Campbell Orthopedichs

Ovid: Rockwood & Green's Fractures in Adults
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Edi tors : Tit le:
Buchol z, Robe rt W.; Heckm an, J ames D.; Court-Brown , Charl es M.
Rock wood & Gre en's Fract ures i n Adults, 6th Ed itio n
C opyright 2006 Lippincott Willia ms & Wilki ns

> Table of Contents > Volume 1 > Section On e - Gene ral Princ ip le s > Chapter 1 - Biomech anic s of Fixation and Frac tures
Chapter 1 Biomechanics of Fixation and Fractures

Al lan F . T encer Th is chapter provide s a fu ndamenta l discussion of the concepts of biomechan ics, demon strate s how these ide as describe th e basic fu nction s of fixation devices, a nd illustra tes how th ey ca n be used to a void clinical probl ems associate d with the mechan ics of fracture fixa ti on. Empha sis ha s been placed on addressing practica l problems. First, fundamenta l concepts of mechan ics as they a pply to the p ra ctice of o rt hop aedic frac tur es a re expl ained. This sectio n is follo wed by a short discu ssio n on the me ch anica l o rganiza tio n of bo ne, its abili ty to carry lo ad, and the re lation ship o f appli ed forces a nd specific fracture patte rns. A di scu ssion of bone inju ry mecha nisms, including spe cific mechanisms observed in ca r crashes, i s next presented. Description of th e me ch anics of he aling bon e follows, w hich is releva nt to u nder standin g the timing of a pplying loa d to hea ling fractur es in patients. Fina lly, the performan ce o f variou s types of fixation systems is discu ssed, with emphasis on fixation o f difficult fractur es, such a s the fe moral neck, and those invo lving osteo poro ti c bon e. The focus of th e discussio n is no t on co mp aring the myri ad n umb er of spec ifi c devic es a vaila ble, bu t rather on d emonstrat in g the c ommo n me ch anica l principle s invo lved in fractur e fixa tion, s o that potentia l p ro blems co mmon to vario us de vice s can be re co gnized an d avoided. In the stu dy o f bio me ch anics as it relates to f rac tur e fixatio n, th e fun dam ental mecha nical ques tion re ma ins: Is the f ixation system stiff and strong enough to allow th e patie nt early mobility, before b ony un ion is co mplete, wi th out delayi ng healin g, cr eating bo ne defo rm ity, or damagin g the impla nt, a nd yet f lexible eno ugh to sti mulate unio n? Th e issue of w hich brand of fixat io n i s stro nges t or stif fes t is no t s pec if ica lly a ddres se d bec au se tha t is n ot the stan dard by whi ch dif fer en t devic es sh oul d be judge d. Wi th in a ra nge of f ixat io n stiffne ss it ha s been sho wn that bon e wil l he al, a nd th e a mou nt of sta bilizing callu s depen ds on the s tiffnes s of t he fixa tion. P.4
BASIC CONCEPTS
Be fore describing the performance of fracture fixation systems, some basic con ce pts used in b iomecha nics will be introduced. As Figure 1-1 demon strate s, loa ds in many differen t direction s may a ct on a fixed frac tur e, includin g bo dy wei ght a nd forces induc ed by mu scle con tra ctio n and ligame nt ten sion . A force c auses a n obje ct to either acce lerate or de ce lerate. It has ma gnitude ( stren gth ) an d a cts in a specif ic dir ec tio n; the re fo re , it i s ter med a vec tor. Howe ver compl ex the system o f fo rce s a cti ng on a bone , each force ma y be separ ated into its ve cto r compo nen ts, and an y nu mb er o f compon ents a cting in the same directi on can be su mmed to yield the net or re su ltant fo rce. Fo r e xample, co nsider the force acting at th e sho e/floor interface du ring amb ulatio n. It ca n be sepa ra ted into a vertical force due to body weight and a horizontal frictional force, which produces the forward th rus t. Similarly, mus cle forces ca n be separa te d in the same mann ero ne force alo ng the axis o f th e long bon e, and one perpendicu lar. The compo nen ts of th e differen t forc es, wh ich a ct in the sa me d ire ctio n, ca n be a dded, an d the resultan t force acti ng on the bone can then be foun d. This co ncept is i mp ortant when des ign ing fractur e fixa ti on syste ms because it allows the des igner to size t he i mp lants so tha t they can withstan d the mechan ical load s applied wit ho ut fail ure. Th e two ma jor loa ds acting on a lo ng bo ne are tho se that cause it to dis plac e in a linea r direction (translation ), and those that cause it to rotate, typically arou nd a j oint center. Mu scle s typically ca use a bone to rotate (e .g., the bice ps causes the fo re arm to rota te , the anterior tibia lis cause s the fo ot to do rsi flex). W hen a force ca us es ro tation, it is ter med a mome nt a nd h as a mo ment arm. T he mom ent arm is the lever a rm aga inst wh ich th e force acts to cause rotation. It is the perpendicul ar d istance of the muscle force from the center of rotation of the joint. As shown in Figure 1-2, the mom ent or rotary force is affected n ot only by th e mag nitude of the f orce a pplied, but a lso by its d ista nce from the ce nter of rotation. In the example, two moments act on the outstretched arm. The w eight ca rrie d in the ha nd rotates the arm down ward, w hile the balancing mu scle forc e rotates the a rm upw ard. E quilibr ium is rea ch ed by bala ncing the moments so th at the arm does no t rota te an d th e we ight can be carr ied. No te th at to ach ieve th is, the muscle force must be eigh t times a s large as
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th e we ight o f the obj ect, arm , a nd h and bec au se its mo ment arm o r dis tanc e fro m the center of the j oin t is only one-eighth as long.
FIGURE 1 -1 Forces a ctin g o n a lo ng bon e du ri ng fun ctio nal use. A vector indica tes that th e force h as bo th magnitude an d dir ec tio n. Th e compl ex system o f fo rces can be split into compo nen ts acting per pend icul ar and pa rallel to t he gro un d, or the axis of the bon e.
Th e ba si c forc esc ompressio n, tran sver se lo ading, torsion , an d ben ding, ca use bone to beha ve i n p re dicta ble wa ys. A compressive f orce (Fig. 1 -3) results in sho rt enin g the length o f the bone , whil e ten sion elongates it. T or sio n ca uses twisting of th e bone abo ut its long axis , wher ea s bendin g cau ses i t to bow at th e cen ter. The force s an d mo ments tha t act o n a lon g bo ne during functiona l u se p ro duc e thr ee bas ic str esse s on the he aling fra ctu re regio n: ten sio n, co mp ression , an d shea r (becau se a ll forces ca n be combined to th eir basic compon ents as shown previou sly). Stre ss, as sh own in F igure 1- 4, is simply the force divided by the area ov er whi ch it acts. This is a conven ient w ay to ex pre ss ho w the forc e affects a m aterial local ly. F or e xample, co mparing two bo nes, one wit h h alf the cross-se ctional area of the other, if the sma ller bone is subjected to ha lf the force o f P.5 th e lar ger bo ne, th e stres s expe rie nced by each bo ne would be t he s ame. The re fore, a sm aller woma n w ith less weight has proportionally small er bones to kee p the stresses on the bon e tissue similar to th at of a larger a nd heavi er man . The stre sses acting on fra ctu re callu s as a resu lt o f the di fferent fo rces, in a n idealized case, a re shown in Figu re 1-5. Just as stress is n ormalize d force (force per un it a rea) , len gth ch anges can also be norma lized. Strain is simply the chan ge in h eight o r le ngth that a b one un dergoes during loa ding divided by its original height o r le ngth, as shown in Figu re 1 -4 . Un der th e same force, a bo ne tw ic e as lon g wil l ha ve twi ce the length cha nge, bu t dividin g t he len gth ch ange by th e o rigina l len gth o f the bon e P.6 sh ows th at th e strain is th e same in both cases. (If both bones are composed of the same materials, th ey sho uld both ha ve a pproxima te ly the same stra in under a g iven stress.)
