1350-4533( 95)00056-9

ELSEVIER

The influence
of external fixators
motion during simulated
walking
T. N. Gardner,

on fracture

M. Evans and J. Kenwright

Oxford Orthopaedic Engineering Centre, University of Oxford,

Orthopaedic
Centre, Windmill Road, Headington, Oxford, UK

Nuffield

ABSTRACT
This expamental
study examines the relative influence
ofJive uniluteral
external jixntors
on tibia1 fructure
.stnbility
during
simulated
walking.
Stability
during
routine patient
uctivity
i.c important,
because cyclic inter-fragmentary
motion, or strain, has been shown to affect ji-arlure
healing. In model stable fractures
simulating
early healing (six
weeks), it was found
thatjxators
do little to constrain
aguinst uxial interfraCgmentq
strains us great as 100% at
on[y nominal
weight-bearing
(6.0 kg). ?he,$e strains may orcur repeatably
at peak nmp?itudes
motion d7cringwalking
Similurly,
peak angular
movements
may &ad to additional
axial strains of up to 25% at the external
cortex and sheur movrmunt.r
may lead to shear strains OJ up to 100%. Such strains nre greut enough to yield and
possibly refracture
the intm gap fracture
tissue that may be composed of a combination
of gvanulation
tissue, Jibrou~~
rartiluCge, cartilage
and bone. It was also shown that the prowdure
releasing
the jxator
column
to trlesrope
(dynamizr)
hnr little inJluence
on peak cyclic axial motion and on loading
at the frarturr.
although
inrrenses
orrurrrd
in peak transverse
and torsional shear strains of up to 100%. Since permanent
interJiiqmentan
trarrskation
(dso arises Jirom thr consequent
compaction
of the intra g@ tissue, it may be permanent
displacement
rathm th,nn
nny rhnngr
in the amplitude
motion that is responsible for the benejrial
rffert on healing claimed for the drnnmizini poruduru.
In unstnblP fractures
that are unable to .support tibia1 load at the fracture.
the peak ampl~tude.~
of
ryrlir
movement
were as <great as those reported forJ+acture.r
stnbilizrd
bv pkast~r
rasts, and were appoximatrl~
twiw
the mo7~ernen t of the rtable frartur-es
simulating
enr!y healing.
There&e,
patients
with unstnblP frarlures
suiported
by cxttmal
fixators,
may be expected to have .similar pallerns
of hen&
to plnstcl-rastrd
pnlirnt.s
with similn~l;.ar2ure\.
C&riqht
0 1496 l&vim
Science I.td.for
IPlNH.

of

qf

qf

Keywords:
healing

Fracture,

external

Med. Brig. Phys., 1996, \ol.

fixator,

fracture

model.

inter

fragmentary

strain, fracture

mov~mcn~,

18, 305-313, June

INTRODUCTION
The biological process and speed of fracture healing is influenced by the inter fragmentary motion
permitted by the fracture fixation device. This is
because fractures usually heal by a combination
of two different processes. The direct process of
repair involves relatively rigid fracture fixation
and primarily osteonal remodelling
at the fragment ends. The more rapid indirect process,
involves a more flexible fixation permitting some
degree of inter fragmentary
motion and results
primarily
in the formation
of callus, usually
initiated
at the periosteum.
During
mainly
indirect healing with external fixation, it has been
shown that the nature of inter fragmentary
motion influences the speed of restoration of
mechanical integrity at the fracture, and therefore
of limb function.. Since the fixation frame pro-

vides the main constraint against this motion during regular motion-inducing
activities such as
walking, the performance of the fixator must have
a profound influence on the process and speed
of healing. Therefore, this study examines experimentally the influence of external fixators on fracture motion during simulated walking.
The properties of inter fragmentary motion that
influence healing (amplitude, direction,
frequency and strain rate)
Kenwright and Goodship showed that passive cyclic axial movements, that are applied mechanically
to tibia1 fractures, can be either inhibitory
or
stimulator-y to the process of indirect healing. For
example amplitudes of 2.0 mm axially in experimental fractures (corresponding
to 67% strain in
the 3.0 mm gaps used) was shown to delay callus
formation in comparison with rigid fixation, and
0.5 mm (corresponding to 17% strain) to produce

Fracture

motion during walking:

T. N. Gardner

et al.

