1 AO philosophy and basic principles

1.2 Biology and biomechanics in bone healing

1 Introduction 9

2 Characteristics of bone 10

3 Fracture of bone 10
3.1 Mechanical and biochemical effects 10
3.2 Fracture and blood supply 11
3.3 Biology of fracture healing 13

4 Biomechanics and bone healing 17

4.1 Methods of fracture stabilization 17
4.2 Nonoperative fracture management 17
4.2.1 Fracture healing without treatment
4.2.2 Conservative treatment of fractures
4.3 Surgical fixation with relative stability 19
4.3.1 Mechanics of techniques of relative stability
4.3.2 Implants
4.3.3 Mechanobiology of indirect or secondary fracture
healing
4.4 Surgical fixation with absolute stability 22
4.4.1 Mechanics of techniques of absolute stability
4.4.2 Implants
4.4.3 Mechanobiology of direct or primary fracture healing

5 Outlook 30

6 Bibliography 30

7 Acknowledgment 31

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 Authors Keita Ito, Stephan M Perren

1.2 Biology and biomechanics in bone healing

The main goal of internal fi xation is to achieve prompt and, if

1 Introduction
possible, full function of the injured limb. Although reliable
fracture healing is only one element in functional recovery, its
The biological and biomechanical basis of fracture manage- mechanics, biomechanics, and biology are essential for a good
ment will be dealt with in this chapter. We will review how outcome. Fracture fi xation is always a compromise: For bio-
fractured bone behaves in different biological and mechanical logical or biomechanical reasons it is often necessary to sacrifice
environments and how this will influence the choice and some strength and stiffness of fi xation and the optimal implant
method of treatment by the surgeon. Any surgical procedure is not necessarily the strongest or the stiffest available.
may alter the biological environment and any fracture fi xation
will alter the mechanical environment. These changes may It is not the purpose of osteosynthesis to permanently
have a profound effect on fracture healing and are determined replace a broken bone but to provide temporary support to
by the surgeon, not the patient. Thus, it is essential that all allow early functional rehabilitation with healing in a proper
trauma surgeons have a basic knowledge of the biology and anatomical position.
biomechanics of fracture healing so they can make wise deci-
sions in fracture management ( Tab 1.2-1). This chapter offers a Under critical conditions, the mechanical requirements may
review for the active clinician rather than a pure scientific gain precedence over biological demands and vice versa.
analysis. In spite of worldwide research, much remains un- Similarly, the choice of implant material is a trade-off, eg, the
known or controversial in this rapidly changing scientific mechanical strength and ductility of steel versus the electro-
field. chemical and biological inertness of titanium. The surgeon
determines which combination of technology and procedure
best fits his experience, environment, and, in particular, the
demands of the patient.

Fracture gap

Simple Multifragmentary

Small (< 2 mm) Large (> 2 mm)

Relative stability Bone resorption, Secondary bone healing

healing delay, or nonunion (callus)

Absolute stability Primary bone healing, Bone resorption,

osteonal remodeling healing delay, or nonunion

Tab 1.2-1 The relationship between fracture type, stability of fi xation, and fracture healing.

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 1 AO philosophy and basic principles

creates a void (cavitation) and results in severe soft-tissue

2 Characteristics of bone
damage ( Video 1.2-1).

Bone serves as a scaffold that supports and protects soft struc- 3.1 Mechanical and biochemical effects
tures and enables locomotion and mechanical functioning of
the limbs. A fracture produces a loss of bone continuity that results in
pathological deformation, loss of the support function of bone,
The important mechanical characteristics of bone are its and pain. Surgical stabilization may restore function immedi-
stiffness (bone deforms only little under load) and strength ately and alleviate pain. Thus, the patient regains pain-free
(bone tolerates high load without failure). mobility and avoids such sequelae as complex regional pain
syndromes (chapter 4.7).
In considering a fracture and fracture healing, the brittleness
of bone is of special interest: Bone is a strong material, but it Fracture of bone ruptures blood vessels within bone and peri-
breaks under very small deformation. This means that bone osteum. Spontaneously released biochemical agents (factors)
behaves more like glass than like rubber. Therefore, at the on- help to induce bone healing. In fresh fractures these agents are
set of natural fracture healing, bone cannot bridge a fracture very effective and scarcely need any boost. The role of surgery
gap which is repeatedly subject to displacement. For an un- should be to guide and support this healing process.
stable or flexibly fi xed fracture (relative stability), a sequence
of biological events—mainly the formation of fi rst a soft and
then a hard callus—helps to reduce the strain and deformation
of the repair tissues (chapter 1.2:4.3.3). Resorption at the frac-
ture ends increases the fracture gap. The repair tissue is less
stiff and this combination reduces the strain at the fracture
site. A lower-strain environment promotes the formation of
Video
bridging callus which increases the mechanical stability of the
fracture. Once the fracture is solidly bridged, full function is
restored. Internal remodeling then restores the original bone
structure, a process which takes years.

3 Fracture of bone

A fracture is the result of single or repetitive overload. The

fracture occurs within a fraction of a millisecond. It results in
predictable damage to soft tissues due to rupture and an Video 1.2-1 Implosion of a bone during
implosion-like process. Rapid separation of fracture surfaces fracture.