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FIGURE 1 -2 In th is example, the outstretche d arm is a lever. Th e mo ment or loa d that rotates the arm down ward a round the elbow, the center of rotation , is defin ed a s the product of the weigh t of th e objec t arm a nd hand distan ce fro m th e elbow (in t his example for sim plicity, the center of gr avit y of the ha nd, arm , an d objec t a re co mbi ned) . This momen t must be cou nteracted by a mome nt in the opposite direction, du e to the vertical component of th e biceps muscle acting through its lever, which is small er than th e leve r arm of the weigh t arm and hand. The biceps force is then calculated from (10 kg sm aller. 24 cm)/3 cm = 80 kg. The biceps force is muc h greater th an t he weight of the o bjec t arm and ha nd be ca use its lever arm is
FIGURE 1 -3 Bas ic forces acting on a lon g bone and the defl ectio n of the bo ne in re spo nse ( top ) . Compre ssion sh ortens the length, tension inc re ases the length , shea r distorts the len gth ( mid dle ) , bendin g cau se s the bon e to bo w, an d (bottom) torsion results in twisting about the
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lo ng axis .
FIGURE 1 -4 The stress is defined as the force acting on a surface divided by the area over which it acts. Stra in is the chan ge in height or l ength of the o bject under load divided by its o ri ginal heigh t or len gth. Stiffness is defined as th e slo pe of a force ver sus displ acement graph, i.e., th e cha nge in force divided by th e co rre spo ndin g cha nge in displ acement. Elastic mo dulus is the corre sponding slope, but of a stress versus strain graph.
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FIGURE 1 -5 Resulting stresses acting in f ra ctu re callus in a ideal ized case with each of the basic forces applied ( top to bottom): unloa ded, co mpre ssive stre sses along th e bone axis and expansive stresses perpen dicular to the b one axis due to compression, tensile and con tra ction str esse s due t o tension , distortio n due to sh earing and tensio n on the c onve x side, co mp ression o n th e co ncave side, an d in ternal shearin g du e to ben ding.
Me ch anica l testing of fractured l ong bones with f ixation dev ice s applie d demonstrates a specific type o f beh avior, as sho wn in Figu re 1 -6. This diagram represents th e da ta mea su red in a n e xperimental test of the structu ral properties of the bon e-fixation construct th at is, th e properties of the fixation d evice and bo ne c ombin ed. Material properties rela te to the properties of the substances th at ma ke u p ea ch co mp on ent (bo ne, stai nless st eel, tita niu m). As loa d is applied to the co nstr uct in a testing ma chine, the construct de forms. Th is deformation is termed elastic beca use wh en the load is re moved, th e co nstruct will return to its original shape (an important con si deration in preven ti ng ma lalignment of the bon e fracture components). At some loads, h oweve r, the construct becomes o ver lo aded , entering the plast ic ran ge. I f the loa d is re leased after loa ding in th e pl asti c range but b efore failure , some perman ent de forma tion remains in the construct. P ractica lly, th is represents a b ent pla te, fixat or, or ro d w ith a mal aligne d fra ctu re. The poi nt a t whic h ela stic behavi or ch anges to p lastic is termed the yield point. T he elastic range represents the working range for the fixation co nstruct. Its two most i mportant properties are i ts yield point, which defines i ts s afe function al loa d
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a nd its stiffness, or the amount it deforms under load in the elastic ra nge. (A th ird very important p roperty, fatigue, will be discussed later.) Note that a fixation construct may have different yield p oints and deg rees of st iffness for loa ds acting in different dir ections. An e xample is a hal f-pin e xternal fixator co nstruct appl ied to a tibia, with th e pins oriented anteriorly-posteriorly. Th e stiffn ess is mu ch greate r in anterior-posterior bending tha n me dial-lateral bending for this constru ct. An other property to consider is the wo rk don e in def ormin g a fixation co ns truct. The produc t o f the fo rce applie d and the distance the construct be nds is defin ed a s the work done, a nd i s represented by th e a re a u nder the f o rce-dis placem en t g raph o f Figu re 1 -6. Tou ghne ss can be defined as the work ca rrie d out to fractu re a co nstru ct or material, including both th e el astic an d plastic re gion s of d eformation. A material may be flexible and tough (e.g., rubber, or a child's bone that deforms but is d ifficult to break ) or stiff but bri ttle (e.g., glass, e lderly bo ne), i f it cann ot abs orb muc h defo rm ation w ithou t fra ctu ring. Th e factors that govern stiffn ess and yiel d point a re the material from which the fixation device is ma de a nd its shape (co nsiderin g a n unun ited f rac tur e i n wh ich th e fr actur e ca llus c o ntr ibut es littl e to structural prope rtie s). A con struct made of higher e lastic modu lus ma terials w ill be stiffer (e.g., stai nless steel as compared to tita nium). Stiffne ss of a con struct is found by dividin g the force a pplied by the def ormatio n th at th e co nstru ct exhi bite d. T he elastic (o r Y ou ng's ) modulus i s d ete rmined by dividin g the s tress applie d by th e re su lting strain . Unlike who le constructs, where it is d iff ic ult to det er min e stres s ( bec ause it is hard to defin e the area o ver wh ic h the f orce is appl ied a nd at least two different materials are involved), uniform blocks of materials can be characterized by th eir el asti c modu lus. The mo duli of some commo n ortho paed ic mat erials are gi ven in Ta ble 1 -1. A s sh own , the elastic m o dulu s of tita nium allo y is abo ut one-ha lf that of stainle ss ste el so , given two p lates o f the sa me size and shape , the one ma de of tit aniu m wo uld be ex pec ted to ha ve about oneh alf the st iffnes s o f the stainless steel plate. Th e sha pe of the implan t is impo rt ant in de te rmi ning the loa ds that it can suppo rt. As sho wn in Figu re 1 -7, th e same wo oden 2 th e ma te ri al o f the 2 4 bea m tha t bend s easily when lo ad is appl ied to it s w ider surfac e, b ecom es mu ch stiffer when lo ad is applie d to its n arr ower surfa ce . This i s bec au se, in the latter case, 4 res is ti ng t h e lo ad is dis tributed farthe r awa y from the cen ter o f the b eam (n ote th at in thi s example, the material of the bea m did not change, j ust its orientation relative to th e load applied). Th is concept of distributi on of mat erial is refl ecte d in the shape property, moment o f ine rtia . The moment of inertia provide s a measure of how the material is distributed in th e cro ss section of the object relative to the loa d ap plied to P.7 i t. The farthe r awa y the materia l is from the center of the beam, the gre ater its stiffn ess will be. Stee l I bea ms wer e develo ped to ta ke a dvantage o f this con ceptgrea te r s tiff ness u si ng le ss ma terial. Fo r cylindrical obj ects like rods, pins, or scre ws, their stiffn ess is rel ated to the fourth p ower of their diameter. This is why, as shown in Figure 1-7, for rods made of the same materials a nd of simila r thickness, a 1 6-mm-di ameter intra medullary (IM) rod is 1.7 times as stiff as a 14-mm ro d | (16 /14) 4 |, and a 7-mm-diameter pe dicle screw is 1.85 ti me s as stiff as a 6-mm-diame te r scre w.
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FI GUR E 1 -6 T op le ft. A fi xation c on stru ct (bone- fixat io n-bon e) set u p in a mechan ical testin g mac hi ne. In this exam ple, a l ong bon e is fixe d with a plate and subjec ted to bend in g. Top rig ht. Th e co nstr uct durin g lo adin g in the elastic regi on, plas tic regio n, and wit h per manen t def ormatio n. Bottom . The resulting mea su rements from the te sting mach ine th at me asures force applied and displacement at th e po int of the applie d lo ad. Th e graph demo nstrates th e ela stic region wh ere the con stru ct acts like a spri ng, return ing to its original sh ape after the lo ad is released, the plastic regio n where the plate ma y have permanen tly ben t, an d the fa ilure lo ad w here th e fixatio n fai ls.