a greater stimulus to callus formation

and fracture
stabilization.
Cast-brace studies have indicated
that tibia1 fracture movements
can be more substantial although
non-unions
are uncommon5,
and in plastercasted
patients shear and angulation was measured at between 3.0 mm and 2
(for three stable fractures) and 2 cm and 21 (for
an unstable
fracture)6.
Although
the fractures
may have all subsequently
united, it is not clear
whether the healing
rate could have been improved by reducing the movement
in either study
to the approximate
strain shown to be beneficial
by Goodship and Kenwright3.
With regard to the direction
of movement,
Goodship
and Kenwright
and Kenwright
and
Goodship
showed that axial movement
can be a
stimulus for healing in both humans and sheep,
and, although it may be difficult to control, angular movement
has also been shown to stimulate
substantial callus in rat tibiae. The disadvantage
of angular movement
is that it may cause random
shear and axial movement,
when both bone fragments do not pivot precisely about the fracture
centre. The effect of shear on healing is unclear.
Although
significant shear movements
have been
shown to cause non-union
in experimental
fractures in the rabbit tibia*, it is suggested that cells
in healing
bone may respond to intermittent
shear strains by significant
tissue proliferationg.
In addition
to displacement,
other factors such
as frequency,
strain rate and the time of commencement
of movement
after injury have all
been shown to influence
healing
by varying
degrees. The frequencies
and strain rates used
successfully to stimulate
osteogenesis have been
physiological,
both in experimental
fractures and
in intact bonelo, while the time to commence
this
movement
would seem to be as early as pain and
discomfort
allows.
In practise however, fractures are regularly
exposed to the random
active movements
that
arise from the routine activities of weight-bearing
and muscle flexion. Healing response is therefore
a consequence
of this mechanical
environment,
as well as the biological
one, and not of the controlled mechanical
environment
discussed above.
Although
active movement
will probably provide
the desired frequency
and strain rate for an
optimum
healing
response, the amplitude
and
direction
of this motion
is not expected to be
appropriate.
The influence on motion of the load-bearing
properties of the fracture site

The structural and material properties of the fracture site influence the performance
of the fixation
system and therefore the amplitude
and direction
of inter fragmentary
motion.
Any evaluation
of
the performance
of unilateral
external
fixators
must therefore encompass the ranges of variation
possible in these two properties.
Owing to the morphology
of healing, there is
continuous
change in the tissue composition
and
geometric
structure
of the fracture,
and this
affects the control of load-bearing
movement
by

306

the fixator framei2. During the initial stages the

fracture is stiffened rapidly by the arching and
bridging
of the callus at the periosteum,
formed
by enchondral
ossification13,
and subsequently
through the process of uniting the inter fragmentary surfaces by fibrous connective tissue, culminating in directly formed bone by intamembranous
or enchondral
ossification13. Since motion at the
fracture becomes more constrained
by the stiffening callus, the amplitude
and direction
of movement will reduce gradually and the demand on
the fixator to provide constraint
is expected to
change. Since the nature of motion will vary, this
effect should be considered
in the performance
evaluation
of a fixator.
Of equal importance
is the influence
on inter
fragmentary
motion of the structural support to
load offered at the fracture site by the interposing
fragment ends brought into contact by tibia1 load.
Here, the distinction
must be made between the
inter fragmentary
motion of fractures where tibia1
load is well-supported
at the fragment ends and
of fractures where load is largely unsupported!.
Owing to the different
degrees of support, the
inter fragmentary
motion of such fractures during
patient activity is expected to be substantially
different. Also, many forms of unilateral
external
fixators now incorporate
an option for changing
the degree of axial support provided by the frame,
referred to as the dynamizing
function.
Consideration must be given to the influence this may
have on load-bearing
motion
in well-supported
fractures, but it is not generally used for unsupported fractures.
The influence of the fixator on inter
fragmentary motion (past work and present
s-59

Numerous
studies have been reported on the performance of different unilateral
external fixators,
using a variety of models and loading configurations14-17, in an attempt
to characterize
the
mechanical
properties
of each device. The difficulty in assessing the importance
of these studies
arises from the uncertainty
as to whether the
experimental
conditions were realistic. As a consequence, it is uncertain
whether the observed
behaviour
is representative
of real fractures of
variable
bone-end
support
that develop
an
increasing
constraint
to movement
throughout
the healing process. Also, in the natural environment of a fracture,
axial, bending
and shear
(transverse and torsional)
loads arise through
weight-bearing
and through muscle, tendon and
ligament
activity. The loading
is therefore
very
and it would require
considerable
complex,
resources to generate and validate an experimental, analytical or numerical
model that was able to
predict, for example, the forces or movements
at
a mid-diaphyseal
tibia1 fracture site.
A more realistic approach has been attempted
for this study. Here, axial, bending
and shear
loads have been applied cyclically to model fractures at physiological
frequency and strain rate.
The magnitude
of the loading ensured that the