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 1.2 Biology and biomechanics in bone healing

3.2 Fracture and blood supply to the flat undersurface of the DCP (Fig 1.2-1a). If the situ-
ation is reversed and the plate has a smaller radius of cur-
Although a fracture is a purely mechanical process, it triggers vature than the bone, there will be contact at both edges
biological reactions such as bone (callus) formation and bone (two-line contact), and the lateral undercuts of the LC-DCP
resorption. These two processes depend on an intact blood will significantly reduce the area of contact (Fig 1.2-1b–c).
supply. The following factors influence blood supply at the Consequences of trauma: Elevated intraarticular pressure
fracture site, and have an immediate bearing on the surgical reduces the epiphyseal bone circulation, especially in
procedure: young patients. The increase in hydraulic pressure (pro-
Mechanism of injury: The amount, direction, and con- duced by an intracapsular hematoma) has been shown to
centration of forces at the fracture site will determine the reduce blood supply to the epiphyseal bone, when the
fracture type and associated soft-tissue injuries. As a result growth plate is still open.
of the displacement of fragments, periosteal and endosteal
blood vessels rupture and the periosteum is stripped. Cav-
itation and implosion of the fracture cause additional soft-
tissue damage.
Initial patient management: If rescue and transportation
take place without splinting of fractures, motion at the
fracture site will add to the initial damage.
Patient recuscitation: Hypovolemia and hypoxia will in-
crease damage to injured soft tissues and bone and must
be corrected early in patient management.
Surgical approach: Surgical exposure of the fracture will
invariably result in additional damage [1]. This can be
minimized by having a thorough knowledge of anatomy,
careful preoperative planning, and meticulous surgical
technique. a b c
Implant: Considerable damage to bone circulation may
result not only from the surgical trauma, but also from the Fig 1.2-1a–c Area of contact under the plate.
contact between implant and bone [2]. Plates with a flat a If the radius of curvature of the undersurface of the plate is
undersurface (eg, DCP) have a large area of contact; the greater than that of the bone, a single line of contact will result.
LC-DCP, which is undercut, therefore was designed to In this situation, the DCP and LC-DCP will have similar areas of
reduce this contact area [3]. However, the extent of the contact.
contact also depends upon the relationship of the radii of b If the radius of curvature of the undersurface of the plate is
curvature of the plate and the bone. When the radius of smaller than that of the bone, the plate will have contact at both
curvature of the undersurface of the plate is larger than edges, producing a double-line contact.
that of the bone, plate contact may be in a single line, and c With contact only at the edge of the plate, the undercut under-
this reduces the advantages of the LC-DCP when compared surface of the LC-DCP reduces the area of contact.

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 1 AO philosophy and basic principles

Dead bone can only be revitalized by removal and replacement An immediate reduction of bone blood flow has been observed
(creeping substitution through osteonal or lamellar remodel- after fracture or osteotomy, with the cortical circulation in the
ing), a process which takes a long time to complete. It is gener- injured parts of the bone being reduced by nearly 50% [4].
ally accepted that necrotic tissue (especially bone) predisposes This reduction has been attributed to a physiological vasocon-
to infection and sustains it (chapter 5.3). Another effect of striction in both the periosteal and the medullary vessels as a
necrosis is the induction of internal (Haversian) remodeling. response to trauma [5]. During repair of a fracture, however,
This allows replacement of dead osteocytes but results in tem- there is increasing hyperemia in the adjacent intraosseus and
porary weakening of the bone due to transient porosis, which extraosseus circulation, reaching a peak after 2 weeks. There-
is an integral part of the remodeling process. This is often seen after, blood flow in the callus area gradually decreases again.
immediately beneath plates and can be lessened by reducing There is also a temporary reversal of the normal centripetal
the contact area of the plate (eg, LC-DCP), which maximizes blood flow after disruption of the medullary system.
the periosteal blood supply and reduces the volume of avascu-
lar bone. Microangiographic studies [6, 7] have demonstrated that
much of the vascular supply to the callus area is derived from
the surrounding soft tissues (Fig 1.2-2), a good reason not to
strip any soft tissues!

3 1 4 2

a
b

Fig 1.2-2a–b The blood supply of callus. b After bony bridging.

a Before bony bridging.

1 Nutrient artery ascending.

2 Nutrient artery descending.
3 Metaphyseal arteries.
4 Periosteal arteries.

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 1.2 Biology and biomechanics in bone healing

Perfusion of callus is of utmost importance and may determine is very similar to the process of embryological bone develop-
the outcome of healing. Bone can only form when supported ment and includes both intramembraneous and endochondral
by a vascular network and cartilage will not persist in the bone formation. In diaphyseal fractures, it is characterized by
absence of sufficient perfusion. However, this angiogenic the formation of callus.
response depends upon both the method of treatment and the
induced mechanical conditions: Bone healing can be divided into four stages:
Vascular response appears to be greater after more flexible inflammation;
fi xation, perhaps due to a larger volume of callus. soft callus formation;
Large strain in tissue, caused by instability, reduces the hard callus formation;
blood supply, especially in the fracture gap [8]. remodeling.
The operative procedure during internal fi xation of frac-
tures alters the hematoma and soft-tissue blood supply. Although the stages have distinct characteristics, there is
Following considerable intramedullary reaming, endos- a seamless transition from one stage to another; they are
teal blood flow is reduced, but there is a rapid hyperemic determined arbitrarily and have been described with some
response if reaming has been moderate. variation.
Reaming for intramedullary nails results in a delayed
return of cortical perfusion, depending on the extent of Inflammation
reaming [9–11]. Reaming does not affect perfusion within After fracture, the inflammatory process starts rapidly and
the fracture callus, as blood supply to the callus is mostly lasts until fibrous tissue, cartilage, or bone formation begins
from the surrounding soft tissues [12]. (1–7 days postfracture). Initially, there is hematoma formation
In addition to the wider exposure of the bone, larger im- and inflammatory exudation from ruptured blood vessels
plant-bone contact will result in a reduction of bone per- (Fig 1.2-3a). Bone necrosis is seen at the ends of the fracture
fusion, as bone receives its blood supply through the fragments. Injury to the soft tissues and degranulation of
periosteal and endosteal lining. platelets results in the release of powerful cytokines that pro-
Damage to the blood supply is minimized by: avoiding duce a typical inflammatory response, ie, vasodilatation and
direct fragment manipulation, minimally invasive sur- hyperemia, migration and proliferation of polymorphonuclear
gery, and the use of external or internal fi xators [13–16]. neutrophils, macrophages, etc. Within the hematoma, there is
a network of fibrin and reticulin fi brils; collagen fibrils are also
3.3 Biology of fracture healing present. The fracture hematoma is gradually replaced by gran-
ulation tissue. Osteoclasts in this environment remove ne-
Fracture healing can be divided into two types: crotic bone at the fragment ends.
primary or direct healing by internal remodeling;
secondary or indirect healing by callus formation. Soft callus formation
Eventually, pain and swelling decrease and soft callus is formed
The former occurs only with absolute stability and is a biological (Fig 1.2-3b). This corresponds roughly to the time when the
process of osteonal bone remodeling (chapter 1.2:4.4). The lat- fragments are no longer moving freely, approximately 2–3
ter occurs with relative stability (flexible fi xation methods). It weeks postfracture.