TABLE 1-1 Basic Engineering Properties of Common Engineering Materials

Ul ti ma te Streng th Ten sil e M ateria l (M Pa) Ul ti ma te Streng th Comp ressive (MP a) Y ield Strength 0.2% O ffset ( MPa ) El astic M odulus Mate rial (M Pa)
Muscle
0.2
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Skin
50
Ca rti lage
10
20
F asci a
10
T endo n
70
4 00
Co rt ical bo ne
1 00
1 75
80
15 ,00 0
Ca ncello us bo ne
1 ,000
Plaste r of paris
70
75
20
Polyethyl ene
40
20
20
1 ,000
PT F E Te flo n
25
5 00
Acrylic bone cem ent
40
80
2 ,000
Titani um ( pure, cold wo rked)
5 00
400
10 0,00 0
Titani um ( Al-4V) ( allo y F 1 36 )
9 00
800
10 0,00 0
Stain less steel (31 6 L) (ann ealed)
>5 00
>200
20 0,00 0
Stain less steel (cold worked)
>8 50
>700
20 0,00 0
Co balt chrome (cast)
>4 50
>50
20 ,00 0
Co balt chrome (wrou ght, an neal ed)
>3 00
>300
23 0,00 0
Co balt chrome (wrou ght, cold wor k)
1 ,5 00
1 ,00 0
23 0,00 0
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Super allo ys (Co NiM o)
1 ,8 00
1 ,60 0
23 0,00 0
MPa , mega pasca l. (Ultimate tensile stre ngth or ma ximum force in tension, yi eld strength at 0.2% o ffse t, the str engt h at w hich th e strain in the mat erial [chang e in len gth/origina l le ngth] is 0.2% , a usual standard for metals, e lastic modulus or stress/strain).
P.8 A third important property of a fra ctu re fixation co nstruct is i ts ability to re sist fatigu e u nder c yclic l oading. A loa d can be applied below the yield point of the construct, yet progressively c re ate a crack th at gro ws un til the lo cal force in the re gion o f the crack is abo ve yield and the co nstr uct fails. So me ma ter ials have an endu rance lim it bel ow whic h they can su pport loads indef initely witho ut fail ure. An i mportant aspect to fatigue performance of a fixation co nstruct is the effe ct of a stress con ce ntrator. In comple te ly uniform ma te ria ls, the stre sses , in ten sion for e xample, will be al mo st iden tical th rough ou t the mat erial. Fixa ti on devices h ave ho les, sc rew th re ads , an d other featu re s whe re sha pe ch anges occur. In a ver y ra dic al ch ange in shape, for exa mp le, a s sho wn in F igur e 1-8, the sh arp co rner between threads of a different diameter in a fixation screw cau se s a stress co ncentrator at the co rner. T h is expla ins wh y the bas e of a screw thread, w here it meets t h e sha ft of the scre w, ha s ro un ded co rn ers. The stresses on a fractur e con str uct are in cre ased w hen applie d in hea vier pa tients, w ith po or bon e- to-bone con tact P.9 a cro ss the fra ctu re s ite, de layed unio n, early weight bear ing bef ore the fractur e has united, and whe n sma ller low-profile fixation devices are used. For these circumsta nces, consider the u se o f larger i mplants, taki ng ca re not to create stress concentra tors by scu ffing or scratching the implan t, and d elay weight bear ing un til some fra ctu re co nsolida tion is a pparent. Th ese steps ca n i ncrease th e n umb er of lo ad cycle s that th e i mp lant ca n bear w ithou t fa ilure.
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FIGURE 1 -7 Concept of moment of inertia or the effect of the geometry of an object on its stiffness. Top . Loo king at th e edg e o f a woo d 2 on its long edge. The area of the 2 4 (us ed in ho me bu ilding), lef t, the 2 4 with the load applied on the shorter side is stiffer than the same 2 4 with the load applied
4 is farther away from the central axis when the load is
appli ed on th e sh ort edge . Bottom . The moment of inertia is a term u se d to describe h ow the material is distribute d within a n object. Left, for a plate, l ooking at its e dge, the mome nt of ine rtia a nd th e stiff ness increase dir ec tly wit h the plate's wi dth a nd th e cube o f it s heigh t. Fo r a tube, such as a n IM rod, the mo ment of inertia increase s with the fourth power of its di ameter. Therefore, a 16-mm-diameter IM rod is 1.7 times as stiff as a 14- mm rod and 2.3 times as stiff as a 13 -mm ro d, if a ll th e ro ds ha ve the same thicknes s and are ma de o f the same material.
A scra tch can al so cause a local sma ll stress con ce ntrator. Whe n immersed in the sa line environment o f the body, stre ss corrosion can occur. Stress corrosi on combines the effects of the local growth of the crack due to cyclic loading with galvanic corrosion. A galva nic cell describes a local e nviron ment w here electrons flow from the more negative to the more positive material when immersed in a liquid co nducto r (s aline , in this c a se) (F ig. 1 -9). Materia l is actually rem ove d fro m th e mo re n egative e lectrode, su ch a s t he surfa ce o f the pla te du ring ga lvan ic corro sio n. In a fi xed frac ture, th e d issim ila r materia ls are the surface o f th e pla te, f or example, stainless steel, which ha s an o xide su rface coatin g a nd th e sam e material wit hin the ju st-o penin g crac k th at h as n ot ye t develo ped th e o xide film. The co ndu ctive f luid is the bloo d and sa line fo un d in the surrou nding tis su es. Galva nic co rrosion can a ccele ra te the failure of a n implant, even when the impla nt is loa ded wel l belo w its y ield po int, by in crea si ng th e rate at whic h t he cra ck grows, bec ause alo ng w ith yie lding at the site of th e crack, material at the crack i s being removed by the corrosion process. Anoth er mechanism of corrosion , termed fretting, results wh en th e surfaces of two implants rub together for ex ample, th e h ead of a screw a gains t th e su rface of the pla te thr o ugh whic h it pa sses. Crevice corrosion, n ot common in mode rn orthopaedic ma te ri als, results from small galvan ic cells forme d by impurities in th e surface of the implan t, causing crevices a s the material corrodes (1).
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FIGURE 1 -8 A stress concentrator is a region of a n object w here stresses a re h igher th an in the surr ou nding mat erial. Le ft. Ta king th e e xample of a fra ctu re pla te s ubjected to bendin g, the bottom surface e longa tes under load. In the region of high est tensile forces, a scra tch starts to grow into a crack th at close s whe n th e load is relea se d, then reopens sligh tly larger wit h the next loa d cyc le, e vent ual ly gro wing to a po int wher e t he p late fails. Crac k growth is accentuated by stress corrosion, poor bon e-to-bon e co ntact a t the fracture, and by loads appli ed by hea vier pa tie nts. Rig ht. Stress co ncentrators (som etimes referred to a s stress risers) occur arou nd hol es, sharp corners, scrat ches, and at co rners f rom ch ange s in cross section .
A final basic pro pert y is vi sco elasticity. Biologic materials do no t act a s pure s prings wh en loa d is a pplied to them. For exam ple, if a loa d is applied to a ten don , an d the lo ad is mainta ined fo r a perio d o f tim e, th e tissue will contin ue to de form or creep. Thi s is the basic principal behin d stret ch ing e xercise s. Un der a constant load, a meta l fixation plate will deform and remain at that deformation u ntil th e load is remo ved (ela sti c beha vior). In contrast, th e ten don bo th def orms elastically and creeps, exhibitin g both viscous and e lastic beh avior. This property ha s important impli ca ti ons for cer tai n types of fixatio n, e spe cia lly th ose that rel y o n lo adin g o f sof t t is sues, suc h as in ce rta in t ype s o f spina l fixatio n (t o be discu ssed later in this cha pter).
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FIGURE 1 -9 A. I llust ration o f cre vice corro sion with a local galva nic cel l cau se d by an impurity in the surfa ce o f a pl ate a nd ions , M+, bein g relea sed, res ultin g in lo ss of ma te ri al a nd formation of a crevice. B . Stre ss corrosion occurs by a local galva nic cell setup between the mat eria l at the ti p of th e crac k, whic h ju st open ed a nd has n ot oxidized an d the remain ing o xidized su rface of the plat e. The released ion s enh ance crac k gro wth o ccurr ing from lo ading. C. Fretting corrosion ca used by the loss of the oxi de layer on th e plate's surface du e to rubbing o f th e ba se of the screw aga inst the plate. D. Ga lvanic corrosio n arou nd a sc rat ch or pi t in the plate (1).