amplitude
and direction
of the resulting
inter
fragmentary
motion
was representative
of the
spectrum of movements
commonly
occurring
in
patients during walking at two to four weeks post
fixation. Inter fragmentary
motion in patients has
been characterized
in previous studies that have
used a displacement
transducer to monitor
the 3dimensional
movements
of well-supported
tibia1
fractures during y ical daily activities over the full
period of healing 8. For these patients, weightbearing ground loads were frequently
over 200 N
from as early as 2 weeks, and the corresponding
peak displacements
throughout
the healing period were not always predominantly
axial. In the
early stages of healing, angulations
in a vertical
plane and transverse shear movements
(of up to
1.0 and 0.7 mm respectively)
were frequently
as
significant as peak axial motion (of up to 1 .S mm)
and often greater lg. During the healing period
(around 2-20 weeks), the stiffening and strengthening of the fracture provided
an increasing
resistance
to three-dimensional
movement.
To
model
the increasing
resistance, four fracture
simulation
materials
of increasing
stiffness were
fixed to the opposing
fragment
ends across the
fracture site. In this way, the relative performances
of the five frames were evaluated throughout
a
simulated
period of healing.
The above tests were carried out using a model
of a well-supported
fracture and by applying the
loads that simulated
the spectrum of movement
found in a group of patients with stable fractures.
The same load combination
was then applied to
a model of an unsupported
fracture (without fracture simulation
material),
to evaluate the relative
performance
of fixators with unstable fractures.
Unfortunately,
the means of appraising
fixator
performance
in relation
to the control of inter
fragmentary
motion
are not readily
available.
Although
the merits of frame strength may be
assessed easily, frame stiffness, and its influence
on inter fragmentary
movement
under load, may
not. The stiffness performances
of fixators should
be evaluated only in relation
to their ability to
control inter fragmentary
motion during normal
activity to that which is required for an optimum
healing response. Some flexibility
is required
to
induce the indirect process of healing desired for
external fixation; but how stiff must the fixator
frames be or what is the motion required? As the
means
of appraisal, a criterion
of performance
was needed against which the performance
of
each fixator could be compared.
Although
an
exact prescription
for motion
could
not be
obtained
from the literature,
it was possible to
form a general guide from what is already known.
Since the effect of shear strain on healing
is
unclear, it seems prudent
to expect fixators to
avoid transverse and torsional
movement
at the
fracture. Also, as angular motion causes non-uniform axial strain around the cortex and the pivot
point can be difficult to control, it seems prudent
to avoid angular
movement.
This leaves axial
motion,
which can be applied
successfully to
stimulate
callus osteogenesis,
provided
that it is
controlled
in amplitude
to avoid axial strains

reaching
yield level in the intra gap tissue.
Therefore,
the preferred
pattern of movement
would be controlled
axial motion, with the avoidance of angular and shear motion.
If fixators control motion in this way, patients
may be encouraged
to walk as early as discomfort
allows, since walking will provide the physiological
frequencies and strain rates also found to be optimum for healing. If they do not, the effect of load
bearing movement
on healing is likely to be more
inhibitory
than stimulator-y. The relative performance of each fixator was therefore evaluated from
the disparity
between the actual fracture
site
motion of a model during simulated walking, and
the preferred motion.
METHOD
Fixators
A group of unilateral
external fixators currently
used clinically were selected for the study of inter
fragmentary
motion. -These were the Dynabrace
(Smith and Nephew) j Bi-roll (Hoffman),
Modulsystem DAF, (Orthofix),
the red and blue Monotubes (Howmedica
International).
Where appropriate,
tests were carried out using both the
dynamizing
and nondynamizing
mode of operation of each fixator, where the individual
dynamizing actions are generally different. For the Dynabrace, tibia1 load causes the groups of screw
clamps either side of the fracture site to slide on
the column towards each other, resisted by spring
pressure. With the other four fixators this is achieved by the column sliding telescopically.
Here,
the Monotubes
provide the possibility of using an
adjustable spring pressure offering variable resistance to axial loading, whereas the Bi-role transfers
all the tibia1 axial load to the fracture site, and
the Modulsystem
is used with or without a compressible ring, (the Dyno-ring)
to resist axial
movement.
The fixator operations
are therefore
referred to as either locked (nondynamizing)
or
unlocked
(dynamizing).
For the tests in the
unlocked
mode, the Monotubes
and Dynabrace
were operated with zero spring return pressure
and the Modulsystem
was used with and without
the Dyno-ring.
Experimental

models

In the laboratory model of the stabilized fracture

(Figure I) each fixator frame was arranged
in a
standard
geometric
configuration,
except for
some variation
in the lateral spacing between
bone screws as a result of the individual
clamp
designs. Two 135 mm lengths of glass fibre tubing
of 25 mm diameter
were arranged
in line to
model the bone each side of a 60 mm gap. Two
6 mm diameter
screws were fixed into each section at 200 mm between pair centres, and at a
tube/screw clamp clearance of 70 mm. In this first
condition
(the unsupported
frature model), only
the fixator framework
provided
stability at the
fracture site; no contribution
to the support of
tibia1 load was made from the fracture site. This

307

Fracture

motion duting

walking:

T. N. Gardner

et al.

