S12

Injury, Int. J. Care Injured 49S1 (2018) S12–S18

Volume 49 Supplement 1 June 2018 ISSN 0020-1383

Contents lists available at ScienceDirect

Injury
Plating of Fractures: current treatments and complications
Guest Editors: Peter Augat and Sune Larsson

j o u r n a l h o m e p a g e : w w w. e l s e v i e r . c o m / l o c a t e / i n j u r y

Pre-operative planning for fracture fixation using locking plates:

device configuration and other considerations
Alisdair R. MacLeoda, Pankaj Pankaja,*
a
School of Engineering, The University of Edinburgh, UK

K E Y W O R D S A B S T R A C T

Screw Most locked plating failures are due to inappropriate device configuration for the fracture pattern. Several
Bone studies cite screw positioning variables such as the number and spacing of screws as responsible for
Working length occurrences of locking plate breakage, screw loosening, and peri-prosthetic re-fracture. It is also widely
Stress
accepted that inappropriate device stiffness can inhibit or delay healing. Careful preoperative planning is
Interfragmentary motion
therefore critical if these failures are to be prevented. This study examines several variables which need to
be considered when optimising a locking plate fixation device for fracture treatment including: material
selection; screw placement; the effect of the fracture pattern; and the bone-plate offset. We demonstrate
that device selection is not straight-forward as many of the variables influence one-another and an
identically configured device can perform very differently depending upon the fracture pattern. Finally, we
summarise the influence of some of the key parameters and the influence this can have on the fracture
healing environment and the stresses within the plate in a flowchart.
© 2018 Elsevier Ltd. All rights reserved.

Introduction In the context of metallic plates for fracture healing, preoperative

planning must consider the different plate types available. The
Preoperative planning is critical to the success of any fracture benefits of locking plates have been demonstrated clinically and
fixation surgery. For any fixation device there are three key clinical experimentally [8,9]. Several studies show that the use of locking
requirements and consequent mechanical demands arising from screws can improve construct strength [10–12] and performance
them [1]: it must support fracture healing; it must not fail during the in osteoporotic bone compared to conventional screws [13–15]. On
healing period; and it should not loosen or cause patient discomfort. the other hand, studies have also shown that the pull-out strength
It is well recognised that an appropriate amount of inter- of conventional screws increases with bone density [16,17] which
fragmentary motion (IFM) between fractured bone fragments is can result in equivalent or even better results than locked plating in
pivotal to healing; too much or too little can delay or inhibit fracture healthy bone [14]. These differences arise due to two main factors:
healing [2]. IFM is determined by the stiffness of the bone-fixator (1) The preloads involved in compression screw tightening increase
construct with stiffness defined as IFM produced on application of strain levels at the screw–bone interface even before physiological
unit load. Moreover, to prevent failure, stresses within the implants loads are applied, whereas locking screws have negligible screw-
should not be too high. Fatigue is normally a more likely cause tightening preload and resulting strains [13,18]; and (2) During
of failure rather than a single traumatic event and the implant is physiological loading, compression plating allows for frictional load
more prone to fatigue failure if healing has been delayed [3]. Small transfer at the plate–bone interface; locked plating, on the other
increases in stress can, therefore, reduce significantly the number of hand, transfers all physiological loads via the screw–bone interface
cycles to failure of the fixation device [4]. High strains/stresses at the [18]. In particular, the localised high tensile strains produced
screw-bone interface are known to cause loosening around screw by conventional screws have been shown to be responsible for
holes and entail a risk of infection [5,6]. In addition, compromising their poorer performance in osteoporotic bone [18]. Therefore,
the integrity of the bone due to screw holes or bone atrophy can lead there should be a very clear distinction made between these two
to periprosthetic fracture during fixation or re-fracture after device screw types; indeed, locking screws are not really screws in the
removal [7]. conventional sense – they are more like bolts [19]. For example,
the use of conventional screws can help reduce the fracture during
surgery; on the other hand, once a locking screw has been inserted,
it prevents further distraction or reduction of the fracture [20].
* Corresponding author at: School of Engineering, Faraday Building, The King’s
Buildings, The University of Edinburgh, Edinburgh EH9 3DW, UK It is well accepted that the majority of locked plating failures are
E-mail address: [email protected] (P. Pankaj). due to inappropriate device configuration for the fracture pattern

0020-1383/© 2018 Elsevier Ltd. All rights reserved.