P.1 0 A s econ d property is lo adin g rate dep ende nce. In simple terms, stretching a soft tissue ca n be th oug ht of as stretching two componen ts, one elastic and one viscous, which ma ke u p tha t tissue. For e xample, co nsider a sprin g con nected in a series to th e handle o f a syrin ge (F ig. 1-1 0). W hen a compressi ve force is appli ed, the spring instantly compresses, representing the elastic re sponse of th e tissue. The syringe plunger sta rts to di splace and co ntinues as it pu sh es fluid throu gh th e orifice. If the f orce is held constant, the plun ger will continue to move, representing the viscous cre ep of the tissue . If th e compressive force is applied slowly, the syringe han dle offers l ittle resistance. As the ra te of force appli ca tion increases, the re sistan ce of the syringe to motion increase s. T his represents th e in cre as e in stif fness of the tis sue at h igher l oadin g ra tes. That i s, the stiffn es s o f the tis sue d epends o n t he rat e at whi ch t he lo ad i s applie d. A we ll-k nown ex amp le of lo ading rat e dep enden ce re lates t o liga ment a nd bone failure. At lo w lo adin g rat es, l igam ent is wea ker tha n bone , an d the l igament fails gen erally in mi dsubsta nce. At highe r loading rates, the ligam e nt beco mes stiffer, a nd failure may occur by avulsion of the bony attachment of the ligament. Stress relaxa tion occurs if the a pplied force , instead of increasing, is he ld co nstant . As th e fluid fl ows out of the syringe, wit ho ut furthe r move ment of the plunge r, the interna l force decre ases. These three properties, creep, stress re laxat io n, a nd load rat e dep ende nce, make up the bas ic tissue vis coela stic properties. K eep in min d th at the mo del u sed in this discu ssion is a s imple linea r series mo del, fo r explan atio n pu rposes o nly. More complex models using combina ti ons of the se basic compon ents h ave succe ssfully descri bed the observed tissue prop erties. Anoth er exa mple of tissue viscoelasticity, besides tendon a nd other soft
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tissue s, is foun d in trabecular bone, e.g., spina l vertebrae . In th is case, th e trabe cu lar structure acts a s the spring co mp on ent, w hile forci ng th e in te rstitial fluid th rough the po ro us mat rix, as the tra becu lae deform represents the viscous com pon ent. U nder high er loading rates, there is re sistan ce to flow , increasing the in te rn al pre ssu re , and there fore , the sti ffness of the structure. These effects h ave been ob serve d at high lo ading rat es, such as during fractur e, as sh own in F igur e 1 -11 (2).
FIGURE 1 -10 Viscoela stic re spo nse is expla ined in this simple mode l con sis tin g o f an ela stic or spring compo nent th at i nstant ly co mp resses wh en a lo ad is appl ied to it , co nn ected in series wit h a vis cous co mp on ent, mo deled here as a syrin ge, thro ugh whic h a flu id is force d. Loa ding the syringe's h andle with a constan t force ca uses it to continu e to creep or displace, in contrast wit h the spri ng, wh ich rea ches its fin al di spla cement instant ly. Furthe r, if the forc e is applied to the syringe handle mo re ra pidly, there is gre ater resistance to motion, explaining the increased stiffness of tissue to incre ased rate s of l oadin g.
P.1 1 In summary, bones and joints can b e subjected to a wide variety of forces, but these forces can be re solved into basic compon ents tha t create tension , compression, sh earing, twisting, and be nding. Th ese forces ca use internal, compressive, ten si le, and sh ear stresses in the tissu e. The stiffness of a fixat io n construc t u se d to stabilize a fractur e des cribes ho w muc h it deforms u nder a give n l oad a cti ng in a spec if ic direction . St iffness ma y va ry with dir ection an d is highl y depen dent on t he shape of the fixation construct. The effect of shape is described by the moment of inertia. In combination w ith th e mo ment o f ine rtia , the elastic mo dulu s o f th e ma te rial describes how stiff th e fixatio n will be u nder loa d an d its abilit y to wi thstand the f orces of , fo r e xample, th e pa ti ent's weigh t durin g a mbulatio n. Fai lure of f ixation can c o me not only fro m loading abo ve its yield poin t but also as a re su lt of re petitive stress. Repe ti tiv e loading can cause growth o f a crack at a stress con centrator and ca n be sig nificantly acc entu ated by corr osio n when the implan t is imm erse d in bod ily fluids. Bi ologic tis sue s beha ve visc o elastic ally and can cr eep u nder co nst ant loa d, stres s relax whe n the elo nga tio n is
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fixed, and increase stiffness a s the rat e of lo ad application in crea ses. In th is cha pte r, these me ch anica l pro perti es are d esc ribed in b a sic units of mea su rements, defined in T able 1-2.
FIGURE 1 -11 T rabecular bon e possesses some features of the sprin g a nd syrin ge viscoe lastic mo del described in Figu re 1 -1 0, although it sho uld be a ppreciated that this is an idealized mo del. The trabecular structure a cts as th e spring element. At hi gher loadin g rates, th e interstitial fluid resists flow ing through the trabecula r spaces, causing increased internal pressure, a nd th erefore, l ong bon e stiffness. Th is anatomi ca l feature allows ve rtebrae and th e metaph yseal ends of long bones to re sist dynamic loa ds caused by ra pidly a pplied forces (2 ).
TABLE 1-2 Definitions of the Units Used to Describe the Basic Properties of Fracture Constructs
Force, newtons (N) 1 N ~ 0.254 lb Displacement, millimeters (mm) Stress, pressure, modulus, megapascals (MPa) wh ere 1 MPa = force of 1 N/area of 1 mm 2 Modu lus = str ess/str ain, wher e s tre ss uni ts are MP a, str ain h as no units St rain (no un its), strain = chan ge in len gth (mm )/origina l le ngth (mm )
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P.1 2
BIOMECHANICS OF INTACT AND HEALING BONE

Bo ne can be co nsidered to have a hiera rch ical str uctur e. As s ho wn in Figure 1-12 , the lo wes t leve l of th e structure co nsists o f single colla gen fibrils w ith e mbe dded a patite crys tals. At th is leve l of str uctur e, chang ing th e co llagen -to -min eral rat io has a sign ifica nt effe ct on the elastic mo dulu s of b one (2,3,4), as i t decreases with loss of mineral (Fig. 1-13). This is importan t from a fractu re h ealin g pers pec tive bec ause minera lizing heali ng ca llus go es thro ugh pha ses of increas ing minera l d ensity a nd co rre spo ndin g in crea sed mo dulu s as h ealin g occu rs. At t he next level of str uctur al organ ization , the orien tation o f the collage n fibrils is important (5,6,7,8,9,10,11 ). As demonstrated i n F igure 1-14 , the o ri entatio n o f it s f iber s a ffec ts the a bilit y o f bo ne to su pport lo ads in s pec if ic d ire ctio ns. Durin g fractu re h ealin g, the callus initia lly starts a s a disorgan ized ra ndom array of fibers, w hich progress ively re organ izes to beco me stiffest a long the direction s of th e maj or applied loads (bo dy we ight and mu scle f orces) tha t the bone is exposed to. At the next level, th e den sity o f th e h aversio n sys tems a ffects bon e strength . It ha s been repea te dly demo nstr ated th at the re is a po wer l aw re lation ship be tw een bon e den sity an d strength at th is level o f struc tur e (Fig. 1-15 ). T his mea ns th at a s bon e de nsity decrea se s, its stre ngth decre ases a s the square of its de nsity (as density d ecreases by half, strength decreases by a factor of 4). This forms the basis for predicting changes in b one strength due to osteoporosis, for example . Similarly, P.1 3 th e mo dulu s chan ges with bo ne density by a power of be tw een 2 and 3 (12,13 ,43 ,117 ). Non invas ive me asures o f bon e de nsity suc h as quan ti ta tive co mp uted to mograph y (qCT) h ave been sho wn to h ave a s ign ifican t predict ive re lation ship to bo ne s tre ngth (1 7,18 ).