Fixator

Figure 1 The model fracture

configuration,
Axial, bending and torsional loads are applied to the model bone cyclically and in phase,
to simulate physiological
loading during walking

model
simulates
the immediate
post-operation
behaviour of cornminuted
fractures or unreduced
fractures with substantial gaps owing to bone loss.
In the second condition,
additional
support was
provided at the fracture site to simulate tibia1 loadbearing across the fracture, between the interposing fragment
ends (the well-supported
fracture
model).
This model simulates the behaviour
of
non-comminuted
fractures well-reduced,
that sub
sequently develop only a marginal
gap. A 30 mm
diameter polyurethane
disk of thickness 12.5 mm
was bonded to aluminium
rods, that were inserted
into the ends of the two tubes across the fracture
site, to simulate the resistance to inter fragmentary motion
provided
by the callus of a healing
fracture. Four grades of simulation
material were
used that had axial stiffnesses of 50, ,385, 526 and
1430 N/mm.
The 50 N/mm
material
modelled
the contribution
to stiffness provided by a wellsupported
fracture at about four weeks post fixationzo, where a soft cartilaginous
callus may be
formed prior to ossification.
This period of low
fracture stiffness is important
because, at this early
stage in healing, the fixator frame is expected to
have a greater mfluence on movement
at the fracture. Also, since there is potential
for greater
movement
during
the initial
stages of fracture
repair, it is suspected that movement
during early
healing may have a greater effect on the outcome
of healing. After this period the contribution
of
the fixator frame to axial stability of the fracture
begins to reduce significantly*l,
as the fracture
heals and stiffens. During this later phase, the gap
tissue and periosteal callus mineralize
form bone
and remodel,
leading to the removal of the fixation device at an axial fracture stiffness of around
1000 N/mm **. This secondary phase was modelled using the 385, 526 and 1430 N/mm fracture
simulation
materials.

of 2 Nm was applied by the piston thruster to the

bottom
(distal) end of the model tibia, in phase
with the vertical load. This simulated
a torsional
loading of the tibia owing to a rotation of the foot
about the long axis of the bone. A bending
moment
of 1.75 Nm was applied to the fracture
site about an axis parallel to the screws, by offsetting the line of action of the axial load at the top
end of the model bone (proximal)
by 16 mm.
This arrangement
simulated
a laterally eccentric
loading of the tibia, applied through
the knee.
The loads were combined as shown in Figure I and
were applied
cyclically
using compressed
air
pulses from a pneumatic
diaphragm
thruster and
cylinder thruster, installed at the lower end of the
model tibia. The combination
of loads on the
unsupported
fracture model produced
approximately the spectrum of inter fragmentary
movement observed in the group of fracture patients.

Measurements

The Oxford Micromovement

Transducer
(OMT)
was clamped between the inner pair of screws parallel to the tibia and immediately
adjacent to the
fracture, to measure 3dimensional
inter fragmentary movement
under loading for both fracture
models. Movements
at the transducer in response
to the loading were measured in 6 degrees of freedom (three linear orthogonal
directions,
and
three angular rotations
about the linear axes).
These movements
were then translated to obtain
the inter fragmentary
motion at the fracture site,
and were finally reduced to the four directions of
movement
shown in Figure 2. Diagrams
(a) and
(6) illustrate
the two linear movements
of transverse shear and axial compression,
while (c) and
(d) illustrate
angular movement
and torsional
shear movement.
(Angular movement
was calculated in the plane for which the angle was the
maximum).
A load cell at the base of the model
measured vertical reaction, and a computer
was
used to acquire load vs displacement
data from
the load cell and transducer over 6 s test periods.

(a)

simulating

walking

An axial load of 220 N was applied

along the
longitudinal
axis of the model tibia by the diaphragm thruster at the base. A clockwise torsion

308

Pa

30
i
iI

i
iI
e

3
Loads

(b)

4
Figure 2 The four
tored at the fracture;
(d) torsional
shear

directions
of inter fragmentary
(a) transverse
shear, (b) axial,

WI
i
i8

I
i
ui
Q

motion
moni(c) angular, and

(a)

RESULTS

2.5 f-

Inter fragmentary
motion was examined
in comparison
with the desired
motion
performance
already discussed.
The control
of axial displacement was considered
to be beneficial
and the constraint imposed
upon shear (both transverse
and
torsional)
and angulation
as being desirable. Also,
it was assumed
that the object of unlocking
the
fixator is to alter the dynamic load at the fracture,
without
affecting the non-axial constraint
(against
angulation
and transverse
or torsional
shear
movement)
. Since well-supported
and unsupported
fractures
have
substantially
different
behaviour,
they were addressed
separately.

