1 Principles of Internal Fixation 3

1 Principles of Internal Fixation

J. Schatzker

the fragment a bending or extrusion wedge. Because it

1.1 is extruded from bone under load, it retains little of its
Introduction soft tissue attachment and has therefore, at best, a pre-
carious blood supply. This must be kept in mind when
planning an internal fixation. Attempts to secure fixa-
1.1.1 tion with lag screws of such extruded fragments may
Mechanical Properties of Bone result in their being rendered totally avascular. If the
extruded wedge is very small, as in fractures of the
The principal mechanical function of bone is to act as radius and ulna, they may be ignored. If larger, as in
a supporting structure and transmit load. The loads fractures of larger tubular bones, it is best to leave
which bone has to withstand are those of pure com- them alone and use indirect reduction techniques to
pression, those of bending, which result in one cortex preserve whatever blood supply remains, and either
being loaded in tension and the other in compression, use a locked intramedullary nail for fixation, or if this
and those of torque, or twisting. Bone is strongest is not possible, a bridge plate.
in compression and weakest in tension. Fractures as Oblique fractures are also the result of a bending
a result of pure compression are therefore rare and force. The extrusion wedge remains attached to one
occur only in areas of cancellous bone with a thin cor- of the main fragments. The fissure between it and
tical shell. Thus, we find pure compression fractures the main fragment is not visible on X-ray. If looked
in such areas as the metaphyses, vertebral bodies, and for at the time of an open reduction, it can often be
the calcaneus. Transverse, oblique, and spiral are the found. During closed intramedullary nailing this
fracture patterns commonly seen in tubular bone. undisplaced extrusion wedge is often dislodged and
Transverse fractures are the result of a bending force becomes apparent on X-ray.
(Fig. 1.1). They are associated with a small extrusion Spiral fractures are the result of an indirect twisting
wedge that is always found on the compression side of force (Fig. 1.1). They often occur in combination with
the bone. If this extrusion wedge comprises less than spiral wedge fragments of corresponding configura-
10% of the circumference, the fracture is considered a tion. These fragments are larger and retain their soft
simple transverse fracture. If the extruded fragment is tissue attachment. It is frequently possible to secure
larger, the fracture is considered a wedge fracture, and them with lag screws without disrupting their blood

Fig. 1.1a–e. Types of fracture

patterns. A lateral bending force
can result in transverse fracture
(a), extrusion or bending wedge
fractures (b), or oblique fractures
(c) in which the extrusion wedge
remains attached to one of the
main fragments. A twisting or
torsional force may result in a
spiral fracture (d) or one with a
single or multiple spiral wedge
fragments (e) a b c d e

1.1 Introduction
4 J. Schatzker

supply. These differences in the degree of soft tissue tures of Long Bones (Müller et al. 1990). The unique
attachment and preserved blood supply are important feature of this system of classification is that the prin-
to consider in the choice of internal fixation. If one is ciples of the classification and the classification itself
dealing with a spiral wedge or a very large extrusion are not based on the regional features of a bone and
wedge, then their soft tissue attachment and blood its fracture patterns nor are they bound by conven-
supply will likely be preserved, and an attempt at tion of usage or the popularity of an eponym. They
absolutely stable fixation with lag screws would not are generic and apply to the whole skeleton. The phi-
render them avascular. If on the other hand the extru- losophy guiding the classification is that a classifica-
sion wedge is small of if the wedge is fragmented or if tion is worthwhile only if it helps in evolving the
one is dealing with a complex fracture, it is best not to rationale of treatment and if it helps in the evaluation
attempt absolutely stable fixation but resort to splint- of the outcome of the treatment (Müller et al. 1990).
ing and secure the fracture with a bridge plate. These Therefore the classification must indicate the sever-
remarks apply, of course, to fractures in metaphyseal ity of the fracture, which in this classification indi-
areas. Diaphyseal fractures are nailed by preference cates the morphological complexity of the fracture,
except in the forearm and humerus. the difficulties to be anticipated in treatment, and its
prognosis. This has been accomplished by formulat-
ing the classification on the basis of repeating triads
1.1.2 of fracture types, their groups and subgroups, and by
Types of Load and Fracture Patterns arranging the triads and the fractures in each triad in
an ascending order of severity. Thus there are three
Bone is a viscoelastic material. Fractures are there- fracture types A, B, and C in ascending order of sever-
fore related not only to the force but also to the rate ity. Each fracture type has three groups, A1, A2, and
of force application. Much less force is required to A3, B1, B2, and B3, and C1, C2, and C3, and each group
break the bone if the force is applied slowly and over three subgroups, A1.1, A1.2, etc. The groups and the
a long period of time than if it is applied rapidly: subgroups are also organized in an ascending order
bone is better able to withstand the rapid application of severity (please see Fig. 1.2). This organization of
of a much greater force. This force is stored, however, fractures in the classification in an ascending order of
and when the bone can no longer withstand it and severity has introduced great clinical significance to
finally breaks, it is dissipated in an explosive and the recognition of a fracture type. The identification
implosive fashion, causing considerable damage to of the Type indicates immediately the severity.
the soft tissue envelope. A good example of this is the The classification considers a long bone to have a
skier who walks away from a spectacular tumble, only diaphyseal segment and two end segments (Figs. 1.3,
to break his leg in a slow, twisting fall. The amount of 1.4). Because the distinction between the diaphy-
energy and the rate of force application are important sis and the metaphysis is rarely well defined ana-
factors since they determine the degree of associated tomically, the classification makes use of the rule of
damage to the soft tissue envelope. We therefore dis- squares to define the end segments with great preci-
tinguish between low- and high-velocity injuries. sion (Fig. 1.4). The location of the fracture has also
Low-velocity injuries have a better prognosis. been simplified by noting the relationship that the
They are more commonly the result of an indirect center of the fracture bears to the segment.
force application such as a twist, and the associated The authors of the Comprehensive Classification
fractures are spiral and the comminution is rarely of Fractures of Long Bones have also developed a
excessive. In high-velocity injuries the fractures are new terminology that is so precise that it is now pos-
not only more fragmented but also associated with a sible to describe a fracture verbally with such accu-
much greater damage to the enveloping soft tissues, racy that its pictorial representation is superfluous.
because of the higher energy dissipation and because The new precise terminology divides fractures into
of the direct application of force. simple and multifragmentary (Fig. 1.5). The multi-
fragmentary fractures are further subdivided into
wedge and complex fractures, not on the basis of the
1.1.3 number of fragments, but rather on the key issue of
Classification of Fractures whether after reduction the main fragments have
retained contact or not. In treatment this is, indeed,
The classification of fractures followed in this book the essence of severity. Thus, a multifragmentary
is based on the Comprehensive Classification of Frac- fracture with some contact between the main frag-

1.1 Introduction
 1 Principles of Internal Fixation 5
Fig. 1.2. The scheme of the classification of fractures for
each bone segment or each bone. Types: A, B, C; Groups: A1,
A2, A3, B1, B2, B3, C1, C2, C3; Subgroups: .1, .2, .3. The dark-
ening of the arrows indicates the increasing severity of the
fracture. Small squares: The first two give the location, the
next three the morphological characteristics of the fracture.
(From Müller et al. 1990)

ments is considered a wedge fracture. It has a rec-

ognizable length and rotational alignment. This is
lost in a complex fracture where contact between the
main fragments cannot be established after reduc-
tion (Fig. 1.6). Articular fractures are defined as
those that involve the articular surface regardless of
whether the fracture is intracapsular or not. A fur-
ther distinction exists between partial and complete
articular fractures (Fig. 1.7).
The diagnosis of a fracture is given by coupling the
location of the fracture with its morphologic com-
plexity. To facilitate computer entry and retrieval of
the cases, an alphanumeric code has been created.
Computers deal with numbers and letters better than
with words. The bones of the skeleton have been
assigned numbers (Fig. 1.8). The segments are num-
bered from one to three proceeding from proximal
to distal. Thus it is possible to express the location
of a fracture by combining the number of the bone
with the number expressing the involved segment:
for instance, a fracture of the proximal segment of
Fig. 1.3. The long bone. 1, Humerus; 2, radius/ulna; 3, femur;
the humerus would be 11- and a fracture of the distal 4, tibia/fibula. The blackened square indicates the portion of
femur would be 33-. The morphological nature of the the alphanumeric code being illustrated. (From Müller et al.
fracture is expressed by the combination of the letters 1990)

1.1 Introduction
6 J. Schatzker

Fig. 1.4. The determina-

tion of the segments of long
bones. The different squares
are parallel to the long axis of
the body and correspond to
the end segments. The mal-
leolar segment (44–) is not
represented here as it cannot
be compared with the other
end segments: 11–, 12–, 13–,
21–, 22–, 23–, 31–, 32–, 33–,
41–, 42–, 43–. (From Müller
et al. 1990)

A, B, and C, which denote the Type; with the numbers The issue of intra- and interpersonal reliability
1, 2, and 3, such as A1, A2, A3, B1, B2, etc., to denote of classification systems has received a great deal
the Groups, and A1.1, A1.2, A1.3, B1.1, B1.2, etc., to of attention in the recent literature. The authors of
denote the Subgroups. The diagnosis can be coded these articles fail to discern the essence of the cause
using an alphanumeric code (Fig. 1.9). As stated, this of the high discordance. The discordance is either the
alphanumeric code is intended strictly for computer result of the classifier not knowing the classification
entry and retrieval and not for use in verbal com- system or because the classifier lacked essential data,
munication. In verbal communication the clinician or relied on pictorial representation of the differ-
should use the terminology which is so precise that ent fractures, and had no method available to check
it describes the full essence of the fracture, making whether all the essential information was available at
a pictorial representation of the fracture no longer the time the fracture was being classified. In order
necessary. to provide the classifier with a check list of essential
We have validated this fracture classification in data which must be available before a fracture can
two separate clinical studies (J. J. Schatzker and P. be classified, the authors of the Comprehensive Clas-
Lichtenhahn, unpublished data; J. Schatzker and H. sification System have developed a system of binary
Tornkvist, unpublished data). The inter- and intrao- questions which allow the classifier to determine
bserver concordance has been evaluated for frac- with precision whether all the essential data neces-
ture types, groups, and subgroups. Concordance for sary to classify a fracture are available. If not, further
fracture types was close to 100%, for fracture groups imaging may be necessary before the classification
between 80% and 85%, but for fracture subgroups can be attempted. At times essential information, for
only between 50% and 60%. We feel, therefore, that instance the damage to the articular cartilage of the
the clinician should rely principally on the recogni- femoral head in an acetabular fracture, may not be
tion of the fracture types and groups. Classification available until the surgery has been completed.
into fracture subgroups should be reserved only for The Comprehensive Classification System has been
research studies. adopted by both the Arbeitsgemeinschaft für Osteo-

1.1 Introduction
 1 Principles of Internal Fixation 7
(Müller et al. 1991). In this most recent attempt a code
for the injury is assigned to each of the elements of
the soft tissue envelope rather than using an exist-
ing classification system. A new classification scheme
which would characterize the morphological compo-
nents of the soft tissue injury, identify its severity,
and indicate the potential functional loss in a simple
and comprehensive manner, and which could be
expressed in a simple code, would be of great value
clinically and in research.