FIGURE 1 -12 The hierarchica l structure of bone is demonstra ted. At the lowest le vel of o rga nizatio n, th e ra ti o of mine ra l crys tals to co llagen fibrils determin es ela stic modulu s o f the combin ed ma ter ial, a s sho wn in Figu re 1 -1 3. At the next le vel, the fiber o rientatio n is impo rta nt in determinin g the differen ce in bo ne stren gth in va ri ous directions. At the final level, th e lame llae of bo ne fibe rs for m haversian systems, which par tic ularly in trabecula r bone, are ori ented in th e direction of the major loads th at th e bone must support.
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FIGURE 1 -13 Ela stic modulu s o f bon e sample s tes te d in tensio n after expo su re to dif fer en t con centration s of HCl. Greate r HCl c on ce ntration pro gressively demineralizes bon e, lea ving ultim a te ly, only co llage n. Thi s diagram illu strates the co ntributio n of bo ne m ineral to t he te nsile ela stic modul us of who le bo ne (3).
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FIGURE 1 -14 Ef fects o f colla gen fibril direction o n th e resistance to loa ds applie d in differen t direction s. The weake st directi ons in r elation to a given lo ad are th ose in w hich th e fiber s separ a te alo ng their ce me nt (bo nding) lines during loa ding (11) .
Se veral addition al factors can affect bone stre ngth. As discu sse d previously, bone is a viscoe lastic ma terial wit h str engt h an d mo dulu s that both increase as loadi ng ra te increa se s (e.g., in fra ctu re i mp act lo ading vs. norm al amb ula tion) (2, 19 ,2 0,2 1,22 ,23). Age also a ffects bon e pro per ties. The b ending stre ngth and modu lus in cre ase as bo ne mi neralizes and mat ures fro m childh ood to adu ltho od a nd sl owly decrease th ereafter (24 ,25,2 6), a nd impa ct ene rgy abso rbe d decreases with age (2 7) a s b one beco me s more brittle. Defects or hole s in bon e (e.g., from drilling for screws) affect its strength (2 8,29,30,3 1,32). The torsional stren gth o f bon e de crea se s as the di ameter o f the hole o r defec t i ncreases (F ig. 1-1 6). As the hole increases to 3 0% o f th e bo ne's diameter, bo ne s tre ngth decre ases to a bou t 50% of that of the in ta ct bon e wi th ou t a defe ct. An imp o rt ant co nsidera tio n, applicable in th e res ec tio n of bon e (suc h as in re moval of a tum o r), is t he sha pe o f the hol e o r def ec t lef t a fter tu mor re moval. Leaving a hole with squ are corners significan tly decreases strength, compared to th e sa me h ole with rounded corners, becau se the squa re c orn er is a la rge stress con centrator. Althou gh oval or circu lar hole s are stil l stress risers, they do not have th e a dditi onal effe ct of the sha rp corner (2 9). Table 1-3 s ummarizes the str en gth o f cortical and cancello us bone materia l as well as th e u ltimate stren gth s o f variou s wh ole bon es. As a fractur e hea ls, it s strength is affe cted by ch anges in its minera l co ntent, ca llus dia meter, an d fiber organ ization , as was discu ssed previously. The ini tial cal lus forms from the periosteal surface o utwa rd, which is be neficial me ch anica lly, becau se a s the oute r diameter of th e healing area e nlarges, its moment of P.1 4 i nertia, and therefore, i ts initial stiffness bo th increase, as sho wn in Figu re 1 -17 (33) . The crosssectional area increase s progressively, as shown in Fi gure 1 -18, as does the min eral co ntent of th e ca llus (3 4). T he mechan ical re su lts of th ese cha nges to bo ne as th e fractur e heals are sh own in F igure 1-19 . F rom to rsional tests of hea ling rabbit l ong bon es, pro gre ssive increa ses were observed i n stiffness and peak torqu e to failure with time (35). Interestingly, in th at exp eriment, the stiffness a ppeared to gain no rm al values, while the peak torque to fa ilure lagged behin d. Figur e 1-18 sho ws th at beyond 4 weeks (in rats, w hose bon es h eal ra pidly), the cross-sectional area starts to decrease a s the bon e remo dels to n ormal shape , whi le the bo ne ti ssue con tinue s to m inerali ze.
FIGURE 1 -15 T he re lation ship of tr abec ula r bo ne dens ity to c o mp re ssive str engt h and modu lus
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demonstrates a power-law rel ation sh ip, so that these properties decre ase by a facto r of abou t four when density decreases by half (2).
FIGURE 1 -16 The re lation ship of ultima te torqu e (failure torqu e) of a long bon e to the diame te r of th e h ole divided by th e o uter di amet er o f the bon e. There is n o ch ange in ultim a te torqu e until th e defec t size increases beyon d grea te r than 1 0% of the bo ne's dia meter (30 ).
Th e mech anical envi ro nmen t cr eated by the fixation s ystem a lon g with the ava ilable bloo d su pply a ffects the type of tissu e formed in a healing fracture. Th e th eory of inte rfragmenta ry strain attempts to rela te the types of tissues formed to the amou nt of stra in experienced by the tissue between the h ealin g bo ne frag me nts (33 ). This the ory is a s imple de pictio n and cann ot re pre se nt the comple x st res ses tha t the hea ling tissu e is exposed to during act ual he aling. Non eth eless, wit h in the l imitation s of th e theory, a s shown in Figure 1-2 0, when large stra ins occu r in the tissu es betwe en h ealin g bo ne surfa ce s, granu lation t issue is f ormed. Interm ediate level str ai ns pro duc e cartila ge, a nd sm a ll strains result in prima ry bo ne healin g, o r direc t de position o f bon e tiss ue with limited ca llus fo rma ti on. Amo ng the limitation s of th is theory, reco gnize th at i t doe s not follow th at zero strain will result i n ma xim um bone formatio n. Lo ad and some resulting stra in are n ecessary with in th e healin g frac tur e to st imu late bo ne fo rm atio n. In a stu dy in whi ch c o ntrolled daily dis placemen ts in a spe cif ic dire ctio n w ere a pplied to h ealin g long bone s using an extern al fixato r, an d the bon e mi neral within the hea ling frac tur e was me asured wit h time, there was a n opt imal displac emen t abo ve or be low wher e less mi neral was created in the fra ctu re callus (Fig. 1-21) (36). Fracture fixation con structs of differen t stiffn esse s, within a certa in range, produ ce hea led fractures with simila r mecha nical properties; h owe ver , they may reach this en dpoin t by diff er ent routes . In a study o f fe moral fixa tion us in g IM ro ds o f either 5% or 50 % o f the torsion al stif fn es s of th e in tact fe mur, the fe murs f ixed w ith the lower stiffness rods produced an abundance of stabilizing callus, as opposed to the femurs with more rigi d fixation ( Fi g. 1-2 2), becau se with more rigid fixatio n, there was le ss necessity for biological fracture sta bilization. In both cases, h oweve r, the mechanical properties of the heale d fractures were u ltimately similar (37). These stu dies dem onstrate t hat some strain du e to loading of the fracture st imu lates h ealing an d tha t bo ne will a dapt a nd heal within a relative ly wide ran ge o f m echan ical stabilization environ ments. In s umm ary, a n umb er of factors a ffect bo ne str en gth, and simila rl y, a hea ling fractur e. Incre asing mi neral conten t in crease s fra ctu re stiffness. C allus that forms on the perios te al su rface is beneficial i n in cre asing the mo ment of in ertia and, th erefore, the stiffness of the fra ctu re d regio n. H ealing fractures exhibit a n umber of stages, w ith stiffne ss returning to norma l followed later by peak load to failu re. Bo ne will heal within a ran ge of mechan ical environ ments . To a certain extent, heali ng bo ne w ill co mpensate fo r mo re flexible fixa tion by fo rmi ng a grea te r qua ntit y o f frac ture callu s; how ever , th ere is an opt ima l ran ge of displacem en t of a healin g callu s withi n w hich sign ifica ntly grea ter mi neral can be sh own to form in the same time.