2
73

;;

2.0

UN

Blue-Mono

The unsupported
only)

fracture

model

(locked

mode

fracture

model

(locked

Thp 50 N/mm .rimulation

material.
Looking
initially
at
the
material
of
lowest
stiffness
(Figw-e-e(a)),
re p resenting
a fracture
in the early
stages of healing. Here, the locked fixator frames
(with an average axial stiffness of 60 N/mmj2,
and
the fracture
simulation
material
(of stiffness

Trarw.

shear

(mm)

q Axial(mm)
d

2.5

E
E
Y
P

2.0

5
t
ytf!

1.0

Angle
Ton.

(deg)
~hcw (deg)

1.5

05
0

Blue-mono

Red-Mono

UN
Bi-roll

UN

Modulsy.

UN

Dynabrace

Gl
%
b

Red-Mono

Bi-roll

Modulry.

Dynabmce

L-Locked
2.0

3
2

1.5

u
;
r;
E
L

0.5

UN-Unlocked

Trans. shear (mm)

Axial (mm)

Angle (de&

Ton. shear (deg)

L
Blue-Mono

UN

L
Red-Mono

UN

UN
Bi-roll

L
Modulsy.

UN

UN

Dynabrace

a. h

and

Figure 4 shows
the peak
amplitudes
of inter
fragmentary
motion seen during simulated
walking, for a well-supported
fracture
model in the
locked
and unlocked
mode of each fixator.

3.0

(b)

Figure

The well-supported
unlocked
mode)

UN

2.5

I:@Lw 3 shows the peak amplitudes

of inter fragmentary
motion
seen during
simulated
walkiqg,
for an unsupported
fracture
model with the fixator in the locked mode. Here, movements
are
substantially
greater than will be seen later with
the well-supported
fracture
model. The greatest
peak axial movement
at the fracture
site occurred
with the blue Monotube
and the Bi-roll, with the
Bi-roll also offering
the least constraint
against
transverse
shear
and angular
movement.
The
Modulsystem
offered
the greatest
constraint
against transverse
shear, the Dynabrace
against
torsional
shear, and the red Monotube
against
angular movement.

50 N/mm),
contribute
almost equally to resisting
tibia1 load (in the ratio of 60:50). That is, the
mechanical
properties
of the fixator
are as
important
as those of the fracture
material
in
influencing
inter fragmentary
motion
at around
two to four weeks post fixation. The Bi-roll allows
the greatest
axial movement
with
the fixator
locked.
Unusually,
with
the Dynabrace
the
expected
change in overall stiffness,
caused by
unlocking
the fixator, appears to have little influence on peak axial displacement;
here friction
may be limiting the axial sliding at the fixator column. The greatest difference
in axial movement
was produced
by the blue Monotube,
(increasing
when unlocked
by 1.1 mm), followed
by the Modulsystem
(0.34 mm),
and the red Monotube
(0.28 mm).
Transverse
shear displacements
were resisted
better in the Dynabrace,
red Monotube
and BiRoll fixators,
than the blue Monotube.
Although
the Modulsystem
Provided
some resistance
to
transverse
shear in the locked mode, it increased
significantly
in the unlocked
mode, as did torsional shear. This was caused by the looseness
of
the telescoping
mechanisms
in both the Monotube and Modulsystem,
when operating
in the
unlocked
mode.
Peak angular
movement
appeared
to reduce
overall when the red Monotube
was unlocked,
but
either remained
unchanged
or increased with the
other fixators.
It is worth noting that peak move-

309

Fracture

motion

during

walking:

7: N. Gardner

et al.

(cl
2.5
s

4
6

2.0

3
2 1.5
B
z 1.0
E
55 0.5
c
u.
0
L

UN

Blue-Mono

UN

Red-Mono

UN

Bi-roll

Ton. shear (dcg)

UN

Modulsy.

UN

Dynabrace

(4

- . x5 r

2
-0

2.0

1.5

;;

ii

L
Blue-Mono

UN

UN

Red-Mono

UN

Bi-roll

UN

Modulsy.