 A.R. MacLeod and P. Pankaj / Injury, Int. J. Care Injured 49S1 (2018) S12–S18 S13

[21–25]. Several studies cite screw positioning variables such as the at the bone-implant interface. In locking plates, it has been shown
number and spacing of screws as responsible for cases of locking that a more rigid screw material (e.g. steel with a higher Young’s
plate breakage, screw loosening, and periprosthetic re-fracture modulus than titanium) reduces the strain concentrations at the
[3,8,26–29]. However, the significance of different variables and screw-bone interface [36] since they deform less in bending. The
manner in which their variation affects mechanical behaviour of same applies to the stiffness of the plate itself – higher stiffness
fixation constructs (and associated clinical expectations) is poorly plates reduce screw-bone interface strain concentrations [36].
understood; many of the findings in this respect are contradictory. As material failure of bone and consequent loosening of screws is
To achieve the clinical requirements, a well-planned device selection governed by strains, their concentration at the bone-screw interface
and configuration is essential, which in turn requires understanding needs to be limited. The concern of high interfacial strains with
the influence of different variables on the mechanical behaviour of titanium in comparison to steel has been previously noted for
bone-plate construct. unilateral fixators [40].
This aim of this study is to examine the role of different variables
that influence pre-operative planning with a particular emphasis on Device configuration: working length
device configuration, which is a key determinant for ensuring that
the clinical requirements are met. One of the most important parameters regulating the device
stiffness is the working length (also known as the bridging span),
Philosophy of fixation defined as the distance between the two innermost screws on either
side of the fracture. Small working lengths in a simple reduced
The decision whether to aim to for promotion of primary (direct) fracture can cause large plate stresses [4,24,41]; but in comminuted
or secondary (indirect) bone healing needs to be made before any fracture patterns with a fracture gap, it is large working lengths
fixation device selection. Delayed fracture healing or non-union is that result in higher plate stresses [9]. This apparent contradiction
very likely to occur when the fracture environment is not controlled has led to some confusion in the literature regarding the influence
to achieve one of these fixation philosophies [30]. Secondary bone of working length. Bottlang et al. [42], for example, noted that
fracture healing is the most common form of healing and the the efficacy of working length, in terms of stiffness reduction, is
surgery required is less invasive and biologically damaging [2,31]. “inconsistent and is gained at the cost of construct strength”. The
To stimulate secondary bone healing, the initial post-operative mechanics for the two cases, one with a fracture gap and the other
interfragmentary movement (IFM) should be in the region of 10– little or no fracture gap, can be explained as follows: When there is a
40% of the total fracture gap [32,33]. As the interfragmentary strain fracture gap, the entire load is transmitted from one bone fragment
governs the healing process, the smaller the size of the fracture to the other via the plate. In this case, upon load bearing, a higher
gap, the smaller the required movement. The appropriate value working length results in flexible system leading to increased
of IFM and resulting interfragmentary strain changes throughout bending, higher plate stresses, higher interfacial bone strains and
the course of healing [34]. Primary bone healing is a much slower higher IFM. However, when there is no fracture gap the loads are
process requiring so-called ‘absolute stability’ of the fracture, and shared between the bone and the plate. In this case a more flexible
therefore aims to completely abolish the fracture gap; consequently, plating system (e.g. due to a larger working length) results in a lower
the required IFM tends to zero [34]. If any significant movement load being transferred via the plate resulting in lower plate stresses
occurs in a small fracture gap, this results in very large strains and lower interfacial strains.
and is disruptive to healing. Conversely, it is almost impossible to Unfortunately, the distinction between the performance of
abolish relative movement between fracture fragments in a severely load-bearing and load-sharing locked plating systems is not fully
comminuted fracture pattern and therefore indirect bone healing understood. For example, some studies have attributed insufficient
should be sought [35]. Clinical studies demonstrate that using a working length to higher plate stresses even for cases with a fracture
lag screw to abolish movement in this situation conflicts with the gap [13,19,20]. This is explained [19] by applying identical angular
goal of indirect healing leading to hardware failure [8]. One of the deformation to the plate – a scenario in which a smaller working
criticisms of locking plates is that the final bone-plate construct length will result in larger plate stresses.
can become overly stiff thereby delaying or preventing healing [20]. A comparison between identical angular deformations with
Therefore, the stiffness of the device should be carefully controlled. different working lengths is not clinically relevant, however, as
plate stresses develop due to the identical loads (and not identical
Implant material selection deformations) that the plate supports during weight-bearing. For a
system with a large fracture gap, identical loads will cause larger
The interfragmentary movement (IFM) at the fracture site is plate stresses in a system with a larger working length (Fig. 1a). This is
largely governed by plate bending [36], and consequently plate due to the lower stiffness of the longer working length which results
stiffness needs to be carefully controlled to avoid it from being too in larger deformations and plate strains. In some cases, when the
high or too low and thereby detrimental to healing. Material choice fracture gap is small, interfragmentary contact can occur between
is known to influence healing rates in distal femur locking plates, fracture fragments [43]. If this happens, then the bone transmits
particularly in the period up to 12 weeks post-operative [37]. It is load and the plate is shielded from stress increases as shown in Fig.
intuitive that titanium, with a lower Young’s modulus than steel, 1b [41,43]. This is a load-sharing situation. In fracture patterns with
produces greater interfragmentary movement (IFM). However, wider gaps or comminution, interfragmentary contact cannot occur
the increase in IFM produced by titanium compared to steel is not and the plate will have to transmit the full weight-bearing loads.
proportional to the difference in material stiffness as the plate This means that an identically configured device can perform
is eccentric to the applied load [38]. The geometry of the plate, very differently depending upon the fracture pattern. For example,
particularly the structural bending stiffness, also influences the IFM using three identical screw configurations, Stoffel et al. [41] found
in a similar manner to the material stiffness. that larger working lengths produced the lowest plate stresses for
Any implant will alter the natural load distribution within the small fracture gaps (1 mm), but the highest plate stresses for larger
host bone. Fixation devices are designed to redirect load and shield fracture gaps (6 mm). A flexible plate will deform more than a rigid
the bone from undesirable motion to allow the fracture to heal [39]. plate under identical loading, developing larger strains in a load-
This redirection of load also results in other unwanted effects: for bearing situation, but allowing load-sharing to occur and relieving
example, stress-shielding in some regions and strain concentration strains if interfragmentary contact can occur.
S14 A.R. MacLeod and P. Pankaj / Injury, Int. J. Care Injured 49S1 (2018) S12–S18

