Basic Principles and

Techniques of Internal
Fixation of Fractures
Brett D. Crist, MD
Original Author: Dan Horwitz, MD; March 2004
Revision Author: Michael Archdeacon, MD, MSE; January 2006
New Author: Brett D. Crist, MD; October 2009

Common Definitions of Fracture Healing

Union
Bones mechanical stability restored to withstand normal
loads
Clinically: no pain at fracture site
Radiographically: 3 out of 4 cortices with bridging callus

Delayed Union
Fx not consolidated at 3 months, but progressive callus

Non Union
No improvement clinically or radiographically over 3
consecutive months
A fibrocartilaginous interface
From: OTA Resident Course Russel, T

High Energy vs. Low Energy

High Energy"
Direct axial load or bending force
Fall from height/Motor vehicle crash
Soft tissue envelope significantly
damaged
Comminuted fracture patterns
Open fractures
Low Energy
Twisting mechanism or direct load on
weak bone
Low
Fall from standing
Energy"
Less soft tissue injury
Simple fracture pattern

High
Energy"

Fracture Patterns
Fracture patterns occur based on mode, magnitude
and rate of force application to bone
Bending Load transverse fx with wedge segment
3-point Bend Wedge fragment
4-point Bend Segmental fragment

Torsional Load oblique or spiral fx

Axial Load Articular impaction (Plateau, Pilon, etc.)

Fracture Patterns
Understanding these patterns and the inherent
stability of each type is important in choosing the
most appropriate method of fixation and surgical
approach

Biology of Bone Healing

THESIMPLEVERSION...
Absolute Stability
=
10 Bone Healing
Haversian
Remodeling

Relative Stability
=
20 Bone Healing

High
HighRate
Rateof
ofHealing
Healing
Minimal
Callus

Fibrous Matrix >

Cartilage > Calcified
Cartilage > Woven
Bone > Lamellar
Bone
Callus

Spectrum of Healing

Biology of Bone Healing

Direct/Primary bone healing
Requires rigid internal fixation
and intimate cortical contact
absolute stability
Minimal callus formation
Cannot tolerate fracture gap
Interfragmental compression will
minimize fracture motion
Relies on Haversian remodeling
with bridging of small gaps by
osteocytes (cutting cones)
Figure from: OTA Resident Course - Russel

Biology of Bone Healing

Indirect/Secondary Bone
Healing = CALLUS
Divided into stages
Inflammatory Stage
Repair Stage
Soft Callus Stage
Hard Callus Stage
Remodeling Stage

3-24 mo

Relative stability
Figures from: OTA Resident Course - Russel

Practically speaking...
Primary/Direct Bone Healing

Secondary/Indirect Bone Healing

Simple fracture patterns

See the fx during surgery
and directly reduce and
fix with:
Lag screws
Plates and screws

Complex fracture patterns

Dont directly see the
fracture during surgery (use
fluoro)
Indirectly reduce the fx and
fix with:
IM Rods
Bridge plate fixation
External fixation
Cast

Fixation Stability
Relative Stability
IM nailing
Ex fix
Bridge plating
Cast

Absolute Stability

Lag screw/ plate

Compression plate

Spectrum of Stability
IM Nail
Ex Fix
Cast

Bridge Plating

Compression
Plating/ Lag
screw

Relative

Absolute

(Flexible)

(Rigid)

Practically speaking.
Most fixation probably involves
components of both types of healing. Even
in situations of excellent rigid internal
fixation one often sees a small degree of
callus formation...

Fixation Stability
Reality

Callus

Absolute
(Flexible)

No
callus

Relative
(Rigid)

Functions of Fixation
Interfragmentary
Compression
Lag Screw

Plate Functions

Neutralization
Buttress
Bridge
Tension Band
Compression
Locking

Intramedullary Nails
Internal splint

Bridge plate fixation

Internal splint

External fixation
External splint

Cast
External splint
*Not internal fixation

Indications for Internal Fixation

Displaced intra-articular fracture
Axial, angular, or rotational instability that
cannot be controlled by closed methods
Open fracture
Polytrauma
Associated neurovascular injury
MULTIPLE REASONS EXIST
BEYOND THESE...

Benefits of Internal Fixation

Earlier functional recovery
More predictable fracture alignment
Potentially faster time to healing

Screws
Cortical screws:
Greater number of threads
Threads spaced closer together
(smaller pitch)
Outer thread diameter to core
diameter ratio is less
Better hold in cortical bone

(pitch is

Cancellous screws:
Larger thread to core diameter ratio
Threads are spaced farther apart (pitch is
greater)
Lag effect with partially-threaded screws
Theoretically allows better fixation in
cancellous bone
Figure from: Rockwood and Greens, 5th ed.