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BIOMECHANICS OF BONE FRACTURE

To a ppreci ate w hy bo ne fra ctu re s in certa in patterns , one mus t u nder stand that , a s sho wn in Ta ble 1 3 , bo ne is we akes t in tensio n and stro nges t i n co mp ressio n. Th erefore, w hen a force creates te nsile stresses in a partic ula r regio n o f a loaded bo ne, failure will occur first in that region . The sim plest e xample, sh own in Figure 1-23, is the transverse fra ctu re created in a l ong bon e su bjected to pu re b ending. Bec ause in this e xample, th e upper, convex su rface unde rgo es th e grea te st elo ngatio n, it is su bjected to the large st tensile stresses, a nd failu re (indi ca te d by a cra ck) initiates here. Th e crack th en progresses transve rsely through the ma terial, and layers j ust below th e outer layer become su bjected to high te nsile stress, u ntil th ey crack as wel l. In th is manner, the crack progresses through the bone transversely u ntil it fa ils. The con ca ve su rface is subjecte d to compression , so the crac k doe s no t ini tia te the re . A seco nd exam ple is the fra ctu re lin e or cr ack th at o ccurs wh en a bone i s subjected to torsion o r axial twisting. I n th at case, a spiral fracture results. Consider, a s shown i n F igur e 1-23 , a rectangu lar area on the surfa ce o f a long bon e th at is loa ded in t o rsio n. Th e rectan gle d isto rts as th e bo ne t wis ts, wit h one diago na l o f the re cta ngle elon gating and the othe r sho rte ning, d ependin g on th e direct io n o f twist. A cra ck will form perpen dicular to th e diagon al that is elongating, a nd it progre sses arou nd th e perime te r of th e bone resulting in a spiral fracture. The region of bone w ith th e smalle st diam eter usual ly ha s the greatest di sto rtion, as it allo ws P.1 5 P.1 6 th e la rges t amo unt of twis t. T hi s explai ns wh y to rsio nal fractures o f the tibia o ften o ccu r in the n arrow distal th ird (F ig. 1-2 4).
TABLE 1-3 Mechanical Properties of Bone Material and Whole Bones in Different Loading Directions
L oad T ype Ela stic M odulus (X 10 E9 Bon e Typ e N/m 2 ) Ult imate Stress (X10 E6 N/m 2 ) Reference
Co rt ical
T ens io n
11 .4 19 .1
10 7 14 6
Cro wnin sh ield Ann Bio med E ng 19 74 ;2:217 Eva ns Ac ta Anat 19 58 ;3 5: 28 5 Eva ns Am J Ana t 19 67 ;1 20 :7 9 W rig ht Med Biol En g 1 976 ;14:6 71 Rei lly J Biomech 19 74 ;7:271
Compression Shea r
15 .1 19 .7
15 6 21 2 73 8 2
Cu r ry 19 84 , Princeton University Pre ss Y am ada 1 970 , W illiams a nd W ilkins, Ba ltimore
Ca ncello us
T ens io n Compression
~0 .2 5 .0 0.1 3
~3 2 0 1.5 5 0
Cu rry J Biomech 19 79 ;1 2: 45 9 Carter J Bone Jt Surg; 19 77 ;5 9A: 95 4 W eaver J Bone Jt Surg 19 66 ;4 8A: 28 9
Page 20 of 69
Gala nte C alcif Tis sue Res 19 70 ;5:236
Shea r
6.6 +/- 1 .7
Ston e J Biomech 19 83 ;1 6: 74 3
Bon e Typ e
Loa ding Di rectio n and Typ e
Ultimate Streng th
Reference
Ce rvi ca l spine
Axial compressive impact
98 0 7,4 00 N
Yoga nan dan J Spina l Disorders 19 91 ;4:73 McElha ney S oc Auto En g 19 83 ;83:16 15 Nusholtz 2 5th STAPP car crash con f 1981;11 97
Ce rvi ca l spine
Exten sion
57 N -m
Nah um Acciden ta l I nju r y 1 993 , Springer -Ver lag
Ce rvi ca l spine
F lexion
12 0 N-m
Ce rvi ca l spine
Lat eral ben ding
54 N -m
Lumba r spine
1,4 00 9 ,0 00 N
Co dy Spi ne 19 91 ;1 6: 14 6 Bell Ca lci f Tiss ue Res 19 67; 1 :7 5 Brassow Eur J Ra diol 19 82; 2 :9 9 Han sson Spine 19 80 ;5:46 Halto n J Anat 19 79 ;1 29 :7 53 Tran Spine 19 94 ;20:19 84
Sac roi liac Join t
3,4 50 3 ,6 94 N
F as ola 1 955 ; W rig ht Patterson AFB
F emoral ne ck
Lat eral to medial at trochanter
1,0 00 4 ,0 00 N
Smith J Bone Jt Surg 19 53 ;3 5A: 36 7
Page 21 of 69
F emoral ne ck
Vert ical impac t at femo ral he ad
72 5 10 ,570 N
Alho C lin Orthop 19 88 ;2 27 :2 92 Leic he r Clin Orthop 19 82 ;1 63 :2 72 Stanke witz J Orthop R es 19 96 ;1 4: 78 6
F emur
T or sio n
18 3 N-m
Martens J Biomech 19 80 ;1 3: 66 7
F emur
fro m i mpa ct at knee alo ng axis
6,2 30 1 7,13 0 N
Pa tri ck 9th S TAPP car cra sh co nf 19 66 :237 Vian o J B io me ch 19 80 ;1 3: 70 1
F emur
Three poin t bending, po st er io r
21 .2 31 .3 Nm
Mather J Biomech 19 68 ;1:331
Pa tella
Impact perpendicular to anterior
6,9 00 1 0,01 2 N
Pa tri ck 9th S TAPP car cra sh co nf 19 66 :237
Tibia
Axial torsio n
10 1 +/ - 35 Nm
Martens J Biomech 19 80 ;1 3: 66 7
F oo t an d an kle
Impact perpendicular to sole
4,1 07 6 ,4 68 N
Assal 4 6th AAAM 20 02 ;273 Yoga nan dan 19 96; Soc Auto Eng 96 24 26 Schue ler I n 19 96; Soc Auto Eng PT 56 , 5 51 Kit ag awa 19 98; Soc Auto Eng 98 31 45 F unk 20 00; Soc Auto En g; 20 00 0 101 55 M cM as ter 2 000 ; STAPP car crash con f 44:357
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FIGURE 1 -17 A co mp arison of th e mo ments o f ine rtia an d res ul tin g st rengths when frac tur e callu s is loc ated (A) o n th e outer s u rface, (B) on the bon e surfaces, or ( C) in the me dullary can al. The st rength and rigidit y a re sign ifican tly in crea sed wh en ca llus is lo ca ted o ver the perio ste al su rface, co mpared to wit hin t he m edulla ry can al ( 3 3).
A compressive loa d results i n failu re of cortical bone by shear, indic ated by slippa ge a long the d iagon al, bec ause bone is weaker in sh ear th an in compression (Fi g. 1-25 ). (The str esses 4 5 t o the compressi ve force within the material are sh ear stresses.) In th is case, compression causes the surfaces of the bone at 45 to the applied load to slide along an oblique surface. At very high load s, su ch a s durin g impact fractur es, crush ing or co mm inutio n of bo ne also occurs , esp ecially at the w eaker P.1 7 me ta physeal ends of a lo ng bone . The tr abec ula r bon e at the metaph yse al ends is weaker in co mpres si on than the diaph yseal co rtical bo ne is in she ar. Bec au se o f this, it is un likely that sh earing failu re wi ll oc cu r in the diaph ysis due to pure com pressive forces. The butterfly fracture (Fig. 1 -2 5) re su lts fro m co mb ined bend in g an d co mp re ssio n. Be nding lo ad cau ses the fra ctu re to star t to fail in tension produc ing a transverse crack, but as th e crack progresses and th e remaining intact bone w eaken s, it star ts t o f ail in co mp ressi on, causing an o blique (sh ear) frac tur e li ne. As the ends o f the faili ng bo ne are driven togethe r, a third fragm ent, the butterfly, may resu lt as th e o blique fragment splits off. Th e pro duction of a butterfly fragme nt pro bably depends on the timing and magnitu de o f th e two ba si c applie d lo ads, compression and bendin g.