Fig. 1.5. The diaphyseal fracture types. A, simple fracture;

B, wedge fracture; C, complex fracture. (From Müller et al.
1990)

synthesefragen/Association for the Study of Internal

Fixation (AO/ASIF) and Orthopaedic Trauma Associ-
ation (OTA) as their classification systems. Currently
these groups are attempting to complete the classifi-
cation of fractures and dislocations not included in
the published version of the Comprehensive Classi-
fication System and to subject their efforts to clinical
validation.
The classification of the soft tissue injury associ-
ated with open fractures continues to be a problem
requiring further elaboration. Many observers have Fig. 1.6. The groups of the diaphyseal fractures of the num-
attempted to grade open fractures (Allgöwer 1971; berus, femur, and tibia/fibula. A1, simple fracture, spiral; A2,
simple fracture, oblique (L30°); A3, simple fracture, transverse
Gustilo and Andersson 1976; Tscherne and Gotzen
(<30°); B1, wedge fracture, spiral wedge; B2, wedge fracture,
1984; Lange et al. 1985). A further classification of the bending wedge; B3, wedge fracture, fragmented wedge; C1,
soft tissue component of an injury was presented in complex fracture, spiral; C2, complex fracture, segmental; C3,
the third edition of the Manual of Internal Fixation complex fracture, irregular. (From Müller et al. 1990)

1.1 Introduction
8 J. Schatzker

Fig. 1.7. The fracture types of the segments

13- and 33-, 21- and 41-, 23- and 43-. A,
extra-articular fractures; B, partial articu-
lar fracture; C, complete articular fracture.
(From Müller et al. 1990)

1.1.4 a fracture is almost never the result of damage to the

Effects of Fracture bone itself; it is the result of damage to the soft tissues
and of stiffness of neighboring joints.
When a bone is fractured, it loses its structural con- In a closed fracture the injury to the surrounding
tinuity. The loss of the structural continuity renders tissue evokes an acute inflammatory response, which
it mechanically useless because it is unable to bear is associated with an outpouring of fibrinous and
any load. proteinaceous fluid. If, after the injury, the tendons
and muscles are not encouraged to glide upon one
another, inflammation may develop and lead to the
1.1.5 obliteration of tissue planes and to the matting of the
Soft Tissue Component and Classification soft tissue envelope into a functionless mass.
of Soft Tissue Injuries In an open fracture, in addition to the possible
scarring from immobilization, there is direct injury
We have alluded to the poorer prognosis of high- to the muscles and tendons and in such cases the
velocity injuries because of the greater damage to the effects of infection must be reckoned with. Indeed,
soft tissue envelope and to the greater devitalization infection is the most serious complication of trauma
of the involved bone. Long-term disability following because, in addition to the scarring related to the

1.1 Introduction
 1 Principles of Internal Fixation 9
initial trauma, infection compounds the fibrosis as a
result of the associated tissue damage and because of
the prolonged immobilization that is frequently nec-
essary until the infection is cured.
Stiffness in adjacent joints in nonarticular frac-
tures is also the result of immobilization. Prolonged
immobilization leads to atrophy of the articular car-
1 tilage, to capsular and ligamentous contractures, and
to intra-articular adhesions. The joint space normally
5 filled with synovial fluid becomes filled with adhe-
sions that bind the articular surfaces together. Added
to the local effects is, of course, the tethering effect of
2 the scarred soft tissues.
6 Although the significance of the soft tissue com-
ponent of open fracture injuries has been recognized
for a long time, the soft tissue component of closed
7 injuries has only recently been classified (Tscherne
and Brüggemann 1976; Tscherne and Östern 1982;
Tscherne and Gotzen 1984; Müller et al. 1991).
3

1.2
Aims of Treatment

4 The loss of function of the soft tissue envelope due

to scarring and secondary joint stiffness can only
be prevented by early mobilization. Thus, modern
fracture treatment does not focus on bone union at
the expense of function but addresses itself princi-
pally to the restoration of function of the soft tissues
8 and adjacent joints. A deformity or a pseudarthrosis
is relatively easy to correct in the presence of good
soft tissue function, while scarring, obliteration of
the soft tissue gliding planes, and joint stiffness are
often permanent. The modern fracture surgeon will
Fig. 1.8. The bones and their segments. An overview of the therefore direct treatment to the early return of func-
whole skeleton. 1, Humerus and its three segments: proximal,
diaphyseal, and distal; 2, radius/ulna and its three segments:
tion and motion, with bone union being considered
proximal, diaphyseal, and distal; 3, femur and its three seg- of secondary importance.
ments: proximal, diaphyseal, and distal; 4, tibia/fibula and its Modern functional fracture treatment does not
four segments: proximal, diaphyseal, distal, and malleolar; 5, denote only operative fracture care. It makes use of
spine and its three segments: cervical, thoracic, and lumbar; 6, specialized splinting of the bone in special braces that
pelvis and its two segments: extra-articular and the acetabu-
lum; 7, hand; 8, foot; 9, other bones: 91.1, patella; 91.2, clavicle;
allow an early return of function and motion. There
91.3, scapula; 92, mandible; 93, facial bones and skull. (From are, however, limitations to the nonoperative system,
Müller et al. 1990) which we will address as we discuss the different frac-

Fig. 1.9. The coding of the

diagnosis

1.2 Aims of Treatment

10 J. Schatzker

tures. It can be applied to fractures where angulation, employed may be rigid but the fixation of the frag-
rotation, and shortening can be controlled. Thus, it is ments may be unstable.
limited only to certain long bone fractures. Its appli- The introduction of compression introduced sta-
cation to intra-articular and periarticular fractures bility. Stability was achieved not by rigidity of the
is very limited. implant, but rather by impaction of the fragments.
Early return of full function following fracture The intimate contact of the fragments brought
can be achieved only by sufficiently stable internal about by compression restored structural continu-
fixation which will abolish fracture pain and which ity and stability and permitted the direct transfer
will allow early resumption of motion with partial of forces from fragment to fragment rather than via
loading without the risk of failure of the fixation the implant. Stable fixation restores load-bearing
and resultant malunion or nonunion. With non- capacity to bone. This greatly diminishes the stresses
functional methods full return of function is rarely borne by the implant and protects the implant from
achieved, and then only after a prolonged rehabilita- mechanical overload or fatigue failure.
tion period. Key (1932) and Charnley (1953) were the first to
make use of compression in order to achieve stable
fixation. Both applied it to broad cancellous surfaces
by means of an external compression clamp. Similar
1.3 attempts to achieve union of the cortex failed. The
Previous Experience with Internal Fixation resorption around the pins of the external fixator
employed to stabilize the cortical fragments was
Internal fixation is not a new science. The first half thought to be due to pressure necrosis of the cortex.
of the twentieth century has provided us with ample Cancellous surfaces under compression united rap-
documentation of the results of unstable internal fix- idly, and it was thought initially that compression
ation. Surgery has frequently proved to be the worst provided an osteogenic stimulus to bone. The failure
form of treatment. It destroyed the soft tissue hinges, of the cortex to unite led to general acceptance of the
interfered with biological factors such as the blood thesis that cancellous and cortical bone behaved dif-
supply and the periosteum, and was never sufficiently ferently and that they probably united by different
strong or stable to permit active mobilization of the mechanisms.
limbs with partial loading. Supplemental external Since then it has been demonstrated that, under
plaster fixation was often necessary. The emphasis conditions of absolute stability, both cancellous and
was on bone healing and not on soft tissue rehabilita- cortical fragments heal by what has been referred to
tion. Healing became evident when callus appeared. as primary direct or vascular bone union (primary
Unfortunately, unstable internal fixation was unpre- bone healing). The simple external fixator of Charn-
dictable and uncertain, and it frequently resulted in ley, applied closely to broad, flat cancellous surfaces
delayed union, nonunion, or deformity. When union of an arthrodesis, was able to achieve absolute sta-
did occur, instead of signifying the end of treatment bility. The same system applied to diaphyseal bone,
it merely signaled the beginning of a prolonged phase where tubular fragments rather than broad, flat sur-
of rehabilitation designed to regain motion in the soft faces were in contact, resulted in a system of relative
tissue envelope and in the stiff joints. The ravages instability with micromotion between the fragments.
of this prolonged nonfunctional form of treatment The resorption around the pins and at the fracture
were such that open reduction and internal fixation was due to motion and not due to pressure necrosis.
were looked upon as the last resort in the treatment Danis in 1949 (Müller et al. 1970) was the first to
of a fracture. demonstrate that cortical fragments stabilized by a
special plate, which was able to exert axial compres-
sion and bring about absolute stability at the frac-
ture, united without any radiologically visible callus.
1.4 Danis referred to this type of union as “primary bone
Rigidity and Stability healing.” Studies on experimental models of healing
under conditions of absolute stability by Schenk and
It is important to distinguish between rigidity and Willenegger (1963) revealed a different type of union
stability. Rigidity is the physical property of an than that commonly associated with the healing of
implant. It refers to its ability to withstand deforma- fractures. Union seemed to occur by direct formation
tion. Thus, in an internal fixation the fixation devices of bone rather than by callus and endochondral ossi-

1.2 Aims of Treatment

 1 Principles of Internal Fixation 11
fication. Different events were seen where bone was ing we see a biological phenomenon which is differ-
in contact and where gaps were present. ent from healing under conditions of relative stability
In areas of contact the healing was seen to be the which is associated with the formation of callus. The
result of proliferation of new osteons which arose so-called primary bone healing is in the early stages
from remaining open Haversian systems. The osteons, of healing weaker than bone bridged by a peripheral
the so-called cutting cones, grew parallel to the long concentric callus.
axis of the bone, through the necrotic bone ends, and
then across the fracture. These osteons can be viewed
as a myriad of tiny bone dowels that reestablish the
continuity of bone. The capillary buds that sprang 1.5
from the capillaries became cutting cones. These Methods of Absolutely Stable Fixation
consisted of osteoclasts, followed by the capillary
bud, surrounded by a cuff of osteoblasts that were
laying down bone. In this way, there was simultane-
ous bone resorption and deposition. This bridging of 1.5.1
a fracture by osteons, which gives rise to an osteonal Lag Screw
union, can occur only where bone is in direct contact
and where there is absolute stability of the fragments Compression exerts its beneficial effect on bone
without any movement at the interface. In this type union by creating an environment of absolute sta-
of union there is no net resorption at the fracture bility where no relative micromotion exists between
interface. For every bit of bone removed, new bone is the bone fragments. Healing is by primary union.
laid down. Under these circumstances, internal fixa- Therefore, viability of the bone fragments is not a
tion does not lead to a relative distraction of the frag- prerequisite to union. As long as absolute stability
ments, because no absolute resorption occurs. is maintained, the fragments will be revascular-
Areas of bone separated by gaps demonstrated first ized and remodeled and primary bone union will
of all an invasion of the gaps by blood vessels with occur. Articular cartilage also benefits from com-
surrounding osteoblasts. The osteoblasts laid down pression because absolute stability is necessary for
osteoid that served to bridge the gaps and to permit articular cartilage regeneration and healing (Mitch-
stage two to begin. Stage two is identical to contact ell and Shepherd 1980). Interfragmental compres-
healing, described above. Examination of human sion results in impaction of the fragments and in a
material (R. Schenk, personal communication) from marked increase in frictional resistance to motion. It
autopsies of patients who had had fractures oper- is therefore the most important and efficient method
ated upon revealed that the experimentally noted of restoring functional and structural continuity to
phenomena of contact and gap healing also occurred bone. It also greatly diminishes the forces borne by
clinically. The study of material from patients whose an internal fixation because the load transfer occurs
fractures had zones of comminution and which were directly from fragment to fragment. Stability is thus
fixed with lag screws and plates to secure absolutely achieved, not by rigidity of the implant, but rather by
stable fixation revealed that, although healing seemed compression and bone contact.
undisturbed, free fragments, whose blood supply had The simplest way of compressing two fragments
been interfered with, lagged very much behind in the of bone together is to lag them together with a lag
degree of revascularization and remodeling. Thus, screw. The lag screw is the simplest and most efficient
the rate of revascularization and union was seen to be implant in use for securing interfragmental compres-
influenced by the severity of comminution, the degree sion (Fig. 1.10).
of initial displacement – for this has a bearing on the The insertion of a screw into bone results in local
severity of devitalization of the fragments, by direct damage that triggers the mechanisms for immediate
reduction and by the methods of fixation as well as by repair. This is seen histologically as the formation of
the presence and degree of severity of the soft tissue new bone that closely follows the profile of the screw
lesion. These observations of interference with blood threads. Thus, after the insertion of a screw, as heal-
supply and delayed revascularization are of particu- ing occurs, the holding power of the screw increases,
lar importance with regard to implant removal, for reaching its peak between the sixth and eighth weeks.
not every fracture, nor all areas of the same fracture, The holding power then gradually declines to a level
will have advanced to the same degree of remodeling well above what it was at the time of insertion (Schatz-
at a given time from injury. With primary bone heal- ker et al. 1975b). This occurs because, as the bone