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 1 AO philosophy and basic principles

At the end of soft callus formation, stability is adequate to towards the center of the fracture and the fracture gap. The
prevent shortening, although angulation at the fracture site initial bony bridge is formed externally or within the medul-
may still occur. lary canal, away from the original cortex. Then, by endochon-
dral ossification, the soft tissue in the gap is replaced by woven
The soft callus stage is characterized by the growth of callus. bone that eventually joins the original cortex.
The progenitor cells in the cambial layer of the periosteum and
endosteum are stimulated to become osteoblasts. Intramem- Remodeling
braneous, appositional bone growth starts on these surfaces The remodeling stage (Fig 1.2-3d) begins once the fracture has
away from the fracture gap, forming a cuff of woven bone solidly united with woven bone. The woven bone is then slowly
periosteally, and fi lling the intramedullary canal. Ingrowth of replaced by lamellar bone through surface erosion and osteo-
capillaries into the callus and increased vascularity follows. nal remodeling. This process may take anything from a few
Closer to the fracture gap, mesenchymal progenitor cells pro- months to several years. It lasts until the bone has completely
liferate and migrate through the callus, differentiating into returned to its original morphology, including restoration of
fibroblasts or chondrocytes, each producing their characteris- the medullary canal.
tic extracellular matrix and slowly replacing the hematoma
[17]. Differences in healing between cortical and cancellous
bone
Hard callus formation As opposed to secondary healing in cortical bone, healing in
When the fracture ends are linked together by soft callus, the cancellous bone occurs without the formation of significant
hard callus stage starts (Fig 1.2-3c) and lasts until the frag- external callus. After the inflammatory stage, bone formation
ments are fi rmly united by new bone (3–4 months). As intra- is dominated by intramembraneous ossification. This has been
membraneous bone formation continues, the soft tissue within attributed to the tremendous angiogenic potential of trabecu-
the gap undergoes endochondral ossification and the callus is lar bone as well as the fi xation used for metaphyseal fractures,
converted into rigid calcified tissue (woven bone). Bone callus which is often more stable. In unusual cases with substantial
growth begins at the periphery of the fracture site, where the interfragmentary motion, intermediary soft tissue may form
strain is lowest. The production of this bone reduces the strain in the gap, but this is usually fibrous tissue, which is soon re-
more centrally, which in turn forms bony callus. Thus, hard placed by bone.
callus formation starts peripherally and progressively moves

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 1.2 Biology and biomechanics in bone healing

Periosteum Necrosis

Endosteum

a
Fibroblasts
Fibroblasts

PMN Polymorphonuclear neutrophil granulocytes

Macrophages
Macrophage

MSC Mesenchymal stem cells

Cartilage Capillary ingrowth

Osteoblasts

Fig 1.2-3a–d Stages of secondary bone healing.

a The inflammation stage. Formation of hematoma resolving into granulation tissue with
the typical inflammatory cascade.
b The soft callus stage. Intramembraneous ossification forming bone cuffs away from the
fracture gap. Replacement of the granulation tissue elsewhere in the callus by fibrous
tissue and cartilage, and ingrowth of vessels into the calcified callus. This starts at the
periphery and moves towards the center.

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 1 AO philosophy and basic principles

Woven bone = hard callus Cartilage

Lamellar bone Osteoblasts

Fig 1.2-3a–d (cont) Stages of secondary bone healing.

c The hard callus stage. Complete conversion of callus
into calcified tissue through intramembraneous and en-
dochondral ossification.
d The remodeling stage. Conversion of woven bone into
lamellar bone through surface erosion and osteonal re-
modeling.

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 1.2 Biology and biomechanics in bone healing

Fixation with relative stability aims to maintain the reduc-

4 Biomechanics and bone healing
tion and still keep the mechanical stimulation for fracture
repair by callus formation.
4.1 Methods of fracture stabilization
The prerequisite for successful relative stabilization is that the
The term stability is widely used by surgeons. Its meaning, displacement occurring under load is elastic, ie, reversible and
though, differs from that used in engineering. The surgeon not permanent. Fortunately, fracture healing by callus forma-
uses the word stability to express the degree of displacement tion can take place within a wide spectrum of mechanical
at the fracture site induced by load. environments. If titanium elastic nails are compared to bridge
plating using a locked plate, there is a large difference in the
A stable fracture is defined as a fracture that does not visi- degree of micromotion at the fracture site. However, both
bly displace under physiological load. will result in callus formation and fracture healing, if correctly
applied.
Fracture fi xation with absolute stability means that there is
no micromotion at the fracture site under physiological load. At either end of the spectrum of relative stability, fracture
healing will be delayed. Callus will not form if there is no mo-
The degree of stability determines the type of fracture tion, but if there is extensive movement and the fracture is
healing. unstable, healing will also be delayed.

Fracture of a bone often produces an unstable situation. Ob- 4.2 Nonoperative fracture management
vious exceptions are impaction fractures of the metaphysis,
nondisplaced fractures with intact periosteum, abduction 4.2.1 Fracture healing without treatment
fractures of the proximal end of the femoral neck, and green- Without treatment, nature stabilizes mobile fragments by
stick fractures. These fractures do not require reduction, and pain-induced contraction of the surrounding muscles, which
stabilization is only required if the fracture will deform under may lead to shortening and malunion. At the same time, he-
physiological load. matoma and swelling increase—although temporarily—the
tissue turgor and have a slight stabilizing effect. Observations
The aim of fracture stabilization, in order of priority, is to made of bone healing without any treatment help to under-
maintain the achieved reduction; stand of the positive and negative effects of medical interven-
restore stiffness at the fracture site (thus allowing func- tion. It is surprising how initial mobility is compatible with
tion); solid bone healing (Fig 1.2-4). In such cases, the residual prob-
minimize pain related to instability at the fracture site. lem is lack of alignment and impairment of function.