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FIGURE 1 -18 Ch anges in th e cro ss-sectiona l a rea of a hea ling femo ral fractur e, whic h peaks an d slowly de crea ses. T here is a sim ilar increase in the min eral conten t. (The da ta come from rat s th at h eal more ra pid ly th an huma ns, in dic ated by the 4 -week time to pea k min eralizatio n [34].)
FIGURE 1 -19 A co mparison of su perimposed torque -angula r displacement plots taken from experimen tal long bo nes at dif feren t stages o f hea ling, sh ows the sign ifica nt in cre ase in bo th stiffness a nd peak to rque to failure wit h i ncreased du rat ion o f hea ling. Nu merical values are time in days postfracture in rabbits (35).
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FIGURE 1 -20 The th eory of interfragmentary strain estimates th at large strain s (>10 0%) resultin g from ve ry flexible fixati on produ ce gran ulation ti ssue within th e fracture site, whereas sm aller stra ins (<1 0%) re su lt in cart ilage, an d very sma ll strain s (<2%), pro duce bon e ( 33).
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FIGURE 1 -21 The effect on bo ne m ine ra l with in a healin g fracture of differen t cyclic displacemen ts applie d dai ly (upper curve, 0 .5 mm; middle cu rve, 1.0 mm; l ower curve, 2 .0 mm for 5 00 cycles /day). This sh ows that th ere is an optima l lo ngitudi nal dis placem en t below or abo ve where less mine ra l is cre ated w ithin the heali ng fract ure (3 6).
FIGURE 1 -22 A comparison of th e diffe re nt h ealin g respon ses of dog femurs with midshaft fractures fixed w ith IM ro ds o f 5% (top) o r 5 0% (b ottom ) of the to rsio na l stiff ness of the intact femur. Although the femurs fixed with rods of lower stiffness produced more callus as additio na l stabiliza ti on aga inst f unctio nal loads, t here was u ltimately no differen ce in mecha nical properties between the femurs fixe d with rods of diffe re nt stiffnesses (37).
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FIGURE 1 -23 Top. A tra nsverse fracture is cre ated by the progressive tensile failure of bone material starting from the convex surface where elongation, a nd th erefore, stress is gre atest, with the cra ck progre ssing to the conca ve side. Bottom. A spiral fracture is created by the progres sive failure in t ension o f fibe rs on the bon e su rface alo ng th e dia gon al th at el onga tes as the mat erial o n th e surface di sto rts when to rqu e i s applie d. ( A rectangle o n th e surface bec o mes a paralle logram , with on e dia gona l el onga ting. Th e crack will be transvers e to th e diago na l.)
Aging, especially with osteopo ros is, chan ges the force re quired to fracture and the type s of fractures th at o ccu r. As s ho wn in Figu re 1 -15, tra bec ular bon e stiff ness varies wi th the cube (thir d po wer ) o f i ts dens ity and str en gth a pproximatel y with the square of its dens ity (2). Bone mas s n ormal ly pea ks a rou nd a ge 2 5 to 30 and dec reases up t o 1 % th er eafte r. If the de ns it y o f trabec ular bon e is d ecreased by 30%, in a 60 - to 70 -ye ar-old due to osteoporosis, th e compre ssive stre ngth is about h alf of that of a 30-y ear-old. Typi ca l fractures due to osteoporos is occu r in the vertebrae, th e distal ra dius, a nd th e f em ora l n eck . I n a ddit ion , o steo poro sis chan ges the cross-se ctio nal shap e o f lon g b ones, dec reas ing thic kness by incr ea sin g the en dost eal diameter, while causin g the perio stea l d iameter to increase. If cortical oute r diameterfor example, in the femur increased and cortical th ickness decrea sed at th e sa me rate, the momen t of i nertia of the bon e cro ss sec ti on would be l arger. Tha t is P.1 8 w hy l arge-diameter th in tu bing can be substituted for small er-diameter thicker tubing in stru ctu res (e.g., sa ilboa t masts ), saving weigh t whi le not sa crif icing stren gth. In the femu r, however, th e in ner su rface of the cortex also becomes more irregula r and porous, decreasing material stre ngth. A common result of loss of femoral bone mass combined with other fa ctors is a hip fractu re u su ally re su lting from a fa ll. The most likely scen ario related to femur fra ctu re was reported to include femal e gen der, patien ts ol der tha n 8 0 years o f age, falling while ambu lating indo ors, a nd fall ing d uring th e a fternoon h ours (3 8).
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FIGURE 1 -24 Cr o ss sectio ns th rough a femur ( left) an d a tibia (right). Th e small cross section o f th e di sta l third of the tibia results in more disto rsion and high er stresse s an d expla ins w hy to rsiona l failu re o ften occurs in th is area .
Au to cra sh es account for man y fractures. Some particula r mechanisms have been observed. Fracture o f the calcan eus o r the malle oli of th e foot an d a nkle ca n occur th ro ugh a combin ation o f the foot b eing fo rced aga inst the brake pedal by th e we ight of the occupa nt du ri ng a h igh-spe ed fr on ta l co llis ion , o r in combin ation wi th the floo r pan o f the auto crus hin g in to th e spac e where the fo ot re sides. Drive rs who we re brakin g du ring a crash were sh own to be much more likely to injure their right foot compa re d with their left foot (39). If the Achilles' tendon a pplies load to resi st the forced d orsifle xion o f the foo t on th e bra ke peda l, the combi natio n o f these two loa ds cause thr ee- poi nt b ending lo ading of the calcan eus, w ith th e po ste rio r facet of the talus as th e fulcrum . A crac k i nitiates on the plant a r or t ensile side o f the calcane us, and a ton gue- type ca lcaneu s fra ctu re can occur. Inversion or e versi on combin ed with compression is likely to result in a malleolar fra ctu re (4 0), al th ough th e forces ca using th ese h igh- energy fra ctu re s are not entirely predic table. A major mechanism of midshaft femur fractures is impact with the d ashboard of the vehicle in a fron tal co llision , espec ia lly unrestrained drivers wh o submarine o r slide forw ard in the s eat. Ten sing th e qu adriceps and h amstrings muscles during a cra sh a pplies significan t additional compression along the femur (41). Its anterior bow causes external compressive force from contact of the knee w ith th e da sh board, and internal mu scle forces to bend the fe mur, resultin g in transverse or oblique fractures. If the fe mur of the occupant hits th e da shboa rd in an a dducted orientation, the femur ca n b e displac ed fro m th e aceta bulum , causing a fractur e of th e ace ta bular roo f and dis loca tio n of t he hi p j oint. Pelvic fra ctu res result from loading in side impact crashes, where th e door punches inw ard a gain st the hip a nd pelvis. The act ua l fract ure pa tte rn ( symphysis, sacro iliac j oin t, or both) is p robably the res ult o f the spe ci fic a lignm en t o f the pe lvis an d the lo ca tion o f the a pplied loa ds at impact. Pelvic fracture classifications are based on the presumed mechanism of injury and specific fo rces applied (42). Bi lateral hip fractur es have been f ou nd to o ccu r in cras hes when the vehicle ha s a la rge cen te r c on sole that ten ds t o trap the pe lvis as fo rce is a ls o P.1 9 a pplied on the hip oppo site tha t wh ich co ntac ts t he doo r. I n cra sh es in wh ich o ccupants have lap but n ot sh ou lder belts, torso forward motion creates th e classic chance fracture, wh ich is combine d co mpres si on an d f lexion failu re o f a l um bar ver te bra, usu ally at the leve l wh er e the la p belt fo rms a fulcrum.