UN

Dynabrace

Figure4
Peak inter fragmentary
motion
at the well-supported
fracture
model during
simulated
walking
for the five fixators.
The
fixator
columns
are either
locked
or unlocked.
Four fracture
simulation
materials
of different
stiffnesses are used to model the
mechanical
properties
of the different
stages of healing
from the
initial growth
of the callus to its ossification
(a) 50 N/mm,
(b)
385 N/mm,
(c) 526 N/mm,
and (d) 1430 N/mm

ments in all directions

were lowered
by 50 to
100% by fitting the Dyno-ring
to the Modulsystern; this also reduced
the additional
transverse
and torsional
shear arising from the looseness
of
the telescoping
mechanism.

The 385 N/mm

simulation
maternal. With
the
385 N/mm
material
(Figure4(b)),
peak
axial
movements
were substantially
reduced for all the
fixators.
This
material
simulated
the
rapid
increase
in stiffness
and the corresponding
reduction
in movement
associated
with the callus
mineralization
stage. Again, axial movement
was
not significantly
changed by unlocking
the Dynabrace and Bi-roll fixators,.and
also on this occasion
there was no sign of the increase in axial movement observed with the 50 N/mm
material when
unlocking
the Monotubes
and the Modulsystem.
Transverse
shear movements
were constrained
to
less than 0.3 mm for the red Monotube
and Biroll in both locked and unlocked
modes, and for
the Modulsystem
in the locked
mode. Again,
owing
to rotational
looseness,
it increased
after
unlocking
with the Modulsystem,
and only slightly
with the blue Monotube.
Peak angular movements
were best constrained

310

with both Monotubes,

but the previous
reduction
in angular movement
caused by unlocking
the red
Monotube
was not apparent
with this simulation
material. The Monotube
fixators provided the greatest constraint
against torsional
shear movement,
but shear.was
substantial
with the Bi-roll and the
Modulsystem;
this was again owing to the fixator
looseness when unlocked.
In general, the model indicates that axial movement
is reducing
proportionately
more
than
angular and shear movement
during
the initial
stiffening
of the fracture
site simulating
calcification. The influence
on healing of angular and
shear movement
may therefore
become
more
important
than axial movement,
as fractures
heal.

The 526 N/mm

simulation
material.
With
the
526 N/mm
material
(Figure 4( c)), representing
a
fracture,
perhaps
at the half-way
sta e to fixator
removal at a stiffness of 1000 N/mm i5 , peak axial
movement
did not appear to be influenced
at all
by the type of fixator or its mode of operation.
Movements
were between
0.4 and 0.5 mm for all
fixators in both the locked and unlocked
modes.
Transverse
shear movement
was constrained
to
below 0.2 mm with the Dynabrace,
but was less
constrained
in the Modulsystem;
again this was
due to fixator looseness.
Similarly,
with torsional
shear, movements
were constrained
to within 0.2
with the blue Monotube
but less so with the Modulsystem
(locked
and unlocked).
Angular
movement was below 0.25 with the blue Monotube,
but was again less constrained
by the Modulsystern, and generally
movement
was increased
by
unlocking
the fixator.
The 1430 N/mm
simulation
material.
With
the
1430 N/mm
material,
representing
a fracture
at
the fixator removal stage, the fracture
movements
were small (Figure 4(d) ) . Axial tibia1 load was
resisted by the combined
fracture
and frame system in proportion
to the individual
stiffnesses
of
the system (1430:60).
Therefore,
axial movements
were again largely controlled
by the fracture
material, rather than by the fixator frames of comparatively low average stiffness, and peak axial displacements
(of around
0.15 mm for all frames)
were largely unaffected
by the type of fixator or
its mode of operation.
However,
both shear movements were again enhanced
with the Modulsystem,
by unlocking
the fixator
and initiating
fixator looseness.
DISCUSSION
Inter fragmentary
fracture

motion

in the well-supported

Validity of the model. The validity of the model was

first established
before conclusions
were drawn
from the results. This was demonstrated
by comparing movements
in the model, using the low
stiffness simulation
material, with those measured
in patients during early healing. Peak axial movements with the fixators
locked
were generally