Fixation with absolute stability aims to provide a mechani- 4.2.2 Conservative treatment of fractures
cally neutral environment for fracture healing, ie, no motion Conservative management requires closed reduction to restore
at the fracture site. However, this also reduces the mechanical alignment. Subsequent stabilization maintains reduction and
stimulus for repair by callus formation. reduces mobility of the fragments, while indirect healing

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 1 AO philosophy and basic principles

a b

Fig 1.2-4a–b Spontaneous healing of a femoral fracture of a Viet-

nam war victim.
a AP x-ray.
b Lateral x-ray.

occurs by callus formation. In conservative treatment, stabili- Fig 1.2-5a–c Fracture reduction and stabilization by means of
zation is achieved by the following means: traction.
Traction: This can be supplied via the skin or a metal pin a–b The figures illustrate that the force reducing the fracture per-
inserted into the bone distal to the fracture (skeletal trac- pendicularly to the long axis decreases with alignment. Thus,
tion). Traction (Fig 1.2-5) along the long axis of the bone gross mobility is reduced, while micromotion persists.
aligns the bone fragments by ligamentotaxis, and reduces c Stabilization of a fracture using a plaster cast. The plaster cast
motion, providing some stability. acts like a splint and the pressure of the soft tissues maintains
External splinting: Application of externally applied alignment. This reduces mobility but does not prevent it. The
splints—made of wood, plastic, or plaster—results in a cer- cast represents a very stiff splint. Mobility occurs because the
tain amount of fracture stabilization. The splint dimen- plaster cast can only be loosely coupled to the bone by soft
sions are the most important mechanical element. Circular tissues. If the plaster is too tight, compartment syndrome will
external splints are very stiff and strong, based on their occur.
curved geometry. However, fi xation with external splints

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 1.2 Biology and biomechanics in bone healing

is inherently unstable because of poor coupling to bone External fixators

caused by the interposed soft tissue. Externally applied External fi xators usually provide relative stability, although
splints maintain reduction by achieving three-point some ring fi xators can be used to apply compression and abso-
contact. lute stability. Unilateral external fi xators are eccentrically lo-
cated, and exhibit asymmetrical mechanical behaviour. They
A curved plaster cast produces a straight bone, a straight are stiffer when loaded in the plane of the Schanz screw than
plaster cast produces a bent bone! in the plane perpendicular to them. Ring fi xators display al-
most uniform behaviour in all planes, so that displacement of
The pressure of the surrounding tissues reduces the movement the bone fragments in relation to each other is mainly axial.
of the fragments. In diaphyseal fractures, correct fragment
length, alignment, and rotation are all that is needed for proper The stiffness of fracture stabilization by external fi xation de-
function of the limb. In articular fractures precise anatomical pends on a number of factors, including
reduction is important to avoid joint incongruity or instability, the type of implants used, eg, Schanz screws and bars;
which may lead to secondary arthrosis (chapter 2.3). the geometrical arrangements of these elements in rela-
tion to each other and the bone, ie, uniplanar, biplanar, or
4.3 Surgical fixation with relative stability circular fi xators;
the coupling of the implant to the bone, eg, Schanz screws;
4.3.1 Mechanics of techniques of relative stability tensioned fi ne wires.
With relative stability, the bone fragments displace in relation
to each other when physiological load is applied across the The most important factors influencing the stability of fi xation
fracture. Displacement increases with the applied load and de- are:
creases with the rigidity of the fi xation device. There is no the stiffness of the connecting rods;
exact defi nition of the required or tolerated flexibility. In the distance between the rods and the bone axis; the stiffer
general, a fi xation method is considered flexible if it allows the rod and the closer it is to the bone axis, the more stable
controlled interfragmentary movement under physiological the fi xation is;
load. Therefore, all fi xation methods with the exception of the number, spacing, and diameter of the Schanz screws
compression techniques may be seen as flexible fi xations that or of the wires, and their tension.
provide relative stability.
The interfragmentary movement of a fracture with a unilat-
4.3.2 Implants eral external fi xator under load is a combination of axial,
Devices such as external fi xators, intramedullary nails, or in- bending, and shearing displacement. A double-tube arrange-
ternal fi xators provide relative stability. The degree of flexibil- ment under partial loading of 200–400 N results in interfrag-
ity can be varied and this is determined by how the surgeon mentary movement of several millimeters and stimulates
applies the device and how it is loaded. All of these devices callus formation. The external fi xator is the only system which
allow interfragmentary movement, which can stimulate cal- allows the surgeon to control flexibility of the fi xation by ad-
lus formation. However, incorrect application of the device can justing the implant without additional surgery. This tech-
result in excessive movement and inhibit bone union. nique, termed dynamization, may be used to modify the