Fig 1. A depiction of the influence of working length on plate stress in a bone plate system under applied axial load where: (a) there is a large fracture gap where no interfragmentary
contact can occur (the plate is supporting all applied loads) resulting in larger plate stresses and larger angular deformation for system with larger working length; and (b) there is
a small fracture gap which enables load sharing resulting in lower plate stresses with larger working length.

Device configuration: bone-plate offset

Locked plating is structurally similar to unilateral external

fixation [1]; however, there is considerable difference in bone plate
offset between locking plates and unilateral fixators. As the bone-
implant distance is much smaller for locking plates compared to
external fixators, the majority of the fracture gap motion is generated
by plate bending [1] which also results in asymmetric fracture gap
closure [44]. The authors have evaluated the influence of bone-plate
off-set using the methodology from previous publications [36,45].
The IFM at the near and far cortex for different values of offset are
shown in Fig. 2. Ahmad et al. [46] demonstrated that increasing the
bone-plate offset can reduce the strength and stiffness of locking
plate constructs. Techniques that utilise bending of the locking
screws to increase the effective bone-plate distance have been
described in a number of studies using: ‘far-cortical locking screws’
[47], ‘dynamic locking screws’ [48] and ‘near cortical slots’ [49]. Fig. 2. The predicted interfragmentary motion (IFM) for a locked plate construct under
These techniques have been shown to generate increased motion at axial loading depending upon the bone-plate offset [36,45].
the fracture site, however, they also produce larger strains at the
screw-bone interface due to the larger lever arm [1,50]. working length on stiffness and fracture gap motion, can often be
The influence of bone-plate offset in relation to the motion at the readily explained by the influence of bone-plate offset.
fracture site appears to have been overlooked by some studies in
the literature. Two studies, Chao et al. [51] and Bottlang et al. [52], Anatomical considerations, fracture pattern and boundary
suggest that findings regarding working length are “inconsistent” conditions
citing articles by Field et al. [53] and Stoffel et al. [41] that evaluated
the influence of screw position in plating (Fig. 3). There are two key The anatomical location of the fracture can dramatically alter the
reasons why the study by Field et al. (1999) is not comparable to demands placed upon the plate. In upper limb fractures plates are
the study by Stoffel et al. (2003) and would, therefore, not provide exposed to considerable torsional loads [55], whereas in the lower
consistent results. Firstly, the studies evaluated different loading limb larger axial forces must also be resisted [56]. Lateral femoral
regimes; Stoffel et al., used axial loading, whereas Field et al., plating causes the plate to be located a considerable distance from
considered bending loads. More importantly, Field et al. considered the mechanical axis due to the off-set of the femoral head. In a load-
compression screws whereas Stoffel et al. considered locking screws. bearing situation, this can result in rapid plate breakage [34,57].
Conventional compression screws pull the plate towards the bone It is important to note that a load-bearing environment can also
during fastening, thus eliminating a bone-plate offset. Similarly, in occur in gap-opening situations (the opposite of the ‘tension-band’
models where the plate was in contact with the bone, Chao et al. principle), or where a displaced wedge fragment does not allow for
[51] and Hoffmeier et al. [54] both found that working length had load-sharing (Fig. 4). Clinical studies, such as Strauss et al. [8], state
very little influence on the fatigue life of constructs. Both studies that longer working lengths can “better distribute stresses” around
acknowledged that the bone-plate contact may have masked any the fracture site. This statement assumes that there is a load-sharing
differences between screw configurations. If a plate is in contact environment at the fracture site, in the case of a small fracture gap,
with the bone, the effective working length is reduced and can be as discussed earlier.
as small as the size of the fracture gap, and all screw configurations The loading and boundary conditions can also influence whether
will produce very similar values of stiffness (Fig. 3b). Therefore, bone-plate contact will occur. Chao et al. 2013 demonstrated that
this apparent conflict in the literature relating to the influence of if the distal portion of the specimen is completely restrained while
 A.R. MacLeod and P. Pankaj / Injury, Int. J. Care Injured 49S1 (2018) S12–S18 S15

