiologic loading of bone
Applied to tension side to
prevent gapping
Plate converts bending force
to compression
Examples: Proximal Femur &
Olecranon
 Tension Band Theory
The fixation on the opposite side from the articular surface
provides reduction and compressive forces at the joint by
converting bending forces into compression
The fracture has tension forces applied by the muscles or load
bearing
JOINT SURFACE

Tension band

Load applied to bone

 The tension band prevents distraction and the force is
converted to compression at the joint
The tension band functions like a door hinge,
converting displacing forces into beneficial
compressive forces at the joint
JOINT SURFACE

Tension band
Load applied to bone
 Classic Tension Band of the Olecranon
Wires can be used for tension
band as well
Ex: Olecranon and patella
2 K-wires from tip of olecranon
across fx site into anterior cortex
to 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
Figure from: Rockwood and Greens, 4th ed.
Bend down and impact wires
 Compression Plating
Reduce & Compress
transverse or oblique
fxs
Unable to use lag screw
Exert compression
across fracture
Pre-bending plate
External compression
devices (tensioner)
Dynamic compression w/
oval holes & eccentric
screw placement in plate
 Examples- 3.5 mm Plates
LC-Dynamic
Compression Plate:
stronger and stiffer
more difficult to contour.
usually used in the
treatment radius and ulna
fractures
Semitubular plates: Figure from: Rockwood and Greens, 5th ed.
very pliable
Figure from: Rockwood and Greens, 5th ed.
limited strength
most often used in the
treatment of fibula fractures
 Compression
Fundamental concept critical for primary bone
healing
Compressing bone fragments decreases the gap
and maintains the bone position even when
physiologic loads are applied to the bone. Thus,
the narrow gap and the stability assist in bone
healing.
Achieved through lag screw or plating
techniques.
 Plate Pre-Bending Compression
Prebent plate
A small angle is bent into the
plate centered at the fracture
The plate is applied
As the prebent plate compresses
to the bone, the plate wants to
straighten and forces opposite
cortex into compression
Near cortex is compressed via
standard methods
External devices as shown
Plate hole design
Plate Pre-Bending Compression
 Screw Driven Compression Device

Requires a separate drill/screw

hole beyond the plate
Concept of anatomic reduction
with added stability by
compression to promote primary
bone healing has not changed
Currently, more commonly used
with indirect fracture reduction
techniques
Figure from: Schatzker J, Tile M: The Rationale of
Operative Fracture Care. Springer-Verlag, 1987.
 Dynamic Compression Plates
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.

This maneuver can be

Figure from: Schatzker J, Tile M: The Rationale of
performed twice before
Operative Fracture Care. Springer-Verlag, 1987. compression is maximized.
 Dynamic Compression Plating
Compression applied
via oval holes and
eccentric drilling
Plate forces bone to
move as screw
tightened =
compression
Lag screw placement
through the plate
Compression can
be achieved and
rigidity obtained
all with one
construct
Compression plate
first
Then lag screw
placed through
plate if fx allows Figure from: Rockwood and Greens, 5th ed.
 Locking Plates
Screw head has threads that
lock into threaded hole in the
plate
Creates a fixed angle at
each hole
Theoretically eliminates
individual screw failure
Plate-bone contact not
critical Courtesy AO Archives
 Locking Plates
Must have reduction and compression done
prior to using locking screws
CANNOT PUT CORTICAL SCREW OR LAG
SCREW AFTER LOCKING SCREW
 Locking Plates
Increased axial
stability
It is much less
likely that an
individual screw
will fail
But, plates can still
break
 Locking Plates
Indications:
Osteopenic bone
Metaphyseal
fractures with short
articular block
Bridge plating
 Intramedullary Nails
Relative stability
Intramedullary splint
Less likely to break with
repetitive loading than
plate
More likely to be load
sharing (i.e. allow axial
loading of fracture with
weight bearing).
Secondary bone healing
Diaphyseal and some
metaphyseal fractures
 Intramedullary Fixation
Generally utilizes closed/indirect 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 bolts
Reduction can be
technically difficult in
segmental and
comminuted fractures
Maintaining reduction
of fractures in close
proximity to
metaphyseal flare may
be difficult
 Open segmental
tibia fracture treated
with a reamed,
locked IM Nail.

Note the use of

multiple proximal
interlocks where
angular control is
more difficult to
maintain due to the
metaphyseal
flare.
 Intertrochanteric/
Subtrochanteric fracture
treated with closed IM
Nail

The goal:
Restore length,
alignment, and
rotation
NOT anatomic
reduction

Without extensive
exposure this fracture
formed abundant callus
Valgus is restored...
by 6 weeks
 Reduction Techniquessome of
the options
Indirect Methods Direct Methods
Traction-assistant, fx table, Incision with direct fracture
intraop skeletal traction exposure and reduction with
Direct external force i.e. reduction forceps
push on it
Percutaneous clamps
Percutaneous K
wires/Schantz pins
Joysticks
External fixator or distractor
 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 must minimize
periosteal stripping and soft tissue damage.
EXAMPLE: supraperiosteal plating techniques
 Direct Reduction Technique
Pointed reduction clamps used to reduce a complex distal femur
fracture
Open surgical approach
Excellent access to the fracture to place lag screws with the
clamp in place
Remember, displaced articular fractures require direct exposure
and reduction because anatomic reduction is essential
 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
Plating through
modified incisions
Indirect reduction
techniques
Limited incision for:
Passing and positioning
the plate
Individual screw
placement
Soft tissue friendly
 Failure to Apply Concepts
Classic example of
inadequate fixation &
stability

Narrow, weak plate that is too

short
Insufficient cortices engaged
with screws through plate
Gaps left at the fx site

Unavoidable result =
Figure from: Schatzker J, Tile M: The Rationale of
Nonunion Operative Fracture Care. Springer-Verlag, 1987.
 Summary
Respect soft tissues
Choose appropriate fixation method
Achieve length, alignment, and rotational
control to permit motion as soon as possible
Understand the requirements and limitations
of each method of internal fixation

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