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 1 AO philosophy and basic principles

loading of the fracture as healing progresses. This can be done Internal fixators and bridging plates
by extending the distance between the rods and the bone, or Plates which span a multifragmentary fracture in the manner
by reducing the number of rods. In addition, some types of of an external fi xator provide elastic splinting. The stiffness of
external fi xators allow axial telescoping, to stimulate the heal- such an internal fi xation method depends on the dimensions
ing process. of the implant, the number and position of the screws, the
quality of the coupling between the screw and the plate, and
Intramedullary nails the coupling between the screw and the bone. This will be
The classical Küntscher nail achieves good stability against influenced by plate design, (eg, locking head screws), the type
bending moments and shear forces perpendicular to its long of bone (eg, cortical versus cancellous), and the degree of os-
axis, but is rather unstable when torque is applied, and is un- teoporosis. The mechanics of this type of fi xation is discussed
able to prevent axial shortening (telescoping). The torsional in detail in the chapters on bridge plating (chapter 3.3.2) and
stiffness of slotted nails is low and the torsional and axial cou- internal fi xators (chapter 3.3.4).
pling between the intramedullary nail and the bone is loose.
Therefore, in the past, the effective application of this intra- Plating with relative stability should only be applied in
medullary nail was confi ned to simple transverse or short multifragmentary fractures and must not be used for simple
oblique fractures, which cannot shorten and will interdigitate fracture configurations as there is a high incidence of delayed
to prevent rotation. The advantage of the Küntscher nail is that union or nonunion. If simple (eg, metaphyseal) fractures are
its flexibility promotes callus formation. plated, a technique providing absolute stability must be
used.
The introduction of locked intramedullary nails and solid or
cannulated nails has overcome many of these restrictions. 4.3.3 Mechanobiology of indirect or secondary fracture
Locked nails withstand torsional moments and axial loading healing
better [18]. The stability under these loads is dependent on the Interfragmentary movement stimulates the formation of a cal-
diameter of the nail, the geometry, and the number of inter- lus and accelerates healing [19–21]. As the callus matures, it
locking screws and their spatial arrangement. The bending becomes stiffer, reducing the interfragmentary movement suf-
flexibility depends on the fit of the nail within the medullary ficiently, so that bridging by hard bony callus can occur
canal and the extent of the fracture. (Fig 1.2-6). In the early stage of healing, when mainly soft tis-
sue is present, the fracture tolerates a greater deformation or
The only drawback of locked intramedullary nails is the non- higher tissue strain than in a later stage when the callus con-
linear stiffness of the nail-bone construction. The locking tains mainly calcified tissue. The manner in which mechani-
holes are larger than the diameter of the interlocking screws— cal factors influence fracture healing is explained by Perren’s
this is to facilitate insertion by “freehand technique”. This al- strain theory (Fig | Animation 1.2-7). Strain is the deformation
lows some motion at the coupling, even at low loads. It may be of a material (eg, granulation tissue within a gap) when a given
decreased by insertion of further interlocking screws or by the force is applied. Normal strain is the change in length (∆ l) in
use of angular-stable locking systems such as the expert tibial comparison to original length (l) when a given load is applied.
nail. Thus, it has no dimensions and is often expressed as a percent-

20

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 1.2 Biology and biomechanics in bone healing

age. The amount of deformation that a tissue can tolerate and

still function varies greatly. Intact bone has a normal strain
Interfragmentary movement

tolerance of 2% (before it fractures), whereas granulation

tissue has a strain tolerance of 100%. Bony bridging between
the distal and proximal callus can only occur when local strain
(ie, deformation) is less than the forming woven bone can tol-
erate. Thus, hard callus will not bridge a fracture gap when the
movement between the fracture ends is too great [22]. Nature
deals with this problem by expanding the volume of soft cal-
lus. This results in a decrease in the local tissue strain to a level
that allows bony bridging. This adaptive mechanism is not ef-
fective when the fracture gap has been considerably narrowed
so that most of the interfragmentary movement occurs at the
Weeks
gap, producing a high-strain environment. Thus, overloading
of the fracture with too much interfragmentary movement
Fig 1.2-6 Typical course of interfragmentary movement monitored later in the healing process is not well tolerated [23].
for human tibial shaft fractures. The initial postoperative interfrag-
mentary movements under 300 N axial load (normalized to 100% at At the cellular level, where the fundamental process of bone
the outset) decrease with the passage of time. After about 13 weeks, regeneration and tissue differentiation occurs, the situation is
healing by callus has stabilized the fracture. more complex. The biomechanical conditions, such as strain
and fluid pressure, have an inhomogeneous distribution within
the callus. The mechanoregulation of callus cells is a feedback
loop in which the signals are created by the applied load and
modulated by the callus tissue. Mechanical loading of the cal-
Small gap Animation
lus tissue produces local biophysical stimuli that are sensed by
the cells. This may regulate cell phenotype, proliferation, apo-
ptosis, and metabolic activities. With alteration of the extracel-
lular matrix, and the associated changes in tissue properties,
the biophysical stimuli caused by mechanical loading are mod-
ulated, producing different biophysical signals even with the
same load. In normal fracture healing this feedback process
reaches a steady state when the callus has ossified and the orig-
Large gap inal cortex has regenerated. The biophysical signals themselves
and the way they interact to produce the biological response
are still being investigated. Several mechanoregulation algo-
rithms have been postulated and have been shown to be con-
Fig | Animation 1.2-7 Perren’s strain theory. sistent with some aspects of fracture healing, but they require

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 1 AO philosophy and basic principles

further corroboration. Transduction of these stimuli into intra- If the interfragmentary strain is excessive (instability), or
cellular and extracellular messenger systems are being inves- the fracture gap is too wide, bony bridging by hard callus is
tigated; so both physical and molecular methods of treatment not obtained in spite of good callus formation, and a hyper-
may be developed to treat delayed union and nonunion. trophic nonunion develops (Tab 1.2-1) [25].

When fractures are splinted, movement of the fragments in The capacity to stimulate callus formation seems to be limited
relation to each other depends on the and may be insufficient when large fracture gaps are to be
amount of external loading; bridged. In such cases dynamization (unlocking of the intra-
stiffness of the splints; medullary nail or external fi xator) may permit bony bridging
stiffness of the tissues bridging the fracture. by allowing the fracture gap to consolidate and increase its
stiffness.
Multifragmentary fractures tolerate more motion between the
two main fragments because the overall movement is shared Callus formation requires some mechanical stimulation
by several fracture planes, which reduces the tissue strain or and will not take place when the strain is too low. A low-strain
deformation at the fracture gap ( Video 1.2-2). Today there is environment will be produced if the fi xation device is too stiff,
clinical experience and experimental proof that flexible fi xa- or if the fracture gap is too wide [22]. Delayed healing and
tion can stimulate callus formation, thereby accelerating frac- nonunion will result.
ture healing [20, 24]. This can be observed in diaphyseal
fractures splinted by intramedullary nails, external fi xators, Again, dynamization may be the solution to the problem. If a
or bridging plates. patient is too immobile to load the operated leg, an externally
applied load might be the way to stimulate callus formation
[26].