1.5 Methods of Absolutely Stable Fixation

12 J. Schatzker

Fig. 1.10a, b. The lag screw.

a The hole next to the screw
head is larger than the diam-
eter of the thread. This is
the gliding hole. The hole
in the opposite cortex is the
thread hole. As the screw is
tightened the two fragments
are pressed together. b Both
holes are thread holes. The
fragments cannot be com-
pressed. (From Müller et al.
1979)

a b

matures and becomes organized, much of the newly end in early failure because of mechanical over-
laid-down woven bone around the screw is resorbed. load. Therefore, the most common use of lag
Screws may be either self-tapping or non-self-tap- screws in the fixation of shaft fractures is in com-
ping. It was formerly thought that self-tapping screws bination with neutralization, buttress, or tension-
provided a poorer hold in bone because they created band plates that protect the screw fixation from
more damage at the time of insertion and became mechanical overload.
embedded in fibrous tissue rather than in bone
(Müller et al. 1979). This has been shown to be incor-
rect. The fibrous tissue forms as a result of instability 1.5.2
and motion between the implant and bone. Instabil- Lag Screw, Neutralization, and Buttressing
ity is seen histologically as bone resorption and the
formation of fibrous tissue, with occasional islands Neutralization plates or protection plates are used to
of cartilage and synovial-like cells (Schatzker et al. protect the primary lag screw fixation. They con-
1975a). Size for size, the different thread profiles of duct part or all of the forces from one fragment to
self-tapping and non-self-tapping screws have almost the other. In this way they protect the fracture fixa-
the same holding power. The advantage of the non- tion from the forces of bending shear and rotation
self-tapping screws is that they can be inserted into (Fig. 1.12).
bone with far greater ease and precision, particularly In metaphyseal areas the cortex is very thin, and
when the screw comes to lie obliquely through thick if subjected to load it can fail. Such failures result in
cortex, which it often does when used to lag frag- deformity and axial overload of the joint. Therefore,
ments. Self-tapping screws offer the advantage of internal fixation in metaphyseal areas requires pro-
speed and are best suited for the fixation of plates to tection with plates that support the underlying cortex.
bone. These are referred to as buttress plates (Fig. 1.13). But-
In order to exert the most efficient degree of tressing may also be achieved with external fixation.
interfragmental compression, lag screws must be
inserted into the center of fragments and at right
angles to the fracture plane (Fig. 1.11). A single 1.5.3
lag screw is never strong enough to achieve stable Tension Band Plate and Compression Plate
fixation of diaphyseal fragments. A minimum
of two, and preferably three screws are required. Short oblique or transverse fractures do not lend
This means that only long oblique and long spiral themselves to lag screw fixation. In diaphyseal
fractures can be stabilized with lag screws alone regions of the tibia and femur and occasionally the
and only in short tubular bones such as phalanges, humerus, as will be seen in the section on splinting,
metacarpals, metatarsals, or malleoli. If lag screws we prefer intramedullary nailing for fixation. There
alone are used for the fixation of long bones such are many transverse or short oblique fractures of
as the femur or the humerus, they almost always diaphyses, such as of the radius and ulna, of the

1.5 Methods of Absolutely Stable Fixation

 1 Principles of Internal Fixation 13

a
b

c
d

Fig. 1.11. a,b In order to exert the most efficient degree of compression, lag screws must be inserted into the center of the
fragments and at right angles to the fracture plane. If they are off-center or angled, the fragments may displace on tightening of
the screw, and reduction will be lost. c A lag screw inserted at a right angle to the fracture plane results in the best compression
but does not provide the best stability under axial load, because the fragments may glide upon one another as the screw tips in
the thread hole. d A lag screw at right angles to the long axis of the bone may cause tendency for the fragments to displace as
the screw is tightened, but it provides the best resistance to displacement under axial load. Displacement can occur only if the
thread rips out of the thread hole or the screw head sinks into the gliding hole. (From Müller et al. 1979)

Fig. 1.12 a–c. The neutralization plate. The two lag screws provide inter- Fig. 1.13. The buttress plate. The T
fragmental compression (a,b). The neutralization plate in c bridges the plate buttresses the cortex and prevents
fracture zone and protects the lag screw fixation from bending and tor- axial displacement. (From Müller et al.
sional forces. (From Müller et al. 1979) 1979)

1.5 Methods of Absolutely Stable Fixation

14 J. Schatzker

humerus, or of long bones close to or involving the

metaphyses, which do not lend themselves to intra- 1.6
medullary nailing. Yet these fractures require stable Methods of Relative Stability or Splinting
fixation. Such fracture patterns can be stabilized
by compression, but the compression has to be in
the long axis of the bone. Such compression can be
generated only by a plate. If a fracture is reduced 1.6.1
and a plate is applied to the bone in such a way External Skeletal Fixation
that axial compression is generated, either by means
of the tension device or by the self-compressing As we have seen from the classical experiments of Key
principle of the dynamic compression (DC) plates (1932) and Charnley (1953), axial compression can be
or limited contact-dynamic compression plate (LC- applied by means of pins which traverse bone and are
DCP), the plate is referred to as a compression plate then squeezed together. This type of fixation is stable
(Fig. 1.14a,b). over only a short length of the bone and only when
Certain bones such as the femur are eccentri- broad, flat, cancellous surfaces are being compressed.
cally loaded. This results in one cortex being under When applied to tubular bone, such fixation is relatively
compression and the other under tension (Müller et unstable. Although not absolutely stable, the exter-
al. 1979; Schatzker et al. 1980). If a plate is applied nal fixator, either as a full frame or as a half frame, is
to the tension side of a bone and placed under ten- extremely useful under certain clinical circumstances,
sion which causes the cortex under the plate to be such as in the treatment of open fractures not suitable
compressed, such a plate not only achieves stabil- for internal fixation, or in the treatment of infected
ity because of the axial compression it generates, fractures or infected nonunions or in the treatment of
but also, because of its location on the tension side closed fractures of the end segment such as the distal
of the bone, as bending forces are generated under radius, or when one wishes to delay the metaphyseal
load, it is capable of increasing the amount of axial reconstruction because of the severity of the closed soft
compression. Such a plate is referred to as a tension tissue injury. Under these circumstances the external
band plate (Fig. 1.15). fixator provides sufficient stability to permit functional

Fig. 1.14. a As the tension device is tightened, the plate is

brought under tension and the bone under compression.
(From Müller et al. 1979). b The dynamic compression plate.
As the load screw is tightened it moves from its eccentric
position to the center of the screw hole. This movement of
screw and bone toward the fracture results in axial compres-
sion. (From Allgöwer et al. 1973) b

1.5 Methods of Absolutely Stable Fixation

 1 Principles of Internal Fixation 15
that allows a nail to control angulation and transla-
tion. Intramedullary reaming is frequently employed
to enlarge the area of contact between the endosteum
and the nail. This enlarges the medullary canal suf-
ficiently to permit the insertion of a nail which is
not only large enough to provide stability but also
strong enough to take over the function of the bone.
Old small nails adapted to the size of the medullary
canal were frequently limited in size to the diameter
of the isthmus, which in young patients is frequently
narrow. As a result, they were rarely strong enough
Fig. 1.15. Tension band plate. In an eccentri- and usually too flexible. Their use led to complica-
cally loaded bone, not only does a compres- tions such as nail migration, nail bending, nail frac-
sion plate secure a degree of compression at ture, delayed union, and nonunion.
rest, but also, when the bone is loaded, the The biological expression of unstable fixation of
bending force so generated is converted by viable fragments of bone is the formation of external
the action of the plate into further compres-
sive stresses. Such a plate is called a “ten- callus. The instability associated with intramedullary
sion band plate” and the force generated nailing is reflected in the amount of callus produced.
“dynamic compression.” The essence of A large intramedullary nail may, when tightly wedged,
dynamic compression is that although the provide sufficient stability to result in primary bone
compressive force fluctuates in magnitude it healing without discernible callus. Most often, how-
never reverses direction
ever, a variable amount of periosteal callus is seen.
As a mode of fixation of weight-bearing extremi-
use of the extremity while maintaining the bones in ties, intramedullary nailing has distinct advantages.
their reduced position. The stability is sufficient in fresh Because it is a load-sharing device and much stron-
fractures to render the extremity painless and encour- ger than a plate, weight bearing can be resumed much
age soft tissue rehabilitation. Because external skeletal earlier after intramedullary nailing than after other
fixation does not result in absolute stability, it behaves means of fixation.
similarly to unstable internal fixation in retarding or Intramedullary nailing prior to the introduction
discouraging bone union. Therefore, when it is used of locking, because of the mode of application and
as the definitive mode of fixation of open diaphyseal the manner in which the nail rendered stability, was
fractures it should almost always be combined with best suited for fractures in the middle one-third of
bone grafting. These statements are true for external the femur and of the tibia. The proximal and distal
fixators, which combine large pins with bars or tubes ends of tubular bones widen into broad segments of
to form frames. Small wires under tension in combina- cancellous bone. In these areas the nail can provide
tion with rings as employed by Ilizarov and many other neither angular nor rotational stability. Axial stability
surgeons provide much greater axial stability and are of a nailed fracture depends on cortical stability and
more successful as a definitive method of treatment, on the ability of the cortex to withstand axial loads.
leading to union in situations in which large pins with Thus, certain fracture patterns were not ideally suited
bars or tubes would result in failure of healing without for intramedullary nailing. These were: long oblique
supplemental bone grafting. and long spiral fractures, and comminuted fractures
in which the cortex in contact was less than 50% of
the diameter of the bone at that level.
1.6.2 An intramedullary nail has distinct mechanical
Intramedullary Nailing and biological advantages. Because of its design and
mode of application it is much stronger than a plate.
The manner in which an intramedullary nail splints Consequently, it will withstand loading for a much
and bestows stability is best likened to a tube within longer period of time than a plate before failure.
a tube. The nail is therefore dependent upon the Reaming combined with closed insertion of the nail
length of contact with cortical bone for its resistance without disturbing the soft tissues surrounding the
to bending and upon friction between the nail and fracture has been associated with a much more rapid
bone and the interdigitation of fracture fragments for and more abundant appearance of callus. Thus, it is
rotational stability. It is the contact with cortical bone an ideal device for tubular bones.