between
1 and 2 mm for the model. This correlates reasonably
well with measurements
obtained
from patients with initially fully reduced fractures,
that had axial movements
of up to 1.8 mm while
walking
at 2 to 4 weeks post fixation.
Also peak
transverse
shear
was
constrained
to within
1.0 mm, and angular movement
to within
1 for
the model, which showed reasonable
correlation
with transverse
shears generally below 0.7 mm and
angular
movements
below 1.0 recorded
in patients.
However,
a slight weakness
in the model is
exposed
by unlocking
the fixators.
Peak cyclic
axial movement
was increased
significantly
with
the low stiffness material by unlocking
the Monotubes, but this was not the case in the clinical condition for a patient fitted with a blue Monotube.
Here, contrary
to general expectation,
a trend of
reducing
axial movement
was seen after unlocking
the
fixator.
Therefore,
the
loaddisplacement
response
of the simulated
fracture
material, which is fully elastic, is not the same as
fracture
tissue which probably
has a viscoelasticplastic response.
That is, full recovery of the initial
gap size on unloading
occurs immediately
in the
model, but in the clinical
situation
recovery
is
timedependan
t because
of
the
viscoelastic
response,
and remains incomplete
because of the
plastic response.
Fix&or ptyformance.
If it is considered
that controlled axial movement
may be applied to fractures to provide
the desired
mechanical
regime
for healing, then do currently
available unilateral
external
fixators
enable the clinician
to control
this movement?
The answer
must be no, since
fracture
movement
arises from
the combined
flexibility
of the frame and the fracture
material,
and is a consequence
of the degree of weight-bearing, the fracture
gap and the support to tibia1 load
provided
by the section of fractured
tibia. Clinicians may only influence
to a degree the magnitude and orientation
of movement
by providing
support
to tibia1 load through
the fracture
site
(for
example
by reducing
non-cornminuted
fractures),
and by unlocking
the fixator where and
when it is desirable.
Since at present
no correlation has been made between
the extremes
of
axial, shear and angular movements
measured
in
patients and their effect on healing, a conservative
approach
to fixator
design should
be adopted.
The frames tested here should constrain
against
movements
not universally
accepted
to be beneficial. Therefore,
those that do not fUy
COIIstrair, against shear and angular movement
need
to be stiffened.
For angular movement
in the locked mode, the
E-roll
and the Modulsystem
provided
the least
constraint
at 1.4 and 1.15, with the greatest constraint provided
by the Monotube
and Dynabrace
fixators. In addition to the possibility
of an inhibitory affect on healing, there is a risk of refracture
at the external cortex with this degree of angular
movement
during walking.
If, for example,
it is
assumed
that the fracture
gap is 1 mm, a 1.4
angular movement
would cause an axial gap strain

of around 25% in line with the external cortex of

the bone. Although
the distribution
of strain in
the non-homogeneous
gap tissue will be complex,
maximum
axial strains are unlikely
to be much
lower than 25%. This amplitude
of strain will be
sufficient
to refracture
all but the spongy granulation tissue formed in the first stage of healing.
If refracture
occurs regularly
through
walking,
at
some point the capacity of the fractures
to heal
will be exceeded by the continual
challenge to the
physiological
repair processes.
This will result in
an inhibitory
affect on healing, which may contribute
to the delayed union of some fractures,
and may cause an increase
in the incidence
of
non-unions
arising from inappropriate
mechanical conditions.
In the same example,
the transverse shears of up to 1.0 mm discussed
earlier
would cause a gap shear strain of 100%.
The overall reduction
in peak angular
movement
for
the red Monotube
that occurred
through
unlocking
the fixator
column
would
reduce the risk of refracture
in the healing callus.
Here the fixator column is allowed to shorten telescopically,
rather
than bend, because
of compression
at the fracture
site. Since bending of the
column
imposes angular movement
on the fi-dcture, the reduction
in bending of the Monotube
leads to a reduction
in angular movement
at the
fracture.
With
the other
fixators,
unlocking
caused the angular movement
at the fracture
to
be either
unchanged
or to increase.
possibly
because of a combination
between
the column
not sliding telescopically
(sticking)
and the looseness in the column
(slack) assisting angular movement. This was not the case with the Modulsystems in the clinical
situation,
where
angular
movement
for the group of 10 patients reduced
by an average of 28% through
unlocking
the columns.
although
the number
of patients
measured was insufficient
to provide statistical
significance at f> > 0.05 for the difference.
However,
healing may also be affected
detrimentally
by the unlocking
of the column,
since
this reduces the constraint
against. transverse
and
torsional
shear. The least constraint
against torsional shear was provided
by the Modulsystem,
and this increase in shear has also been observed
in tibia1 fracture
patients
stabilized
by Modulsystems. At 6 weeks
post fixation,
the average
increase in torsional
and transverse
shear at the
fracture
site through
unlocking
was fotlnd to be
around
100% I.
For the three stiffer fracture
materials,
simulating all but the initial stage of healing, axial movement was influenced
only by the the stiffness of
these materials;
it tias only slight9 influenced
by
the contribution
to combined
stiffness
made by
any of the fixation devices. Therefore,
the choice
offixator
is expected
to have little influence
on
the peak axial movement
and the healing of well
supported
fractures
that are additionally
stabilized
b!. the formation
and calcification
of callus. Also,
unlocking
the fixators
had little effect on axial
movement.
although
with
the Modulsystem
it
again reduced
significantly
the constraint
against
other directions
of movement
(particularly
trans-