Video
4.4 Surgical fixation with absolute stability

If a fracture is bridged by a stiff splint, its mobility is reduced

and little displacement occurs under functional load. Although
stiffness of the implants contributes to reducing the mobility
of the fracture, the only technique which will effectively abol-
ish motion at the fracture site is interfragmentary compres-
sion.

Absolute stability abolishes deformation (strain) of repair tis-

sue at the fracture site during physiological loading and results
Video 1.2-2 The same deforming force produces more strain at in direct bone healing. Reduction of strain to a level below the
the site of a simple fracture than at that of a multifragmentary critical level will reduce stimulation of bone formation, caus-
fracture. ing the fracture to heal without visible callus.

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 1.2 Biology and biomechanics in bone healing

In a low-strain environment bone heals directly by osteonal compressing in an axial direction [27]. Even overloaded bone
remodeling—the same homeostatic mechanism that exists does not undergo pressure necrosis provided overall stability
for normal physiological bone turnover. is maintained (Fig 1.2-8).

This process is also called primary bone healing. It is much

slower than healing by callus formation and so the implant
must not only provide and maintain absolute stability for a
prolonged period of time, it must also be strong enough to re-
sist fatigue failure during the prolonged healing period.

Direct bone healing is not the primary goal of this fracture

fi xation method but rather an unavoidable consequence of us-
ing a technique that obtains and maintains a perfect anatom-
ical reduction. Anatomical reconstruction is the true goal of
surgery in articular fractures and in some diaphyseal fractures
such as the forearm.

Disturbance of bone biology or vascularity is far more seri-

ous than delayed union or nonunion resulting from a high-
strain environment because the fi xation is too flexible.

It takes much more experience and greater skill to treat a com- a

plication due to disturbed vitality than to fi x a simple reactive
(hypertrophic) nonunion, which just needs enhanced me-
chanical stability (chapter 5.2; 5.3).

4.4.1 Mechanics of techniques of absolute stability

Absolute stability is achieved by using a compressive pre-

load and friction.
b
Compressive preload
Compression maintains close contact between two fragments,
provided compression at the fracture site exceeds the traction Fig 1.2-8a–b Stabilization by application of compression. The com-
forces acting at the fragment ends (Fig 1.2-8). Studies in sheep pressive preload prevents displacement of the fracture fragments
showed that compressive preload (static compression) does not and results in absolute stability as long as the compression produced
produce pressure necrosis, neither in lag screws nor in plates is greater than any traction produced by function.

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 1 AO philosophy and basic principles

Friction 4.4.2 Implants

When fracture surfaces are pressed against each other, friction
is produced. Friction counteracts shear forces that act tangen- Lag screws
tially, so sliding displacement is avoided (Fig 1.2-9). Shearing The lag screw is an implant which stabilizes a fracture by com-
stems, in most cases, from torque applied to the limb, and this pression alone (chapter 3.2.1). The lag screw is applied to have
is more important than forces acting perpendicular to the long purchase only in the remote cortex, and approximation be-
axis of the bone. The amount of resistance to shear displace- tween the thread and the head of the screw results in inter-
ment depends on the compression-induced friction and the fragmentary compression between the cortices. The fracture
geometry of the surfaces in contact (interdigitation). For located between the far and near cortices is thereby compressed,
smooth bone surfaces the normal forces produce somewhat and absolute stability is obtained by preload and friction.
less than 40% of friction. Rough surfaces allow a fi rm fi xation
and interdigitation of the fragments, which additionally coun- In vivo experiments have shown that lag screws produce high
teracts displacement due to shear forces. _ 2,500 N) (Fig 1.2-10), and such forces are
loads of force (>

Fig 1.2-9 Stabilization by application of compression producing Fig 1.2-10 Photoelastic model showing the compression exerted
friction. As long as the amount of friction is greater than the force upon an oblique osteotomy. The lag screw produces forces of
that tends to displace the fracture along the fracture plane, absolute 2,500–3,000 N.
stability is maintained. Screw fi xation of a plate relies on the same
principle.

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 1.2 Biology and biomechanics in bone healing

maintained over a period which exceeds the time required for prewarning to the surgeon who may apply too much torque.
fracture healing. Compression produced by a lag screw acts Titanium screws are only slightly weaker than steel screws
optimally from within the fracture, in contrast to compression (chapter 1.3), but their ductility (plastic deformation before
produced by plates (chapter 3.2.2). rupture) is low.

There are two disadvantages of compression fi xation by lag Plates

screws alone. Lag screws provide high compression force, but A fracture fi xed with one or more lag screws results in fi xation
the lever arm of such compression is, in most instances, too without motion (absolute stability), but in general such fi xa-
small to resist functional loading. This applies to both bending tion tolerates only minimal loading. A splint bridging the frac-
and shearing because the area of compression is small when ture site can reduce the load placed on the screws. Therefore,
viewed from the center of the screw. Thus, in diaphyseal frac- lag screws are usually combined with plates acting as splints
tures, lag screws must always be combined with a plate that to protect the screw by reducing shear or bending forces. The
protects them from these forces (= protection plate, previously term protection plate (earlier called neutralization plate) refers
called neutralization plate). The other disadvantage of lag to a plate functioning in this way.
screw fi xation is its lack of tolerance to single overload. When
a screw thread strips, it loses its compressive action and is un- A plate can be used to function in five different ways (chap-
able to recover its function. This is a contrast to plate fi xation ter 3.2.2):
where loss of function of a single screw may be compensated protection;
by the rest of the fi xation. compression;
tension band;
Lag and plate screws must not be tightened to a level where bridging;
they start to give way. With this mode of application, the bone buttress.
threads are partially damaged and/or the screws are plasti-
cally deformed and may fail. A plate may be applied to one side of a fracture and then ten-
sioned (by using eccentric placement of screws in the plate or
The more the screw is tightened, the greater the risk that it will by using the articulated compression device) to compress the
fail. Either the bone thread strips or the metal breaks with bone (and fracture) along its long axis. This is only effective in
complete loss of function. It is especially important to consider simple transverse or short oblique fractures. However, when a
this when titanium screws are used, as titanium provides little straight plate is applied to a straight bone, this will produce