1.6 Methods of Relative Stability or Splinting

16 J. Schatzker

The limitations imposed on the conventional nail of solid unreamed nails for the femur and for the
by the location of a fracture and its pattern have tibia (Synthes). The unreamed solid nail for the
given rise to the development of the interlocking nail femur (Synthes) is a second-generation implant that
(Kempf et al. 1985). The first-generation interlocked embodies a number of very elegant proximal lock-
nails greatly extended the indications for intra- ing techniques.
medullary nailing to fractures of the proximal and
distal part of the diaphyseal segment of the femur
and tibia. Certain fractures of the proximal femur, 1.6.3
such as subtrochanteric fractures involving the Bridge Plating
lesser trochanter or associated with intertrochan-
teric fractures, could not be stabilized with the first- Once reduction is achieved a fracture must be immo-
generation nails. This stimulated the development of bilized. The approach of the early AO/ASIF school
the second-generation nails such as the reconstruc- in the treatment of a multifragmentary fracture was
tion nail (Smith Nephew Memphis, TN, USA) or the to secure stable fixation of each of the fragments
short and long gamma nail (Howmedica) and more (Fig. 1.16) and in this way convert the many pieces
recently the PFM (proximal femoral nail; Synthes, into a solid block of bone. The emphasis was on abso-
Paioli, PA, USA). lute stability, and primary union of bone was the
For many years intramedullary reaming was con- object of an internal fixation. Because multifragmen-
sidered an essential component of modern intra- tary fractures united very slowly, it was mandatory
medullary nailing techniques because it not only to bone-graft them in order to prevent failure of the
improved the stability of the fixation, but, more fixation with the resultant malunion or nonunion.
importantly, surgeons were able to use larger nails, Experience with closed locked intramedullary nail-
thus avoiding the complications of nail bending and ing strongly suggested that leaving the fragments
breakage. A number of studies (Rhinelander 1973; alone preserved their blood supply and greatly accel-
Perren 1991; Waelchli-Suter 1980) demonstrated erated their union.
that reaming produces extensive damage to the end- Extramedullary splinting was tried with a plate
osteal blood supply of bone. The desire to use intra- (Heitemeyer and Hierholzer 1985). In this technique
medullary nailing for the fixation of open fractures of plating the fracture is first reduced by means of
and recognizing the fact that dead bone would fur- indirect reduction. The zone of fragmentation is then
ther infection led to the development of unreamed bridged with a plate that is fixed to the proximal and
nails. Metallurgical and technical advances have distal main fragments. This maintains length, rota-
overcome many of the early problems of bend- tion, and axial alignment but reduction is not ana-
ing and fracture with small-diameter nails. Recent tomical. This type of internal fixation is referred to as
experimental evidence that hollow nails appear to bridge plating. It is a form of splinting. It is not abso-
support infection has given rise to the development lutely stable and union is by callus. Bridge plating is

Fig. 1.16. In this manner of internal fixation

each fragment is lagged to the other, converting
the many pieces into a solid block of bone. The
necessary stripping robs these fragments of their
blood supply (from Müller et al. 1970, p56, Fig.
49c)

1.6 Methods of Relative Stability or Splinting

 1 Principles of Internal Fixation 17
indicated only for the fixation of multifragmentary 1.6.4
fractures. If one chooses to plate a simple transverse Methods of Reduction
or oblique fracture, then absolute stability must be
achieved by means of interfragmental compression, Direct reduction is the direct manipulation of bony
or excessive strain at the fracture site will likely cause fragments during an open reduction of a fracture.
failure. As a prerequisite, the fracture site must be exposed,
In stable fixation of a multifragmentary fracture, which results in the stripping of soft tissue attach-
union depends on the revascularization of the dead ments and periosteum. The reduction is usually car-
fragments. As a result union is slow and failure to ried out with the help of surgical instruments such as
bone-graft is the most common cause of failure of levers and bone-holding clamps. It is a major cause
stable internal fixation. The bone graft is required of devitalization of bony fragments.
to form a biological bridge opposite the plate and Indirect reduction is the reduction of a fracture by
in this way protect the internal fixation. In bridge means of traction. In fractures that are being treated
plating the union is rapid, and by callus. As a result by closed methods, it is the principal method of
the techniques of indirect reduction and bridge securing reduction. Reduction of the fragments fol-
plating have made bone grafting of diaphyseal and lows because of the application of an external force
metaphyseal multifragmentary fractures unnec- and because of the soft tissue attachments of the frag-
essary. Bone grafting is now largely reserved for ments. As traction is applied, the fragments tend to
metaphyseal defects of articular fractures and for approximate themselves into reduction. Similar tech-
open fractures. niques have been adapted to open reduction in order
Not all fractures of long bones lend themselves to to preserve the blood supply to the bony fragments
these techniques. Anatomical reduction of the diaph- and in order to simplify the reduction. Simple pull on
yses of the femur, of the tibia and of the humerus is a limb during an open reduction and the reduction
not necessary. As long as length, rotation, and axial of a fracture on a fracture table are classic examples
alignment are restored there will be no interference of indirect reduction. The fragments are not manipu-
with function. The radius and the ulna are an excep- lated directly, and their soft tissue attachment is not
tion. Pronation and supination and normal elbow disturbed. As a result there is minimal interference
and wrist function depend on the preservation of with their blood supply.
the normal anatomical shape and relationship of Indirect reduction with the use of the distractor
these two bones. Therefore anatomical reduction of (Fig. 1.17) is a much more efficient technique because
these two bones is mandatory, and absolute stability the distractor is fixed to the fragments being reduced.
of internal fixation is still the goal here. A multifrag- As a result the distraction is controlled and much less
mentary fracture of the radius and ulna, despite the force is required. The distractor can be used alone
use of indirect reduction techniques, thus requires to help in the reduction of a fracture (Fig. 1.18), as
bone grafting to accelerate union. is most often the case in the reduction of diaphyseal

Fig. 1.17. The femoral dis-

tractor. This type will allow
distraction, interlocking, and
manipulation of the proxi-
mal and distal fragment of
the femur in all planes. (From
Mast et al. 1989)

1.6 Methods of Relative Stability or Splinting

18 J. Schatzker

Fig. 1.18. a A simple fracture of the mid-

shaft of the femur. Holes 4.5 mm in diam-
eter are made in the proximal and distal
fragments such that they will not interfere
with the definitive implant after reduction.
b With the femoral distractor attached,
distraction of the fracture fragments is
carried out. With distraction there is a ten-
dency towards straightening of the femur
and, if distraction forces are high, creating
a deformity in the opposite direction from
the distraction force – in this case a varus.
c The tendency towards straightening may
a be corrected by carrying out the distraction
over a bolster. The bolster acts as a fulcrum
to maintain the antecurvatum of the femur.
(From Müller et al. 1991)

fractures, but also most effectively in combination multifragmentary, preservation of the blood supply
with plates in the reduction of metaphyseal frac- to fragments greatly aids in union, but in order to
tures such as supracondylar fractures of the femur achieve union the correct mode of fixation must be
(Fig. 1.19). One can also use the articulating ten- chosen. As already outlined for simple fractures and
sion device in its distracting mode to secure indirect articular fractures, absolute stability is required. For
reduction, but this first requires the fixation of a plate multifragmentary fractures, splinting by either a nail
to one of the main fragments of a fracture (Fig. 1.20). or a bridge plate is the method of choice.
Lastly, the implant itself can be used to secure reduc-
tion of a fracture. The classic example of this is the
reamed intramedullary nail. As the nail fills the med-
ullary canal it secures axial realignment of the frac- 1.7
ture. A straight plate, when properly contoured, can Changes to the Early Concepts in Internal
also be used to secure reduction (Fig. 1.21). Fixation
Indirect reduction techniques are very important
because they not only help to preserve the blood At the time of the founding of the AO, the prevailing
supply to bone, but also because they make the reduc- schools of fracture treatment, such as the schools
tion easier and therefore safer. It must be kept in of Sir Reginald Watson-Jones in Great Britain and
mind, however, that indirect reduction alone will not Böhler in continental Europe, concentrated on bone
bring about union. Whether the fracture is simple or union. In contrast the AO concentrated on function.

1.6 Methods of Relative Stability or Splinting

 1 Principles of Internal Fixation 19
Fig. 1.19. a A severely comminuted frac-
ture of the distal femoral shaft extending
into the supracondylar and intracondy-
lar area. The articular segment has been
reconstructed and fixed. The blade plate
has been inserted. The connecting bolt has
been placed in the first hole of the plate,
and the femoral distractor has spanned the
comminuted area and portion of the femo-
ral shaft to be plated. The plate is attached
to the proximal fragment by means of a
Verbrugge clamp. b Using a small instru-
ment, such as a dental pick, comminuted
fragments with their soft tissues attached
are gently teased into approximate reduc-
tion. (From Mast et al. 1989)

a b

Fig. 1.20. The articulating tension device

is placed as close as possible to the end
of the plate and the tab turned to the dis-
traction mode. The device is fastened to
the bone by means of a uni- or bicorti-
cal screw, depending on the quality of
the bone. Distraction is then carried out
according to how much elongation of the
segment is needed, determined in the pre-
operative plan. If the fracture morphol-
ogy allows, the Verbrugge clamp may be
tightened, the articulating tension device
turned into compression mode, and an
attempt made to load the fracture. It may
be surprising, but by using pointed reduc-
tion clamps in a couple of key places, a
comminuted fracture can be impacted
and preloaded so that both mechani-
cal stability and biological viability are
achieved. Lag screws are inserted in the
location previously occupied by clamps.
However, in highly comminuted fractures
this will be impossible, and a pure but-
tress function of the plate is all that can be
realized. (From Mast et al. 1989)