Lag Screw Fixation

Screw compresses both sides
of fx together
Best form of compression
Poor shear, bending, and
rotational force resistance

Partially-threaded screw
(lag by design)
Fully-threaded screw (lag by
technique)

Lag Screws
Lag by technique
Using fully-threaded
screw
Step One: Gliding hole =
drill outer thread diameter of
screw & perpendicular to fx
Step Two: Pilot hole= Guide
sleeve in gliding hole & drill
far cortex = to the core
diameter of the screw

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

Operative Fracture Care. Springer-Verlag, 1987.

Lag Screws
Step Three: counter sink near
cortex so screw head will sit
flush
Step Four: screw inserted and
glides through the near cortex
& engages the far cortex which
compresses the fx when the
screw head engages the near
cortex

Figurefrom:SchatzkerJ,TileM:The
RationaleofOperativeFractureCare.
SpringerVerlag,1987.

Lag Screws
Functional Lag Screw
- note the near cortex
has been drilled to the
outer diameter =
compression

Position Screw - note

the near cortex has not
been drilled to the
outer diameter = lack
of compression & fx
gap maintained

Lag Screws
Malposition of screw, or neglecting to
countersink can lead to a loss of reduction
Ideally lag screw should pass perpendicular to fx

Figure from: OTA Resident Course - Olsen

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

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

Operative Fracture Care. Springer-Verlag, 1987.

Buttress / Antiglide Plates

Hold the bone up
Resist shear forces during
axial loading
Used in metaphyseal
areas to support intraarticular fragments
Plate must match contour
of bone to truly provide
buttress effect

Buttress Concepts
Order of fixation:
Articular surface compressed with
bone forceps and provisionally fixed
with k-wires
1. Bottom 3 cortical screws placed
Provide buttress effect
2. Top 2 partially-threaded cancellous
screws placed
Lag articular surface together
3. Third screw placed either in lag or
normal fashion since articular
surface already compressed

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

Operative Fracture Care. Springer-Verlag, 1987.

Antiglide/Buttress Concepts
Plate is secured by three black screws distal to
the red fracture line
Axial loading causes proximal fragment to
move distal and to the left along fracture line
Plate buttresses the proximal fragment
Prevents it from sliding
Buttress Plate
When applied to an intra-articular fractures
Antiglide Plate
When applied to diaphyseal fractures

Bridge Plates
Bridge/bypass
comminution
Proximal & distal fixation
Goal:
Maintain length, rotation, &
axial alignment

Avoids soft tissue

disruption at fx = maintain
fx blood supply

Tension Band Plates

Plate counteracts natural
bending moment seen w/
physiologic loading of bone
Applied to tension side to
prevent gapping
Plate converts bending force
to compression
Examples: Proximal Femur &
Olecranon

Tension Band Theory

The fixation on the opposite side from the articular surface

provides reduction and compressive forces at the joint by
converting bending forces into compression
The fracture has tension forces applied by the muscles or load
bearing
JOINTSURFACE

Tensionband
Load applied to bone

 The tension band prevents distraction and the force is

converted to compression at the joint
The tension band functions like a door hinge,
converting displacing forces into beneficial
compressive forces at the joint
JOINTSURFACE

Tensionband
Load applied to bone

Classic Tension Band of the Olecranon

Wires can be used for tension
band as well
Ex: Olecranon and patella
2 K-wires from tip of olecranon
across fx site into anterior cortex
to maintain initial reduction and
anchor for the tension wire
Tension wire brought through a
drill hole in the ulna
Both sides of the tension wire
tightened to ensure even
compression
Bend down and impact wires

Figure from: Rockwood and Greens, 4th ed.

Compression Plating
Reduce & Compress
transverse or oblique
fxs
Unable to use lag screw
Exert compression
across fracture
Pre-bending plate
External compression
devices (tensioner)
Dynamic compression w/
oval holes & eccentric
screw placement in plate

Examples- 3.5 mm Plates

LC-Dynamic
Compression Plate:
stronger and stiffer
more difficult to contour.
usually used in the treatment
radius and ulna fractures

Semitubular plates:
very pliable
limited strength
most often used in the
treatment of fibula fractures

Figurefrom:RockwoodandGreens,5thed.
Figure from: Rockwood and Greens, 5th ed.

Compression
Fundamental concept critical for primary bone
healing
Compressing bone fragments decreases the gap
and maintains the bone position even when
physiologic loads are applied to the bone. Thus,
the narrow gap and the stability assist in bone
healing.
Achieved through lag screw or plating techniques.