25

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 1 AO philosophy and basic principles

compression underneath the plate with slight distraction (ten- A buttress plate is used in the metaphyseal areas. A buttress is
sion) of the opposite cortex (Fig 1.2-11). This is not a stable a construction that resists axial load by applying force at 90°
situation. Overbending of the plate, so there is a small gap to the axis of potential deformity. Under such conditions, the
between the plate and the bone at the level of the fracture, will plate initially carries full functional load. It can be used to
achieve compression of both the near and far cortex and pro- provide absolute stability and is often combined with lag
duce absolute stability (Fig 1.2-12). A plate may be placed on screws.
the tension side of the bone to act as a tension band. When the
bone is loaded, the plate converts tension into compression at A bridging plate is used in multifragmentary fractures. It is
the far cortex and produces absolute stability. This principle is used to fi x only the two main fragments and restore length,
discussed in detail in chapter 3.2.3. alignment, and rotation. There is minimal disturbance of the

Fig 1.2-11 Compression with a straight plate. This photoelastic pic- Fig 1.2-12 Compression with a prebent plate. Symmetrical com-
ture shows that by applying tension to the plate, compression of the pression may be achieved by prebending the plate. The slightly
plated bone segment can be produced. Thus, compression acts curved plate is applied to the bone surface with the middle part
within the bone along its long axis. Such compression is effective elevated. When the screws are tightened, the far cortex opposite to
only in transverse fractures. With a straight plate, there is only com- the plate is compressed as well.
pression in the near cortex, underneath the plate.

26

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 1.2 Biology and biomechanics in bone healing

fracture site and no fi xation of further fragments. This tech- treat hypertrophic nonunions, where the provision of absolute
nique always provides relative stability with healing by callus stability will allow rapid fracture union. Circular frames can
formation. A comprehensive description of the function and also be used to apply compression across oblique fractures, but
application of plates is given in chapter 3.3.2. this requires careful planning and a more complex frame de-
sign. The frame adjustments that allow compression in differ-
The locking compression plate (LCP) can be used to function ent planes are difficult to calculate but computer programs are
in the five different modes described above. Thus, the LCP can now available to aid the surgeon in achieving this goal.
be used to provide absolute or relative stability. It resembles a
LC-DCP but has combination holes. The smooth part of the 4.4.3 Mechanobiology of direct or primary fracture healing
dynamic compression unit allows insertion of conventional Bone healing is different in cortical and cancellous bone. The
screws so the plate can be used in the same way as a DCP or basic elements correspond qualitatively, but as the vascularity
LC-DCP. The threaded part of the combination hole allows and the volume to surface ratio are very different, the speed
locking head screws to be inserted to produce a mechanical and reliability of healing is generally better in cancellous
coupling between the plate and the screw. For multifragmen- bone.
tary fractures, the LCP can be used as a standard bridging
plate. However, if locking head screws are used for the entire Diaphyseal fractures
fi xation, the plate is not compressed against the cortex and acts In the diaphysis, absolute stability is achieved by means of
like an external fi xator. This is the internal fi xator principle. interfragmentary compression to maintain the fracture frag-
It provides relative stability with minimal interference with ments in permanent apposition (chapter 3.2.2). Pain will sub-
the blood supply to the fracture. side and allow for early functional treatment within a few days
of surgery.
When using the LCP, it is essential that the surgeon under-
stands the different functions of the plate and knows how to Radiologically, only minor changes can be observed: Under
use this device to achieve the goals of surgery. Careful pre- absolutely stable fi xation, there is minimal visible callus for-
operative planning is essential and must include the order mation or none at all [28]. The fact that the fragment ends are
of screw insertion, which can fundamentally alter the bio- closely approximated means that only a fi ne line can be seen
mechanical function of this device. on x-rays. This renders the judgment of fracture healing
difficult. A gradual disappearance of the fracture line with
The use of the LCP is explained in detail in chapter 3.3.4. trabeculae growing across this line is a good sign, while a wid-
ening of the gap is a sign of instability. The surgeon judges the
External fixators progress of healing by the absence of radiological signs of ir-
Circular external fi xators, as developed by Ilizarov, allow ritation, such as bone resorption or the formation of a cloudy
complete control of length, alignment, and rotation of a frac- “irritation” callus, as well as by clinical symptoms, such as the
ture. These devices can be used to provide absolute stability. presence or absence of pain and swelling.
The same principle applies when circular frames are used to

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 1 AO philosophy and basic principles

The histological sequence of healing under conditions of abso- Fractures in cancellous bone
lute stability: Fractures around the metaphysis have a comparatively large
In the fi rst few days after surgery there is minimal activity fracture surface with good vascularity. This offers the oppor-
within bone near the fracture site. The hematoma is re- tunity of good fi xation in terms of bending and torque, and
sorbed and/or transformed into repair tissue. The swelling thus these fractures tend to be more stable, and healing occurs
subsides while the surgical wound heals. more rapidly. Radiological evaluation is somewhat impeded by
After a few weeks, the Haversian system starts to re- the complex 3-D structure of trabecular cancellous bone. The
model the bone internally as visualized by Schenk and main histological activity seen in fracture healing of cancel-
Willenegger (Fig 1.2-13; 1.2-14) [29]. At the same time, gaps lous bone occurs at the level of the trabeculae. Healing—due
between imperfectly fitting fragment surfaces—if stable— to the larger surface per volume—is likely to occur faster than
will start to fi ll with lamellar bone, the orientation of in cortical bone. Because vascularization of cancellous bone is
which is transverse to the long axis of the bone. better than in cortical bone, necrosis is less likely to occur.
In subsequent weeks, the cutter heads of the osteons reach
the fracture and cross it wherever there is contact or only The advantage of absolute stability is that it maintains perfect
a minute gap [30]. The newly formed osteons crossing the reduction of the articular surface and allows early functional
gap provide a kind of microbridging or interdigitation. rehabilitation. The disadvantages are that internal Haversian