1.7 Changes to the Early Concepts in Internal Fixation

20 J. Schatzker

a b c

Fig. 1.21a–c. Reduction of a distal third oblique fracture using an antiglide plate. a Following surgical exposure, a seven- to
ten-hole plate, depending on the fracture, is selected. It is first twisted so that there is a torsion in the plate of approx. 25°, then
it is placed in a bending press and a mild concavity is pressed into its distal two-thirds. This may be checked at surgery by using
a marking pencil and a 20-cm length of suture thread to draw an arc on a flat surface against which the curve of the plate can
be checked. The curvature may also be ascertained by a comparison AP X-ray of the opposite side. b The plate is then fixed
to the distal fragment at the level of the buttress of the medial malleolus with one screw. Care must be taken not to enter the
joint with the screw because it is so low and because the curve of the plate has the natural tendency to direct the screw into the
joint. There the normal 3.2-mm drill guide is used and a screw is inserted parallel with the joint. The screw is snugged but not
definitively tightened. The plate is then rotated around the distal screw until its original orientation to the distal fragment is
correct in the sagittal plane. The fit of the plate against the proximal fragment will be a little tight at this point. To accommo-
date this, the distal screw may need to be loosened slightly The tightness of the proximal end of the plate against the proximal
fragment represents the plate-bone interference that in the end will reduce the fracture. With only the distal screw in place,
the alignment of the fractures will be improved. At this time rotation should be corrected by gently twisting the patient’s foot,
and therefore the distal fragment, in the appropriate direction. c When little or no shortening is present, the next screw hole is
drilled through the plate with a neutral drill guide. The screw length, which will be a little greater because the plate is not yet
positioned snugly against the bone, is measured and the screw is tapped and inserted. The distal screw and the second screw
are then tightened together, but not definitively. The distal fragment of the fractured bone will be drawn in toward the plate.
(From Mast et al. 1989)

The AO group felt that immobilization resulted in sufficiently strong and lasting to allow functional use
plaster disease which was characterized by atrophy without the danger of nonunion or malunion.
of the soft tissues, severe osteoporosis, thinning of Stability of the fixation was achieved by com-
articular cartilage, severe joint stiffness, and cau- pression, which recreated the structural continu-
salgic pain. To fight this disease the AO introduced ity of the bone. The lag screw became the building
“functional rehabilitation,” a concept of fracture care block of stable internal fixation, and where neces-
based on the fact that if one achieved absolutely stable sary it was combined with protection or neutraliza-
fixation of a fracture, then fracture pain would be tion plates or buttress plates. Simple transverse or
completely abolished. This made it possible for the oblique fractures, because they could not be stabi-
patient to move the extremity almost immediately lized by means of lag screws, were brought under
after surgery and commence rehabilitation while the axial compression by means of compression plates.
fracture was healing. The emphasis in fracture treatment was on mechan-
This type of fracture treatment required the reduc- ical stability, and the goal of internal fixation was to
tion to be anatomical and the fixation of the fracture take many pieces of bone and convert them into a
not only sufficiently stable to abolish all pain, but also single solid block.

1.7 Changes to the Early Concepts in Internal Fixation

 1 Principles of Internal Fixation 21
Simple fractures of the mid-diaphysis of long bones in the presence of bone necrosis result in non-union.
such as the femur and tibia could also be treated by Under conditions of absolute stability such as with
intramedullary nailing. Although this form of treat- lag screw fixation, union takes place thorough a pro-
ment, called splinting, achieved sufficient stability to cess called primary bone union. In this type of union
allow functional aftertreatment, it did not provide the dead bone stimulates in the adjacent living bone
absolute immobilization of fragments, which there- a proliferation of capillary buds which form the
fore healed with callus. In contrast, bone immobilized so-called cutting cones. These grow from the living
by means of interfragmental compression, and there- bone into the dead bone, forming new osteons that
fore stable, healed without the radiological evidence not only bridge the fracture but eventually also lead
of callus by what was referred to as primary bone to revascularization of the dead bone fragment. Pri-
union. mary bone union in reality is the remodeling of dead
Bone grafts were used frequently to ensure union of bone in the presence of absolute stability at the frac-
plated multifragmentary fractures and to fill defects ture. Such union is much slower than union with the
in both cortical and metaphyseal bone. Indeed, fail- formation of callus, and the revascularization of the
ure to bone-graft was the most frequent cause of fail- bone fragments is even slower. This must be kept in
ure of an internal fixation. mind when removal of fixation devices is being con-
More than 40 years have passed since the formu- sidered. Devices used to provide absolute stability
lation of the initial AO principles and methods. The should not be removed from large tubular bones in
initial goals of the AO – the improvement of frac- less than two years, even though the bone may have
ture care with emphasis on the return of full func- the radiological appearance of having remodeled
tion – have remained the same. There have been completely. Premature removal results in refractures.
major changes, however, in principles, techniques, The appreciation of these fundamental differences is
and implants. The most significant change has been the key to choosing the correct technique of internal
a shift of emphasis from the mechanical to the bio- fixation of a fracture. This applies also to the treat-
logical aspects of internal fixation, with great empha- ment of articular fractures.
sis on the preservation of the blood supply of bone
and of soft tissue. This has led to the development
of new methods of surgical reduction, approaches, 1.7.1
and exposure, and methods of stabilization. The Articular Fractures
recently developed minimally invasive approaches
with specially designed and developed techniques In the 1960s and 1970s, the principles of internal
and implants to achieve fixation, which fall under the fixation and stability were the same for articular frac-
acronym of MIPO (minimally invasive plate osteo- tures and for fractures of the diaphysis. In the years
synthesis), are an example. to follow we came to appreciate that the mechanical
Paralleling these changes at a more fundamental and biological requirements of articular and diaph-
level has been the recognition that only living bone yseal fractures are different. This has led to major
is capable of overcoming motion at the fracture by alterations in the principles and methods of their
the formation of callus which then leads to union. treatment.
This has led to a rational approach in the choice of The principles of articular fracture surgery –
treatment methods. If the bone is alive, then splint- – Atraumatic anatomical reduction of the articular
ing methods such as bridge plating and intramedul- surface
lary nailing, which provides only relative stability, – Stable fixation of the articular fragments
will lead to rapid union with abundant and strong – Correction of axial deformity
callus. If on the other hand blood supply and other – Metaphyseal reconstruction with bone grafting of
biological factors have been compromised as in an defects
open fracture, then if one chooses splinting, or even – Buttressing of the metaphysis
absolutely stable fixation, a bone graft is likely to be – Early motion
required to facilitate and accelerate union. If in con- – still apply today. What has changed is the timing
trast one is dealing with a fracture situation where of the different steps of the metaphyseal recon-
one or more fragments are necrotic, then one must struction.
choose absolutely stable fixation in order to achieve
union. A fracture of the proximal pole of the scaph- Articular reconstruction must be undertaken as
oid is a good example. Methods of relative stability early as possible and with the least trauma to the tis-

1.7 Changes to the Early Concepts in Internal Fixation

22 J. Schatzker

sues. A delay leads to permanent deformity because the goals, to the biological era, with emphasis on
articular fragments unite rapidly and defy late the biological aspects of internal fixation with splint-
attempts at reduction. The nature of the intraarticu- ing, relative stability, and healing with callus as the
lar fracture is a factor to consider. A simple articu- preferred method. Today the dominant theme in the
lar fracture can be taken apart and reduced even at fixation of diaphyseal fractures of long bones is the
6 weeks. A multifragmentary articular fracture with status of the soft tissue envelope combined with the
impaction of the fragments already at 4 weeks may biology of bone and the preservation of the blood
defy attempts at reduction. Articular cartilage does supply to bony fragments. Absolute stability is no
not remodel. Any residual incongruity becomes longer the object of internal fixation.
permanent and can lead to post-traumatic arthritis
(Llinas 1993, 1994). In contrast, the diaphysis and 1.7.2.1
metaphysis have tremendous capacity for remodel- Locked Intramedullary Nailing
ing. Furthermore, any residual deformity can be rela-
tively easily corrected by osteotomy. Whereas at one time the lag screw and plates were
The preservation of the viability and integrity of the building blocks of stable internal fixation of frac-
the soft tissue envelope of the metaphysis is the key tures of the diaphysis, today the locked intramedullary
to success (Marsh and Smith 1994; Stamer 1994). nail has become the choice implant for the fixation of
Thus, external fixation is frequently used as a tempo- diaphyseal fractures of major long bones. The develop-
rary measure to achieve length and alignment of the ment of locking of the main fragments onto the nail
metaphysis while the soft tissue envelope is recover- has greatly increased the scope of intramedullary nail-
ing. The definitive reconstruction is then delayed for ing. Whereas before, multifragmentary fractures were
2–3 weeks or longer if necessary. If the articular frag- a contraindication, today a multifragmentary fracture
ment is small and does not afford purchase for the is the indication for using a locked intramedullary nail.
external fixator, the joint is bridged temporarily with Locking has also made it possible to stabilize fractures
the external fixator to provide the necessary immo- of the proximal and distal third of the diaphysis and
bilization. Whenever the definitive reconstruction is to treat subtrochanteric fractures with involvement of
carried out, either as a primary or delayed procedure, the lesser trochanter and ipsilateral fractures of the
all measures are taken to minimize the damage to shaft and neck of the femur (Kyle 1994).
the blood supply of the soft tissue and bone. These
measures include indirect reduction, minimal expo- 1.7.2.2
sure, and percutaneous screw fixation of fragments. Reaming
Buttressing continues to be important in preventing
axial deformity, but the methods of buttressing today The biological and mechanical events associated with
are designed to minimize soft tissue trauma. Thus, reaming or nail insertion and the consequent cardio-
buttressing today may be in the form of plating or pulmonary events have become the subject of major
it may be achieved by means of an external fixation controversy among trauma surgeons. Reaming has
frame or it may be a combination of both. These prin- been recognized as contributing significantly to the
ciples which we have followed for many years consti- damage of the blood supply to the cortex. Reaming
tute today the core of the treatment protocols of most has also been recognized to cause a marked increase
major trauma centers. in the intramedullary pressure of bone (Stürmer 1993)
and in a marked rise in the associated embolization
of marrow contents to the lung (Wenda et al. 1993).
1.7.2 These observations have resulted in the development
Diaphyseal Fractures of unreamed intramedullary nails for the tibia and
femur, which as one might expect have not eliminated
As already alluded to above under general consid- the cardiopulmonary events. In recent years we have
erations of the changes to the early concepts, the witnessed a lively debate as to whether one should
most notable change in the principles and methods nail the long bone fractures of polytrauma patients
of treatment of fractures has been in the handling of with a high Injury Severity Score, who have been
diaphyseal injuries. The shift has been from what one in shock, and who have concomitant injuries to the
might call the mechanical era during which emphasis thoracic cage and lung contusion (Pape et al. 1993).
was on the mechanical aspects of internal fixation, Many studies completed during and since the peak
with absolute stability and primary bone union as of this controversy have shown that the presence of