Fig. 3. (a) Axial stiffness values from Stoffel et al. 2003 who used locked plating with a bone-plate offset and (b) bending stiffness values from Field et al. 1999 who used compression
plating with bone-plate contact. With permission from Elsevier. The screw configurations used in the two studies are not comparable and are simply used to illustrate the difference
in the range of values found using different loading regimes.

the proximal portion can rotate (Fig. 5a), this results in significant
shear motion which can lift the plate away from the bone if the
working length permits (Fig. 5b and c). In in vitro experiments,
methods of load application where the restraint condition is
the same proximally and distally produce more symmetrical
deformation patterns [38]. The deformation behaviour of plates
under more physiological loading is still not well understood and
it is not clear which in vitro experimental testing regime best
predicts in vivo performance. The restraint provided by the knee,
for example, is extremely difficult to recreate experimentally.
Different experimental testing regimes such as bending, torsion
or axial loading set-ups can yield dramatically different results
in relation to the effects of device configuration. Moreover, even
when using the same loading direction, the method of restraining
the specimen can produce conflicting results [58].

Effects of fracture healing

A load-bearing system can become a load-sharing system with

the progression of fracture healing. With increased callus formation,
the bone will transmit an increasing proportion of the load [56]. If
Fig 4. Depiction of (a) the tension band load-sharing principle; (b) a gap-opening load- fracture healing does not occur or is delayed, then the plate must
bearing situation; (c) a displaced wedge fragment load-bearing situation. The tension
band situation (a) is safe for patient weight-bearing, however, weight-bearing in the
support all applied loading and plate breakage will eventually occur
other two situations (b and c) would result in very large stresses within the plate and [22]. Previous experimental studies that have considered load-
a high risk of plate breakage. bearing scenarios have found that more rigid constructs perform

Fig 5. (a) The experimental set-up adopted by Bottlang et al. 2009 and Chao et al. 2013. The results from Chao et al. 2013 show the influence of this specific loading scenario when
using (b) a longer working length and (c) a shorter working length. Reprinted from Biomed Central, Chao et al. BMC Veterinary Research 2013;9:125 (open access).
S16 A.R. MacLeod and P. Pankaj / Injury, Int. J. Care Injured 49S1 (2018) S12–S18

Fig. 7. The influence of callus formation at the fracture site on plate strain for different
working lengths.