Fig 1.2-13 Histological appearance of direct cortical bone healing. Fig 1.2-14 Schematic diagram of Haversian remodeling. The osteon
The areas of dead and damaged bone are replaced internally by carries at its tip a group of osteoclasts that drill a tunnel into the dead
Haversian remodeling. The fracture line has been graphically en- bone. Behind the tip, osteoblasts form new bone with living cells and
hanced. a connection to the capillaries within the canal.

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 1.2 Biology and biomechanics in bone healing

remodeling starts late and takes a long time and that the ab- obtained by friction between the plate and bone, which re-
sence of any movement at the fracture gap does not stimulate quires a minimum area of contact. Extensive and continuous
callus formation. Therefore, the implant alone must provide contact between any implant and bone results in circum-
stable fi xation initially and for a longer period than fractures scribed areas of bone necrosis in the cortex directly under-
treated with relative stability. neath the plate. This may lead to temporary porosis of the bone
and, exceptionally, to sequestration. Recent studies have
Recovery of blood supply shown that reduction of the implant-bone interface may im-
Absolute stability also has positive effects on the blood supply. prove resistance to local infection and enhance fracture heal-
Under stable conditions, blood vessels may cross a fracture site ing (Fig 1.2-16).
more easily. Despite the deleterious effects of surgical proce-
dures used to achieve absolute stability, once obtained, it sup-
ports the repair of blood vessels (Fig 1.2-15).

In plate fi xation, the comparably large contact area (footprint)

of conventional plates is considered a disadvantage. Bone tol-
erates mechanical loading quite well and protects its inner
blood vessels from being affected by it. The blood vessels enter-
ing bone from the periosteal and endosteal sides are, however,
very sensitive to any external contact. When plates are placed
onto the bone surface, they are likely to disturb the periosteal
blood supply. In conventional plating, part of the stability is

Fig 1.2-15 The effect of stability on revascularization. The osteot- Fig 1.2-16 Bridging plate. The plate spans a critical fracture
omy of a rabbit tibia has been reduced and stably fi xed. As early as area and is fi xed only near its two ends. Thus, periosteal
2 weeks after complete transection of the bone and medullary cavity contact at the fracture site that could impede circulation is
the blood vessels have reconstituted and are functioning, as this avoided and there is the possibility of placing a bone graft
angiography at 14 days shows. under the bridge.

29

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 1 AO philosophy and basic principles

5 Outlook 6 Bibliography

Today’s state-of-the-art technology of surgical fracture [1] Farouk O, Krettek C, Miclau T, et al (1999) The topography of the
treatment offers interesting possibilities, but it is wide open to perforating vessels of the deep femoral artery. Clin Orthop Relat Res;
(368):255–259.
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ments/implants. The goal is a simple and cost-effective tech- plated bone after internal fi xation: Result of stress shielding or vascular
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nology, which allows reliable healing and early return to full
[3] Perren SM (1991) The concept of biological plating using the limited
function of the limb and patient. The technology must be of contact-dynamic compression plate (LC-DCP). Scientic background,
appropriate quality and its application must be safe and easy design and application. Injury; 22(Suppl 1):1–41.
[4] Grundnes O, Reikeras O (1992) Blood flow and mechanical
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However, any advances will be based upon the building blocks Acta Orthop Scand; 63(5):487–491.
of basic science and the principles described in this book. It is [5] Kelly PJ, Montgomery RJ, Bronk JT (1990) Reaction of the
circulatory system to injury and regeneration. Clin Orthop Relat Res;
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of both. [6] Brookes M, Revell WJ (1998). Blood Supply of Bone. Scientic aspects.
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[7] Rhinelander FW (1974) Tibial blood supply in relation to fracture
healing. Clin Orthop Relat Res; (105):34–81.
[8] Eckert-Hübner K, Claes L (1998) Callus tissue differentiation and
vascularization under different conditions. 11 (Abstract). 6th Meeting
of the International Society for Fracture Repair.
[9] Danckwardt-Lilliestrom G, Lorenzi GL, Olerud S (1970)
Intramedullary nailing after reaming. An investigation on the healing
process in osteotomized rabbit tibias. Acta Orthop Scand Suppl; 134:1–78.
[10] Smith SR, Bronk JT, Kelly PJ (1990) Effect of fracture fi xation on
cortical bone blood flow. J Orthop Res; 8(4):471–478.
[11] Klein MP, Rahn BA, Frigg R, et al (1990) Reaming versus non-
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[16] Farouk O, Krettek C, Miclau T, et al (1999) Minimally invasive

plate osteosynthesis: does percutaneous plating disrupt femoral 7 Acknowledgment
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[17] Sarmiento A, Latta LL (1995) Functional Fracture Bracing. Berlin We wish to thank Lutz Claes for his contribution to this
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[24] Goodship AE, Kenwright J (1985) The influence of induced
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[27] Perren SM, Huggler A, Russenberger M, et al (1969) The reaction
of cortical bone to compression. Acta Orthop Scand Suppl; 125:19–29.
[28] van Frank Haasnoot E, Münch TW, Matter P, et al (1995)
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[29] Schenk R, Willenegger H (1963) [On the histological picture of so-
called primary healing of pressure osteosynthesis in experimental
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[30] Rahn BA, Gallinaro P, Baltensperger A, et al (1971) Primary bone
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