1.7 Changes to the Early Concepts in Internal Fixation

 1 Principles of Internal Fixation 23
a lung contusion is by far the deciding factor as to The techniques of indirect reduction and bridge
whether cardio-pulmonary complications are likely plating have made bone grafting of diaphyseal and
to develop. Each patient and each particular problem metaphyseal multifragmentary fractures unnec-
must be evaluated on its merits. The intramedullary essary. Bone grafting is now largely reserved for
nailing of a single extremity in most cases will not metaphyseal defects of articular fractures and for
constitute a problem. However, if more than one bone open fractures.
must be nailed in a patient with the risk factors enu- Anatomical reduction of the diaphyses of the
merated above, then it is preferable to stabilize the femur, of the tibia, and of the humerus is not neces-
fractures in these patients either definitively with sary. As long as length, rotation, and axial alignment
plates or by means of temporary external fixator (O. are restored there will be no interference with func-
Trentz, personal communication) with conversion to tion. The radius and the ulna are an exception. Pro-
definitive intramedullary nailing when the condition nation and supination and normal elbow and wrist
of the patient has stabilized. function depend on the preservation of the normal
Although locked intramedullary nailing is the anatomical shape and relationship of these two bones
preferred method for internal fixation of diaphyseal and fractures of these two bones. They are not unlike
fractures, there continue to be indications for plating. articular fractures. Therefore anatomical reduction
These will be discussed in detail in the ensuing chap- of these two bones is mandatory, and stability should
ters. Whenever plating is carried out, the surgeon has be achieved with an appropriate plating technique.
the choice of carrying out either a direct or an indi-
rect reduction. Direct reduction is the major cause of 1.7.2.4
the devitalization of bony fragments. Indirect reduc- Blood Supply to Bone and Implants
tion techniques have been popularized to minimize
the damage to the blood supply of bone and of the Preservation of the blood supply of the bony frag-
soft tissue envelope (Mast et al. 1989). The method ments has been achieved not only by indirect reduc-
of reduction does not determine the degree of sta- tion and by changing the methods of internal fixa-
bility. Although stable fixation is usually practiced in tion, but also by changes in the design of implants.
association with direct reduction, indirect reduction The unreamed intramedullary nail was developed to
techniques are equally applicable. minimize the damage to the endosteal blood supply of
long bones. The observations of Perren (1991; see also
1.7.2.3 Gunst et al. 1979; Waelchli-Suter 1980), who studied
Bridge Plating the effects of plating on the blood supply of bone, led
to the discovery that the porosis of the cortex beneath
The method of bridge plating (Heitemeyer and Hier- the plates was not the result of stress protection but
holzer 1985) was developed to help prevent the devi- rather the result of local bone necrosis and its accel-
talization of fragments of multifragmentary fractures erated haversian remodeling. The degree of necrosis
(Perren 1991). In this technique of plating the frac- was determined by the degree of contact that the plate
ture is first reduced by means of indirect reduction made with bone. This explained the seeming paradox
in order to minimize the devitalization of fragments, that the so called haversian remodeling was greater,
as bridge plating is very dependent on the viability with flexible and elastic plates which were being used
of bone for the formation of callus and union. In this to overcome the stress protection of the stiffer metal-
technique, once length and rotation are reestablished, lic plates. The flexible plates made closer contact with
the zone of fragmentation is bridged with a plate that the bone and interfered to a greater degree with the
is fixed to the proximal and distal main fragments. blood supply of the underlying cortex.
The correct contouring of the plate reestablishes cor-
rect alignment. This type of internal fixation is a form 1.7.2.5
of splinting. It is not absolutely stable, and union The Limited Contact-Dynamic Compression Plate
is by callus. This technique of plating is indicated (LC-DCP)
only for the fixation of multifragmentary fractures.
If the surgeon chooses to plate a simple transverse These observations have led to the development of
or oblique fracture, then absolute stability must be plates that have been designed in such a way as to
achieved by means of interfragmental compression, minimize their contact with the underlying bone.
or excessive strain at the fracture site is likely to cause The limited contact-dynamic compression plate (LC-
failure (Perren 1991). DCP) is an example of such a plate (Fig. 1.22).

1.7 Changes to the Early Concepts in Internal Fixation

24 J. Schatzker

e
Fig. 1.22a–e. The developments in AO internal fixation plates. In a–d, upper (left) and lower (right) surfaces are shown. a
The round hole plate (Müller et al. 1963). The conically undercut screw head allows for only a perpendicular position of the
screw. The distance between the inner screw holes is larger. The plate undersurface is smooth. b The dynamic compression
plate (DCP; Perren et al. 1969). The spherical contact geometry allows for 20° tilting of the screw along the long axis of the
bone. c The dynamic compression unit (DCU; Klaue and Perren 1982). The completely symmetric screw holes are distributed
at even distances throughout the plate. Symmetric screw holes with oblique undercut for improved range of inclination. d The
limited-contact dynamic compression plate (LC-DCP; Perren et al. 1969) viewed from above; symmetric arrangement of the
screw holes without a solid elongation between the innermost screw holes. The screw holes themselves are symmetric and are
provided with two sloped cylinders. Lateral undercuts allow for bone formation at the plate (tension) side of the periosteal
surface. Less damage to blood supply results, and the trapezoid cross-section allows for easier and less traumatic removal of
the plate. (From Müller et al. 1991). e The combi (combination) hole permits the insertion of a fixation screw through that
portion which is identical to the screw hole in an LC-DCP plate. The threaded portion is designed to lock the screw head and
provide “locked” angularly stable fixation.

1.7.2.6
The PC Fix or the Point Contact Plate (PCP) and tightened to the maximum possible. The moment a
Angularly Stable Fixation screw loosens, the compression between the plate and
underlying bone is lost and the degree of fixation
In conventional plating, the stability of plate fixation drops dramatically.
is dependent on the degree of compression between The development of the LC-DCP was an attempt
the plate and the bone and on the interdigitation of to limit the contact of the plate with the underly-
the bony fragments and their interfragmental com- ing bone and thus limit the damage to the periosteal
pression. To achieve maximum friction and compres- blood supply. Beyond this, the LC-DCP functioned
sion between the plate and bone, the screws must be similarly to all conventional plates.

1.7 Changes to the Early Concepts in Internal Fixation

 1 Principles of Internal Fixation 25
To avoid any contact between the plate and bone jected to a bending force, whereas in conventional
and thus decrease even further any damage to the plating each screw acts alone. Since all the screws act
blood supply of bone derived from soft tissue, Perren in unison they provide vastly superior holding power
and Buchanan (1995) developed the PCP (point con- in bone because of a much larger segment of bone
tact plate) or PC Fix (point contact fixator). The PCP providing the fixation.
functions like an external fixator applied internally.
The key to this is the fact that the screw heads are 1.7.2.7
very securely fixed to the plate, just as the Schanz The Advantages of Locked Fixation
screws are fixed to the tubes of the tubular fixator. and Its Angular Stability
This made it possible for this new plate to have no
contact with the underlying bone. The transmission
of forces is from bone to screw to plate, and not from Sparing of Periosteal Blood Supply
bone to plate. The PC Fix is anchored to the bone
with unicortical screws that are self-drilling and self- Since in the locked compression plate (LCP) the fixa-
tapping. The head of the screw is conical in shape and tion which the plate provides does not depend on
fitted out with a thread. The screw hole of the plate the compression between the plate and the bone but
has an identical profile and is also threaded, which rather depends on the fixation of the screw to the
makes the heads self-centering. Upon insertion the plate and the anchorage of the screw in the bone, the
screw head threads itself into the plate to become plate no longer needs to make any contact with the
one. Although the PC Fix underwent extensive clini- underlying bone. The immediate advantage of this
cal trials, it never came into general clinical use. The is that there is absolutely no interference with the
advantages of locked fixation were first explored in periosteal blood supply.
spine surgery and then in fracture surgery in the
LISS (limited internal stabilization system), which No Need to Contour the Plate
was developed specifically to exploit all the advan-
tages of minimally invasive surgery combined with Another advantage is that the plate no longer needs to
angular stability. Today because of the enormous fit exactly to the shape of the underlying bone. Thus
advantages of angular stable fixation, the AO Foun- a plate no longer needs to be carefully contoured. It is
dation and its commercial partner Synthes Inc. have simply held in place as the screws are inserted.
extended the principle of locked plate fixation to all
plates. This was made possible through the devel- Improved Holding Power
opment of the “combi hole” for plate fixation (see
Fig. 1.22e). The combi hole has replaced the screw Because the screw is locked to the plate, it is angu-
holes developed for the DCP and the LC-DCP. The larly stable. In a conventional plating the moment
combi hole is shaped like a figure-eight. The end fur- the screw loosens and backs out ever so slightly, fixa-
ther away from the middle of the plate retains all the tion begins to fail and displacement can take place,
features of the old DCP hole, which allows the inser- which sets up a vicious irreversible cycle leading to
tion of screws either eccentrically in the “load posi- greater and greater loss of fixation. With a screw that
tion” to achieve axial compression or in the “neutral is locked to the plate, this loss of fixation is not pos-
position” for fixation of the plate to bone. The end of sible. The only way displacement can take place is for
the hole closer to the middle of the plate is threaded. the anchorage of all of the screws in the bone to fail
The pitch of the thread and shape of the hole mirror simultaneously. Unlike conventional screws where
those of the head of the screw, and the pitch of the the holding power of each screw is dependent on its
thread is the same as that of the screw thread used own pull-out strength, in locked fixation where the
for the attachment of the plate to bone. When the screws are fixed to the plate, the screws act in concert
threaded conically shaped screw head engages in the and the holding power is additive with all the screws
threaded hole, it locks when tightened. This fixation acting together. In conventional plating when failure
of the screw to the plate creates an angularly stable under bending begins to occur, there is failure of the
construct. The fixation of the plate to bone no longer first screw subjected to a pull-out force, followed then
depends on compression between the plate and the by the second screw and so on. Where all the screw
underlying bone, but simply on the holding power heads are locked to the plate, under a bending force
of the screws in bone. Because the screws are fixed that is tending to pull the screws out of bone, the
to the plate, all the screws act in unison when sub- load is shared by all of the screws, since the pull-out