Fig. 6. The influence of rigid and flexible locking plates on (a) the interfragmentary the screws can initiate loosening and result in infection and further
movement (IFM) produced at the fracture site for a given callus Young’s modulus; loosening [40,62–64]. Deterioration of bone quality, due to ageing
(b) the resulting plate stresses.
or diseases, increase the risk of loosening [40,65]. MacLeod et al.
showed [36] that while bone quality affects loosening its influence
better under cyclic loading [41,51,54,59]. On the other hand, on IFM is small. This has also been previously shown with respect
clinical studies show that more flexible plates promote faster callus to Ilizarov external fixators [66]. This implies that the required
formation; this includes the use of titanium instead of steel [37], but provision of appropriated IFM (or stiffness) can be considered
also the use of longer working lengths [60]. independent from the requirement of loosening prevention. On the
The authors have developed validated finite element simulations other hand, screw loosening is not independent of the stiffness of the
of locked plate constructs [61]. These models were used to evaluate bone-plate system; it has been found that the position of the screws
the influence of callus formation on the plate stresses. Fig. 6a shows on either side of the fracture affects these strain concentrations,
the predicted IFM at the fracture site assuming an exponential with the working length being the most influential parameter [36].
increase in callus stiffness over time. Two screw arrangements In addition, the rigidity of the plate has also been shown to be highly
are shown – a short working length resulting in a rigid plate-bone influential. Both of these parameters alter the stiffness of the fixation
system; and a longer working length resulting in a more flexible construct and therefore the environment at the screw-bone interface
plate-bone system. As expected, IFM reduces over the healing [1]. Generally, therefore, factors that increase the interfragmentary
period. The stresses in both plates also decrease over the healing movement will also increase strains at the screw-bone interface.
period, however, they decrease faster for the more flexible plate Strains, however, can also be manipulated by the positioning of the
despite starting higher (Fig. 6b). This clearly illustrates the transition remaining screws (outside the working length). It should be noted
from load-bearing to load-sharing and the advantages of different that for the majority of factors, the influence of screw placement
working lengths for each situation. It can be inferred that, clinically, was not affected by bone quality, however, increasing the screw
the reason longer working lengths reduce the risk of plate failure spacing on either side of the fracture can dramatically reduce strain
in the medium-to-long-term is because of increased load-sharing concentrations in osteoporotic bone [36].
at the fracture site. Therefore, the influence of working length in
the presence of callus formation is similar to the small fracture gap Optimising device configuration
situation shown previously in Fig. 2b (Fig. 7)
Most plate failures are not due to a single traumatic event but
Bone quality are the result of fatigue failure [4]; minimising stress in the plates
and screws should, therefore, be one of the goals of internal fixation
It has been clinically found that locking plates perform better than [4]. If healing progresses more rapidly, however, the demands
conventional plates in poor quality bone [13], whereas in healthy upon the fixation are reduced [67]. The most beneficial healing
bone conventional plating can provide equivalent or even better conditions require the correct level of fracture site movement –
results than locked plating [14]. The biomechanical reasons for this and this appears to be moderate axial motion and minimal shear
were described in a recent study [18]. Healthy bone has a thicker movements [68,69]. As discussed, the axial motion produced by
cortex and better mechanical properties compared to osteoporotic locked plating can be altered by many variables: working length,
bone meaning that it can better withstand the transverse screw the offset distance between the bone and plate and the material
fastening loads. Interestingly, incomplete reduction or the presence properties of the plate [41,46,59]. Additionally, this review has
of a fracture gap was found to increase the strains within the demonstrated that there is confusion in the literature regarding the
bone around the screws much more in conventional plating than influence of some parameters in different fracture scenarios. This
in locked plating. Even in locked plating, complications resulting indicates that a more rigorous understanding of the mechanics
from screw loosening occur at least as often as plate breakage and of locked plating is required. Current screw positioning guidance
delayed healing [24]. Strain concentrations within the bone around includes the appropriate plate length and the number of screws
 A.R. MacLeod and P. Pankaj / Injury, Int. J. Care Injured 49S1 (2018) S12–S18 S17

Fig. 8. Summary of the influence of different variables on plate stress including: bone-plate offset, fracture gap size and working length. Note: non-locking screws that compress
the plate against the surface of the bone will always eliminate the bone-plate offset and, therefore, screw placement will have no significant influence on the plate stress under
weight-bearing loads.

to use (AO guidelines, [70]). Unfortunately, there are no guidelines Acknowledgment

regarding working length, which is known to be one of the primary
determinants of interfragmentary motion in locking plates [41]. The authors of this manuscript express their thanks to the
Better guidelines could inform the selection of an appropriate Osteosynthesis and Trauma Care Foundation for the sponsorship of
working length for a given fracture, which would reduce the the publication of this Supplement in Injury.
likelihood of mechanical failure or delayed healing.
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