311

Fracture

motion during

walking:

T. N. Garde

et al.

verse and torsional

shear), which increases the
potential
for refracture. There was no reduction
in angular
movement
through
unlocking
the
Monotubes
as seen with the least stiffest simulation material.
This is because the axial compression of the stiffer materials was substantially
lower than with the 50 N/mm
material.
Therefore, in the initially
locked mode, there was a
reduction
in the angular movement
imposed at
the fracture site by column bending.
Inter fragmentary
fracture

motion

in the unsupported

Movements
are substantial
at around
3 mm
(axial), 2 mm (transverse shear) and 1.5 (angular
movement),
and are similar to those that occur
with largely well-supported
fractures using more
flexible
forms of stabilization
such as plaster
castP. They are about twice the movements
of the
well-supported
fracture during early healing (O-6
weeks). Therefore
the healing
response
for
unsupported
externally
fixated fractures may be
closer to that of a fracture stabilized by plaster.
The influence
on inter fragmentary
motion
mechanical
conditions
at the fracture
site

of

For well-supported
fractures, the control of inter
fragmentary
motion
during patient activity and
the consequent
effect on healing should be of
great concern. Here, there is more restriction
to
axial movement
which is potentially
beneficial,
while the shear and angular movements,
that may
be disruptive,
remain possible. Again, for largely
unsupported
fractures,
fracture
movement
is
important
since little resistance to movement
is
offered at the fragment ends, and in place of this
the frame is comparatively
flexible.
Here, the
dominant
influence
on fracture motion
is the
degree of weight-bearing.
The results demonstrate
the load-bearing
interplay between the fixator frame and the fracture
site, during the progressive stiffening of a fracture
as it heals. This can be explained
using JQUW 5
showing the proportion
of axial tibia1 load supported bv the bone ends across the fracture. The
curve of increasing fracture stiffness is obtained
from the work of Cunningham
et aLz3 against
which an average frame stiffness of 60 N/mm
can
be compared.
As soon as the fracture site shows

---A-0
Figure
ture

314

/-

,/

//

//

4
/f:acture
/ stiffness

------

of axial

stiffening

20

General

observations

A criticism may be made of this study in relation

to the measurement
of inter fragmentary
movement
at the fracture,
and the prediction
of
strain as movement
in proportion
to gap size. It
has been necessary to take this simplistic view of
what is really a non-isotropic
strain field within a
material
for two reasons.
non-homogeneous
Initially
it was to provide legitimate
mechanical
conditions
for the performance
comparison,
and
subsequently it was to provide some means of predicting
the consequences
of the mechanical
An accurate
characteristics
of each fixator.
detailed
distribution
of strain may only be predicted
by using comprehensive
S-dimensional
finite element
models of the complex geometry
of a real fracture,
in conjunction
with the
measurements
of inter fragmentary
movement.
This may not be a practical solution,
in view of
the difficulty of this approach.
However, it has become apparent from this limited study that fixator design does not make the
best use of the little that is known about the
influence
of mechanical
conditions
on fracture
healing. A more informed
approach would be to
avoid the reduced
constraint
in directions
for
which the effect of movement
on healing is unclear.
REFERENCES

fixator ----stiffness

VVeLs d&t-fiGtion

5 The proportion
during
progressive

1100

fracture
loa

signs of stabilizing
(at 4 weeks in this example)
almost all the tibia1 load is very quickly transferred
from the fixator to the fracture, because of a comparatively low frame stiffness. However, during the
initial stage of healing (O-4 weeks), there is very
little tissue solidity at the fracture and it is then
that the degree of support from the interposing
fragment ends is critical; this period may be prolonged in the case of an unsupported
fracture.
For well-supported
fractures, it has been found
from clinical studies that the mean peak cyclic
compression
is of the order of 1.0 mm before
most of the axial tibia1 load is transferred across
the fracturelg. This means that the fixator will sup
port only the initial 60 N (6 kg) of any tibia1 load
before the gap is compressed and further movement is restricted; any additional
load thereafter
is transferred
between the fragment
ends. Here
the fracture may be loaded at almost full body
weight and, although
inter fragmentary
movement at the fracture may be small, inter fragmentary strain may be substantial.
For largely unsupported fractures during this period, load equates
directly with movement.
In the example,
each
60 N of axial tibia1 load produces 1.0 mm of compression; therefore movement
at the fracture may
be substantial although
inter fragmentary
strain
may be small.

24

tibia1 load supported

as it heals

by the

frac-

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313