1.7 Changes to the Early Concepts in Internal Fixation

26 J. Schatzker

load is equally transmitted to all of them. The result the fracture is the focus where maximum deforma-
is a much greater holding power. The advantages tion of tissues occurs. Hence under loading it is the
of this are several. First of all, because the holding site of maximum strain. Bone tissue is brittle, with a
power is a summation of the screws together, the very low strain tolerance. Thus bone cannot bridge a
locked type of plate fixation offers much better and fracture gap during healing as long as deformation is
stronger fixation. Hence it is superior in providing taking place. Hence the formation of callus, a tissue
fixation of fractures in osteoporotic bone. Because with graduated strain tolerance in which the tissues
the holding power is greater, there is no need for are arranged in accordance with the strain they are
bicortical screw purchase. Unicortical screw engage- subjected to and one they can tolerate. On a relative
ment is sufficient. One caveat which applies here and scale, the strain tolerance of fibrous tissue is 100; that
which must be remembered since in practice it has of cartilage is 10, and that of bone, 2. During heal-
contributed fairly commonly as a cause of failure is ing the deformation of callus is gradually reduced
that because the bone is tubular the only time uni- through increasing stiffness, the result of differentia-
cortical fixation is at its optimum is when the screw tion of tissue into cartilage. The cartilage matrix then
is at 90° to the tangent at its point of entry. As the degenerates, mineralizes, becomes invaded by blood
direction of the screws is determined by the attitude vessels, and is eventually changed for bone, a process
of the plate, the alignment of the plate at the start of known as endochondral ossification.
the fixation is also crucial. The plate must be in the As previously explained, the so called primary
middle of the cortex, and its tilt must be such that bone healing under conditions of absolute stabil-
the screws are directed at 90° to the tangent at their ity achieved with compression takes place only if
point of entry. the interfragmental strain in the fracture zone is
near zero, because bone tissue is brittle and cannot
Self-Drilling and Self-Tapping Screws bridge a fracture during healing as long as deforma-
tion is taking place. Induction of callus under such
The advantage of unicortical screws is that they can conditions is minimal. In the early days of AO it was
be made self-drilling and self-tapping, and if one thought that pain-free mobilization was only possible
limits the length of the screws to slightly greater than under conditions of absolute stability. However, expe-
the thickness of the cortex, one can do away with the rience with intramedullary nailing and bridge plat-
measurements of screw length. From the foregoing ing showed that relative stability also allows pain-free
one can readily see that the use of a locked plating mobilization. Relative stability must allow also the
has decided advantages. The one prerequisite to suc- induction of callus formation. Elasticity of the fixa-
cessful application of locked internal fixation which tion is a precondition for the induction of callus for-
often presents considerable clinical difficulties is that mation. Thus deformability of the implant is the key.
the fracture must be reduced and must be maintained A screw is relatively rigid compared to bone. Under
as reduced when the plate is applied. Unlike conven- peak load which exceeds the strength of bone, the
tional plating, where the plate imparts its shape to screw will lose its anchorage and become irreversibly
the underlying bone (a principle often invoked in loose. Bridge plates, intramedullary nails, and exter-
using the plate to secure reduction), in locked plating, nal fixators are splints that under peak load bend
whatever the position of the bone when the screws elastically. Locked plates and external fixators will
are inserted, that is the position which remains. In undergo plastic deformation under extreme load as
order to increase the holding power of the screws in long as this load does not exceed the holding power
cancellous bone, one not only uses bicortical screws of their anchorage in bone.
which require predrilling of their hole, but the direc- The clinical problem encountered with the PCP or
tion of the individual screws can be altered. Their PC Fix was that the technique employed still required
‘misalignment,’ so to speak, greatly increases their an open reduction of the fracture. The decided
holding power in cancellous bone and conversely in advantages of closed techniques, which entail mini-
osteoporotic cancellous metaphyses. mal exposure and no exposure of the zone of injury,
the so called biological plating techniques, stimu-
Locked Angular Fixation and Bone Healing lated further development of implants which com-
bined the advantages of locked plate fixation with
In using this type of fixation there are certain mechan- minimally invasive techniques, particularly for those
ical aspects that must be considered. In a fracture areas which do not lend themselves to intramedul-
under load, because of the discontinuity of stiffness, lary nail fixation.

1.7 Changes to the Early Concepts in Internal Fixation

 1 Principles of Internal Fixation 27
The first device to appear was the LISS (lim- oped under the auspices of the AO-ASIF Foundation
ited internal stabilization system; Frigg et al. 2001; and are sold under the trademark “Synthes”.
Fig. 17.22a–d). The LISS is an ingenious device that
makes full use of the locked internal fixator concept.
The shape of the LISS was chosen to fit best the great-
est number of femora. Because of a bow built into the 1.8
design to mimic the physiological bow of the femur, Biological Plating and Minimally Invasive
the device has a right and a left side. Distally the LISS Plate Osteosynthesis (MIPO)
flares and is fixed to the femur with longer self-tap-
ping screws that lock in the plate. Proximally in the During the early years of the AO school of operative
diaphyseal portion, the LISS is fixed to the bone with treatment of fractures, form and function were con-
unicortical self-drilling and -tapping screws that also sidered to be inextricably linked. Hence the dictum
lock in the plate. The screw heads have a threaded of the AO of anatomical reduction as a prerequisite
conical profile, which provides stable angular fixa- for the return of function. The AO pioneers also
tion of the screw-fixator junction; the screws are thought that only absolute stability would render
self-centering in the hole. There is also “the puller,” a extremities sufficiently painless to permit early
provision made to be able to bring the proximal shaft motion, which was recognized as essential in the
closer to the plate and correct the frequent valgus recovery of function. Hence in the treatment of
malalignment which arises during the insertion of fractures all efforts were directed to the achieve-
the device. The LISS also has an insertion handle ment of absolute stability. Absolutely stable fixation
that is securely fixed to the plate prior to insertion. led to bone union without radiologically discern-
This ingenious device is used first to guide the plate ible callus. This type of union was called “primary
into position, and then when the plate is in position bone healing,” and primary bone healing became
it serves as a guide for the insertion of the fixation the goal of treatment whenever one attempted an
screws. internal fixation. Callus was considered a sign of
The major shortcoming of the LISS is that it instability; it was bad, a danger signal, and a signal
requires the femur to be reduced prior to the fixation of impending failure. Anatomical reduction was
of the plate to the bone. The screws lock in the plate also considered important in restoring the inher-
and maintain the bone in the “position of reduc- ent structural stability of bone. Compression by
tion” achieved by the surgeon. The angular stability means of lag screw fixation or axial compression by
of the system greatly enhances the holding power of means of compression plates became the founda-
its screws in bone and makes it most attractive also tion of absolutely stable fixation. When dealing with
for the fixation of supracondylar fractures in osteo- multifragmentary fractures all efforts were made to
porotic bone, which have time and again defied the convert the many pieces into a solid block of bone
skills of the surgeon because of the failure of fixation (see Fig. 16.5). The achievement of mechanical sta-
devices. bility was of paramount importance. The atraumatic
Further developments in the implant design and handling of soft tissue was considered important to
manufacture have led Synthes Inc. to the extension prevent infection but was not considered an impor-
of locked internal fixation to all small-fragment and tant factor in securing bone healing. Blood supply
large-fragment plates. These plates, now referred to of bone hovered in the background as a factor of
as LCPs (locked compression plates) have also been much lesser importance than stability. It was rec-
fitted with a further refinement – the “combination ognized that the absence or interference of blood
hole” which allows the surgeon when using these supply delayed healing and risked failure because
plates to choose between locked internal fixation, of mechanical breakdown of the fixation. Hence the
conventional fixation, or a combination of both tech- dictum to bone-graft all multifragmentary fractures
niques. In addition to the modification of existing in order to hasten the formation of a bony bridge
plate designs to LCP, there has also been the devel- which would then protect the mechanical fixation.
opment of plates for special anatomical regions such The bone once united would then gradually revas-
as the Philos plate for the proximal humerus, special cularize and remodel. Osteoporosis was seen in
periarticular plates for the proximal and distal tibia, association with plating but was initially thought
the LCP (locked condylar plate) for the distal femur, to be the result of mechanical shielding of the bone
a LISS plate for the tibia, and special plates for the from physical stresses, and was referred to as “stress
upper extremity. All these devices have been devel- protection.” Intramedullary nailing was recognized

1.8 Biological Plating and Minimally Invasive Plate Osteosynthesis (MIPO)

28 J. Schatzker

as a good form of treatment of simple fractures of are achieved the plate is fixed to the main fragments.
the mid-diaphysis of femur and tibia. It was recog- The plate acts as a splint and provides relative stabil-
nized as a form of relatively stable form of fixation, a ity, which stimulates callus formation.
form of splinting. Callus was recognized as a means When a force is applied to an extremity to produce
of union of bony fragments when stability was not a fracture, it creates a zone of injury. The zone of injury
absolute. It was also recognized that such healing encompasses the bone and its soft tissue envelope.
was stronger and mimicked the type of union that The severity of the injury to the soft tissue envelope is
occurred when fractures were treated closed without a reflection of the amount of energy involved in pro-
surgical intervention. However, intramedullary nail- ducing the fracture. Surgical exposure of the fracture
ing, because of its inherent mechanical limitations, through the zone of injury is not infrequently com-
played a limited role as a form of fracture fixation. plicated by problems with wound healing, which may
Locked intramedullary nailing and its very obvi- result in sepsis. The desire to gain access to the bone
ous advantages are responsible for the shift from the as one does in closed intramedullary nailing without
mechanical approach in fracture treatment to what having to cut through the injured soft tissues resulted
is referred to as the biological approach or biologi- in the development of the technique of minimally
cal internal fixation. Locked intramedullary nailing invasive plate osteosynthesis (MIPO). MIPO consists
is a closed technique. The fracture and injury zones of precontouring the plate to the shape of the bone.
are never exposed. The reduction is by indirect An small incision is then made at a point removed
means and does not jeopardize the blood supply from the fracture, which allows the plate to be slid
of the bony fragments in the zone of comminution. under the soft tissue envelope, under the muscle, and
Locked intramedullary nailing also helped to estab- across the fracture zone. Once indirect reduction is
lish clearly the biological and biomechanical differ- carried out, the plate is fixed to the other main frag-
ences between diaphyseal fractures and articular ment of the bone.
fractures. Diaphyseal bone requires only the rees- Attempts to execute MIPO with conventional
tablishment of length, rotation, and axial alignment plates ran into many technical problems. This, cou-
for normal function. Locked intramedullary nailing pled with the considerable research evidence which
showed conclusively that the displacement of inter- indicated that conventional plates even if slid under
mediary fragments was not a significant factor, and the muscle envelope without direct interference with
that as long as the viability of these fragments was the zone of injury and fragmentation still interfered
not interfered with, they rapidly incorporated in the with the blood supply of bone because of the manner
abundant callus that would form. Articular frac- in which these plates were fixed to bone, stimulated
tures, in contrast, required anatomical reduction further development in plate design and the manner
and absolutely stable fixation. Locked intramedul- of their fixation to bone. This resulted in the evolu-
lary nailing is only relatively stable. It is a form of tion of an entirely new generation of implants and
splinting, an elastic form of fixation. Guided motion, manner of fixation referred to as the LISS plate (see
the result of splinting, results in stimulating callus Chap. 17, “Supracondylar Fractures of the Femur”).
formation. It was also recognized that only living These locked plates or internal fixators are designed
bone is capable of producing callus – thus the need to be slid under the soft tissue envelope through min-
to preserve the blood supply of the bony fragments. imal exposures. Reduction of the fracture follows by
Closed locked intramedullary nailing results in indirect means, and the plates are then fixed to the
rapid healing, low complication rate, and excellent underlying bone by means of “locked screws” which
return of full function. It is the best example of the make it possible for the plate to provide fixation with-
benefits of minimally invasive surgery, of indirect out making contact with the underlying bone. Thus
reduction, of preservation of the blood supply of MIPO is capable of mimicking all the advantages of
bone, and of splinting to induce the rapid formation locked intramedullary nailing, that is, minimal expo-
of callus and union. sure, closed surgical technique, indirect reduction,
The desire to reproduce with plates the effects of splinting of the fracture, with rapid callus formation
closed intramedullary nailing resulted in the devel- and healing for bone segments not suitable for intra-
opment of the techniques of indirect reduction which medullary nailing. The LISS and the locked compres-
were coupled with bridge plating. In bridge plating sion plates are examples of these newly developed
the plate spans the zone of injury and fragmentation systems of bone stabilization designed to optimize
of bone. No effort is made to reduce the intervening MIPO and secure all its advantages when treating
fragments. Once length, rotation, and axial alignment fractures.