Plate Pre-Bending Compression

Prebent plate
A small angle is bent into the
plate centered at the fracture
The plate is applied
As the prebent plate compresses
to the bone, the plate wants to
straighten and forces opposite
cortex into compression
Near cortex is compressed via
standard methods
External devices as shown
Plate hole design

Plate Pre-Bending Compression

Screw Driven Compression Device

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

DynamicCompressionPlates
Note the screw holes in the
plate have a slope built into
one side.
The drill hole can be purposely
placed eccentrically so that when
the head of the screw engages the
plate, the screw and the bone
beneath are driven or compressed
towards the fracture site one
millimeter.

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

Operative Fracture Care. Springer-Verlag, 1987.

This maneuver can be

performed twice before
compression is maximized.

Dynamic Compression Plating

Compression applied
via oval holes and
eccentric drilling
Plate forces bone to
move as screw
tightened =
compression

Lag screw placement

through the plate
Compression can
be achieved and
rigidity obtained
all with one
construct
Compression plate
first
Then lag screw
placed through
plate if fx allows

Figure from: Rockwood and Greens, 5th ed.

Locking Plates
Screw head has threads that
lock into threaded hole in the
plate
Creates a fixed angle at
each hole
Theoretically eliminates
individual screw failure
Plate-bone contact not
critical

Courtesy AO Archives

Locking Plates
Must have reduction and compression done
prior to using locking screws
CANNOT PUT CORTICAL SCREW OR LAG
SCREW AFTER LOCKING SCREW

Locking Plates
Increased axial
stability
It is much less
likely that an
individual screw
will fail
But, plates can still
break

Locking Plates
Indications:
Osteopenic bone
Metaphyseal
fractures with short
articular block
Bridge plating

Intramedullary Nails
Relative stability
Intramedullary splint
Less likely to break with
repetitive loading than
plate
More likely to be load
sharing (i.e. allow axial
loading of fracture with
weight bearing).
Secondary bone healing
Diaphyseal and some
metaphyseal fractures

Intramedullary Fixation
Generally utilizes closed/indirect or
minimally open reduction techniques
Greater preservation of soft tissues as
compared to ORIF
IM reaming has been shown to stimulate
fracture healing
Expanded indications i.e. Reamed IM nail is
acceptable in many open fractures

Intramedullary Fixation
Rotational and axial
stability provided by
interlocking bolts
Reduction can be
technically difficult in
segmental and
comminuted fractures
Maintaining reduction
of fractures in close
proximity to
metaphyseal flare may
be difficult

 Open segmental
tibia fracture treated
with a reamed,
locked IM Nail.
Note the use of
multiple proximal
interlocks where
angular control is
more difficult to
maintain due to the
metaphyseal
flare.

 Intertrochanteric/
Subtrochantericfracture
treatedwithclosedIM
Nail
Thegoal:
Restorelength,
alignment,and
rotation
NOTanatomic
reduction

Withoutextensive
exposurethisfracture
formedabundantcallus
by6weeks

Valgus is restored...

Reduction Techniquessome of
the options
Indirect Methods
Traction-assistant, fx table,
intraop skeletal traction
Direct external force i.e.
push on it
Percutaneous clamps
Percutaneous K
wires/Schantz pins
Joysticks
External fixator or distractor

Direct Methods
Incision with direct fracture
exposure and reduction with
reduction forceps

Reduction Techniques
Over the last 25 years the biggest change
regarding ORIF of fractures has probably
been the increased respect for soft tissues.
Whatever reduction or fixation technique is
chosen, the surgeon must minimize
periosteal stripping and soft tissue damage.
EXAMPLE: supraperiosteal plating techniques

Direct Reduction Technique

Pointed reduction clamps used to reduce a complex distal femur
fracture
Open surgical approach
Excellent access to the fracture to place lag screws with the
clamp in place
Remember, displaced articular fractures require direct exposure
and reduction because anatomic reduction is essential

Reduction Technique - Clamp and Plate

Place clamp over bone and the plate
Maintain fracture reduction
Ensure appropriate plate position proximally and distally with
respect to the bone, adjacent joints, and neurovascular structures
Ensure that the clamp does not scratch the plate, otherwise the
created stress riser will weaken the plate

Figure from: Rockwood and Greens, 5th ed.

Percutaneous Plating
Plating through
modified incisions
Indirect reduction
techniques
Limited incision for:
Passing and positioning
the plate
Individual screw
placement

Soft tissue friendly

Failure to Apply Concepts

Classic example of
inadequate fixation &
stability
Narrow, weak plate that is
too short
Insufficient cortices engaged
with screws through plate
Gaps left at the fx site

Unavoidable result =
Nonunion

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

Operative Fracture Care. Springer-Verlag, 1987.

Summary
Respect soft tissues
Choose appropriate fixation method
Achieve length, alignment, and rotational
control to permit motion as soon as possible
Understand the requirements and limitations
of each method of internal fixation
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