1.8 Biological Plating and Minimally Invasive Plate Osteosynthesis (MIPO)

 1 Principles of Internal Fixation 29

Fig. 1.23. Examples of deficiencies of the

cortex opposite the plate which will result
in cyclic bending of the plate and in its ulti-
mate failure. (From Müller et al. 1979)

1.9 fragments. As a result, union is slow and failure to

Implant Failure and Bone Grafting bone-graft is the most common cause of failure of
stable internal fixation. In bridge plating, union is
Metal plates or other devices, no matter how rigid or rapid and by callus. As a result, the techniques of
how thick and strong, will undergo fatigue failure and indirect reduction and bridge plating have made
break if subjected to cyclical loading. Metal is best bone grafting of diaphyseal and metaphyseal mul-
able to withstand tension; bone is best able to with- tifragmentary fractures unnecessary. Bone grafting
stand compression. Thus, in an ideal internal fixation, is now largely reserved for metaphyseal defects of
the biomechanical arrangement should be such that articular fractures and for open fractures.
the bone is loaded in compression and the metal in The newly developed LCPs, in which the anchor-
tension. If a defect is present in the cortex opposite ing screws have angular stability because they are
the plate, and the bone is under bending load, the fixed to the plate and which function biomechani-
fulcrum will move closer and closer to the plate until cally like an internally placed external fixator pro-
it eventually falls within the plate (Fig. 1.23). Con-
sequently, with repetitive loading, even if due only
to muscular contraction, the implant is repeatedly
cycled and may fail. Internal fixation can therefore be
viewed as a race between bone healing and implant
failure.
In order to prevent the possibility of implant failure
after stable fixation, whenever there is comminution,
whenever there is a defect in the cortex opposite the
plate, whenever there is devitalization of fragments
(as is frequently the case in high-velocity injuries),
and whenever enormous forces must be overcome
(as in plating of femoral shaft fractures), the fracture
should be bone-grafted. Such a graft, once it becomes
incorporated into an osteoid bridge opposite the
plate, rapidly hypertrophies and matures because it is
subjected to compressive stresses. As soon as it rees-
tablishes the continuity of bone opposite the plate, it
acts as a second plate and prevents the cycling and Fig. 1.24. Once it becomes incorporated into an osteoid
bridge, a bone graft, if it is under compression, rapidly matures
inevitable fatigue failure of the implant (Fig. 1.24). and hypertrophies. It reestablishes the continuity of the bone
In stable fixation of a multifragmentary fracture, opposite the plate and prevents further cycling of the plate and
union depends on the revascularization of the dead its failure. (From Müller et al. 1979)

1.9 Implant Failure and Bone Grafting

30 J. Schatzker

viding relatively stable elastic fixation, can be used Following removal of an implant, the bone must
on simple fractures as well as multifragmentary be protected from overload. The screw holes act as
fractures. Their very secure anchorage to the bone stress raisers, and if the bone is suddenly loaded
(the result of angular stability of the screws) allows before the screw holes have filled in – a process that
the fixation construct with an LCP to be more elas- takes 6–8 weeks in experimental animals – the bone
tic than a conventional plate fixed to bone, which may fail. Similarly, the ridges that frequently develop
has made it possible to fix simple fractures with this on each side of the plate should not be osteotomized,
implant without supplementing the plating with a as this further weakens the bone and may contribute
bone graft. The elasticity that is distributed over the to its failure.
whole construct prevents stress concentration at the Implant removal is carried out only if there are
fracture. This makes it possible for callus to arise specific indications. It is a procedure with inherent
and for secure union, without the risk of implant risks and should not be entertained lightly.
failure and non-union.

1.10 References
Implant Removal
Allgöwer M (1971) Weichteilprobleme und Infektrisiko der
Early on after fracture, bone that has united by pri- Osteosynthese. Langenbecks Arch Chir 329:1127
Allgöwer M, Matter P, Perren SM, Rüedi T (1973) The dynamic
mary bone healing is weaker than that united by compression plate. Springer, Berlin Heidelberg New York
callus. A callus, because of its spatial disposition, is Charnley J (1953) Compression arthrodesis. Livingstone,
further away from the central axis of bone than a Edinburgh
plate, and therefore is in a mechanically more advan- Frigg R, Appenzeller A, Christensen R, Frenk A, Gilbert S,
tageous position to withstand force. The osteons of Schavan R(2001) The development of the distal femur Less
Invasive Stabilization System (LISS). Injury Vol. 32 Suppl.3
primary healing are closer to the central axis, and the S-C 24-S-C 31
union is therefore mechanically weaker. Gunst M, Suter C, Rahn BA (1979) Die Knochendurchblutung
Primary bone healing is also weaker than that by nach Plattenosteosynthese. Eine Untersuchung an der
callus, because it undergoes a tremendous remodel- intakten Kaninchentibia mit Disulfinblau-Vitalfaerbung.
ing, which is manifested by a proliferation of haver- Helvetica Chir Acta 46:171–175
Gustilo R, Andersson JP (1976) Prevention of infection in the
sian canals. Thus, such bone, although unchanged in treatment of one thousand and twenty-five open fractures
its cross-sectional diameter, contains less bone per of long bones. J Bone Joint Surg 58A:453
cross-sectional area because of the haversian prolif- Heitemeyer U, Hierholzer G (1985) Die überbrückende Osteo-
eration. This continues until the accelerated remodel- synthese bei geschlossenen Stückfrakturen des Femur-
ing ceases and the architecture gradually returns to schaftes. Akt Traumatol 15:205–209
Kempf I, Grosse A, Beck G (1985) Closed locked intramedul-
normal. Based on their studies, Matter et al. (1974) lary nailing. J Bone Joint Surg 67 A: 709–720
suggested that the intense remodeling subsides some Key JA (1932) Positive pressure in arthrodesis for tuberculosis
12 months or so after fracture. Factors which prolong of the knee joint. South Med J 25:909–915
the remodeling phase are the patient’s age, the degree Klaue K, Perren SM (1982) Fixation interne des fractures
of comminution, the degree of devitalization, the size parl’ensemble plaque-vis à compression conjuguée (DCU)
Helv Chir Acta 49:77–80
of the gaps, the accuracy of the reduction, the stabil- Kyle RF (1994) Fractures of the proximal part of the femur. J
ity of the fixation, and whether the fracture was bone- Bone Joint Surg 76A:924–950
grafted. Furthermore, it is important to note whether Lange RH, Bach AW, Hansen ST, Johansen KH (1985) Open
there were any signs of instability during the time of tibial fractures with associated vascular injuries: prognosis
healing or whether the fracture progressed unevent- for limb salvage. J Trauma 25(3):203
Llinas A, McKellp HA, Marshall GJ, Sharpe F, Bin Lu MS,
fully to union. Kirchen M, Sarmiento A (1993) Healing and remodelling
All these factors must be borne in mind when of articular incongruities in a rabbit fracture model. J Bone
implant removal is being contemplated. If the implant Joint Surg 75A:1508–1523
is removed prematurely, the bone will fail and refrac- Llinas A, Lovasz G, Park SH (1994) Effect of joint incongruity
ture. We feel that most implants should be left in place on the opposing articular cartilage. Annual AAOS meeting,
Los Angeles, CA
for 2 years before their removal is contemplated. This Marsh JL, Smith ST (1994) Outcome of severe tibial plateau
timing may be modified by the factors indicated in fractures. Annual OTA meeting, Los Angeles, CA
the preceding paragraph. Mast J, Jakob R, Ganz R (1989) Planning and reduction tech-

1.9 Implant Failure and Bone Grafting

 1 Principles of Internal Fixation 31
nique in fracture surgery. Springer, Berlin Heidelberg New Schatzker J, Horne JG, Sumner-Smith G (1975a) The effects of
York movement on the holding power of screws in bone. Clin
Matter P, Brennwald J, Perren SM (1974) Biologische Reaktion Orthop 111:257–263
des Knochens auf Osteosyntheseplatten. Helv Chir Acta Schatzker J, Sanderson R, Murnaghan P (1975b) The holding
[Suppl] 12 power of orthopaedic screws in vivo. Clin Orthop 108:115
Mitchell N, Shepard N (1980) Healing of articular cartilage Schatzker J, Manley PA, Sumner-Smith G (1980) In vivo strain
in intraarticular fractures in rabbits. J Bone Joint Surg gauge study of bone response to loading with and without
62A:628–634 internal fixation. In: Uhthoff H (ed) Current concepts of
Müller ME, Allgöwer M, Willenegger H (1963) Technik der internal fixation of fractures. Springer, Berlin Heidelberg
operativen Frakturenbehandlung. Springer, Berlin New York, pp 306–314
Müller ME, Allgöwer M, Willenegger H (eds) (1970) Manual of Schenk R, Willenegger H (1963) Zum histologischen Bild
internal fixation, 1st edn. Springer, Berlin Heidelberg New der sogenannten Primärheilung der Knochenkompakta
York, p 10 nach experimentellen Osteotomen am Hund. Experientia
Müller ME, Allgöwer M, Schneider R, Willenegger H (eds) 19:593
(1979) Manual of internal fixation, 2nd edn. Springer, Stamer DT, Schenk R, Staggers B, Aurori K, Aurori B, Behrens
Berlin Heidelberg New York F (1994) Bicondylar tibial plateau fractures treated with a
Müller ME, Allgoewer M, Willenegger H (eds) (1991) Manual of hybrid ring external fixator: a preliminary study. Annual
Internal Fixation, 3rd edition, Springer Verlag, Berlin Hei- Orthopaedic Trauma Association meeting, Los Angeles,
delberg New York Müller ME, Nazarian S, Koch P, Schatz- CA
ker J (1990) The comprehensive classification of fractures Stürmer KM (1993) Measurements of intramedullary pressure
of long bones. Springer, Berlin Heidelberg New York in an animal experiment and propositions to reduce the
Pape H-C, Regel G, Dwenger A, Sturm JA, Tscherne H (1993) pressure increase. Injury 24 (Suppl 3):7–21
Influence of thoracic trauma and primary femoral intra- Tscherne H, Brüggemann H (1976) Die Weichteilbehandlung
medullary nailing on the incidence of ARDS in multiple bei Osteosynthesen, insbesondere bei offenen Frakturen.
trauma patients. Injury 24 (Suppl 3):82–103 Unfallheilkunde 79:467
Perren SM Buchanan JS ( 1995) Basic concept relevant to the Tscherne H, Gotzen L (1984) Fractures with soft tissue injuries.
design and development of the Point Contact Fixtor (PC- Springer, Berlin Heidelberg New York Tokyo, pp 1–9
Fix. Injury 26 (Suppl 2) : S-B1-S-B4 Tscherne H, Östern HJ (1982) Die Klassifizierung des Weich-
Perren SM (1991) The concept of biological plating using the teilschadens bei offenen und geschlossenen Frakturen.
limited contact-dynamic compression plate (LC-DCP). Unfallheilkunde 85:111
Scientific background, design and application. Injury 22 Waelchli-Suter C (1980) Vascular changes in cortical bone fol-
(Suppl 1):5 lowing intramedullary fixation. In: Uhthoff HK (ed) Cur-
Perren SM, Russenberger M, Steinemann S, Müller ME, All- rent concepts of internal fixation of fractures. Springer,
göwer M (1969) A dynamic compression plate. Acta Orthop Berlin Heidelberg New York, pp 411–415
Scand [Suppl] 125:31–41 Wenda K, Runkel M, Degreif J, Ritter G (1993) Pathogenesis
Rhinelander FW (1973) Effects of medullary nailing on the and clinical relevance of bone marrow embolism in medul-
normal blood supply of diaphyseal cortex. A.A.O.S. Instruc- lary nailing – demonstrated by intraoperative echocardiog-
tional Course Lectures. Mosby, St. Louis, pp 161–187 raphy. Injury 24 (Suppl 3):73–81

1.1 Introduction