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FIGURE 1 -25 A. Tensile fracture (left) cau ses a stepped su rface as fibers pu ll a part. The crack progresses, th en steps to an adjacent region where fa ilure contin ues. P ure com pression (right ) o f co rtical bo ne res ults in failu re by sh earin g or sliding alo ng obliqu e su rfaces . In realit y, pure compressio n o f a lon g bo ne (in a fall, for exa mpl e) results in crus hi ng of the muc h weaker metaph yseal tra becular bon e with a pilo n fractur e of the dis tal ti bia o r a t ibial pla tea u fractur e as the re su lt. B. Some fractur es that co mb ine bend i ng and co mp ressi on demo nstra te tran sve rse cr acking due to bendin g follo wed by a n o blique cr ack ch aracter isti c of co mpres sive failure. The butterfly fracture w ith a dditional splitting o f th e fragment seconda ry to the initia l fracture is an exa mple.
BIOMECHANICS OF FRACTURE IMPLANTS Avoiding Mechanical Problems With Fracture Fixation Devices
Th is section discusses the function of commonly used fixation devices for ske letal fracture fixa tion. O bse rv ed fixation problems wi th devi ces such as wire, cable, screws, plates, IM rods, an d externa l fixato rs are explain ed w ith th e object ive of reducin g the po te ntial for mecha nical damage o r failure of th ese devi ce s during use.
Cerclage Wire Breakage

Th e ten sil e strengt h of su rgi ca l wire ha s been s hown to increase direc tly with its dia meter, an d wh en twi sted, the optimal nu mber of tu rns is between four and eight. Solid wire is very sensitive to n otches or scrat che s, ho wever. Tes ting sho ws tha t notch es as small as 1% of the diam eter of the wir e can reduce its fatigue life by 63%. For this reason, cable has been introduced for cerclage a pplicatio ns. Ca ble has sign ifica ntly bett er fatigu e pe rforma nce co mpared to w ire, as shown in F igure 1 -26 (43).
Screw Breakage by Shearing During Insertion

A sc re w is a me ch anical device that is used to conve rt rotary force (torque) into compression be tw een a pla te and bone, or P.2 0 b etw een bon e fragments. As shown in F igure 1-27 , the thread of a screw if unwo un d f rom th e sha ft is
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re ally a ra mp o r inclin ed pla ne that pulls , for example, unde rl ying b one towa rd the fixation pla te , ca using compression between the m. The basic compone nts of a screw are sh own in Figure 1-28. Be ca use of its f unctio n, th e screw head an d shaf t mu st be f ree to tu rn in the pla te ; othe rw ise, the co mpres si ve f orce gener ated may be l im ite d. ( This do es n ot a pply to screws th at a re des igne d t o be th readed into the plate holes in locki ng plates.) One commo n problem is that sometimes th reads a re ta pped in to both bon e co mpone nts. The bon e co mpone nt in wh ich th e screw head will rest should be d rilled oversize to allow the shaft of the screw to turn freely, and only the other should be tapped. Ta pping is necessary in cort ical bone so that the to rque applied can be us ed to create compression i nstead of cut ting thr eads and ove rco ming friction betwee n th e screw th read and bon e tha t it i s being d rive n into (Fig. 1 -29) (44) . W ith ca ncello us bo ne, as discussed later, tappi ng is less ad vantageo us, u nless th e bo ne is very dense. One commo n pro blem during screw placeme nt is sh ear failure of t he sc rew, ty pica lly th e head tw istin g off, leaving the sh aft embedded in bone and dif ficu lt to remo ve. Th is can occur especially when u si ng smal ler (less tha n 4 mm in diameter) screws in de nse bone, e spe ci ally withou t tapping. The stiffness a nd strength o f a screw are re lated to th e fourth po wer of its d iameter (the effect of moment of inertia, for screws of the sa me ma terial). A 6-mm-diameter screw i s approximately five times a s stiff as a 3-mm-diameter screw and 16 times a s resistant to shear failu re by ove r-to rqu ing the sc rew during insertio n.
FIGURE 1 -26 A co mparison of th e fat igue resistanc e of wi re an d cable s made of th e in dic ated materia ls. Wire, 316 SS (sta inless st eel); c ab le, 316 SS ; Cp T i, comme rcia lly pu re titan ium; C oCr -W -Ni, co balt chrome; Ti 6Al 4V, ti ta nium allo y; MP3 5N, nickel alloy (43 ).
Screw Pullout
Particularly in cancell ous bon e, the maximu m force th at a screw can wi th stand alon g its axis, the p ullout force, depends on the size of the screw and the density of the bone it is placed into. As shown i n Figure 1-30 , wh en the f orce ac ting on the scre w exceed s its pul lout stren gth, th e screw w ill pu ll o r sh ear o ut of the ho le, c a rryin g the shea red bo ne wit hin its th re ads , becau se it is us ua lly th e bo ne that fails and not the screw . The maximum pullout force increases with larger screw diameter, a l onge r len gth embed ded, and grea te r density of the bo ne it is pl aced in to (4 5,46 ,47,4 8). Th e d iameter a nd length of the embed de d sc rew ca n be tho ught of a s def ining the ou te r sur face of a cyli nder a lon g wh ich the screw sh ears. Given the maximum stre ss that bone o f a pa rti cu lar de nsity ca n w ith sta nd, increasing the su rface area of th e screw cylinder increases the pu llou t force (force = stress area over which it acts). To en han ce screw pu rch ase, consider embedding th e l argestd iameter screw possible into bon e of the greatest den sity, ov er as lon g a purcha se len gth a s possible (45,46). Pullout strength also increases significantly if the screw is placed through both bone co rtice s.
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FIGURE 1 -27 A screw is a mechanical de vice that con verts torque in to compression between o bjects. The screw thread is a ctually an inclin ed pla ne that slo wly pulls th e o bjects it is embedde d into together. For this reason, the head an d screw shaft in one part must be free to rota te . If this pa rt of the screw i s threade d into the hole of the first part (for e xample, the plate), it will not allow the surfaces to compress. (Fn, normal or compressive force acting aga inst the screw h ead; F t, tan gent ial or frictio nal force acting alo ng the screw thr ead; Fz, resultan t of th e two forces; , angle of th e sc rew th read. Th e sm all er the an gle (f iner threa d) is, the lo wer the frictio nal force wi ll be.
In cancell ous bon e, screw pullou t becomes a more significant problem because the porosity of ca ncellous bone reduces its density a nd, therefore, its sh ear strength (49). Hole prepara ti on, specif ically drilling but not tapping, improves the pullo ut st rength of scr ews placed into cancello us b one (such as pedicle P.2 1 screws in th e ve rtebral body) (47). Th e reason that tapping reduces strength , as sh own in Figure 13 1, is tha t runn ing the ta p in an d out o f the hole remo ves bo ne, ef fectively incr easing the diameter of th e h ole an d reduc in g the amo unt of bo ne mat erial that interacts wi th the screw threa ds . Tappin g ha s mo re e ffect as bone den si ty dec reases and ca n re duc e th e pu llou t stre ngth fro m 10% to a s muc h as 3 0% . It should also be n oted that th e findin gs of stu dies rela te d to pullout s trength rela te to the time i mme diately after insertio n. As th e bo ne hea ls, it als o P.2 2 re mo dels arou nd th e screw, po ss ibly do ublin g its i nitial pullo ut strength (50 ).
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FIGURE 1 -28 Nomenc lature of screws. The root diameter is th e inner diameter of the screw , an d the pitc h defines the distance between threa ds.
FIGURE 1 -29 Schematic diagram sh owin g the appro xim ate dis tribu tion o f to rque ac ting on screw pla ced in to co rt ical bo ne. With a pretapped ho le, ab out 65 % of the applied torque produc es compression, a nd 35% go es to ove rcome the friction associated with driving the screw. When the hole is not tapped, only about 5% of the torque is used to produce compression; the rest goes to overcome friction and to cut th reads in bone. These observations do no t a pply in can ce llou s bon e (4 4).
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FIGURE 1 -30 The factors that determine the pullout strength of a screw are its outer diameter an d len gth of enga gem ent (th is def ines the di me ns ion s o f a cylin der o f bon e tha t carried in the thr ea ds an d is sh eared out as th e screw is pulle d out o f bon e) an d the shea r st rength of bo ne at the scre w/bone interface, which is directly rela ted to its de nsity. A finer-pitch screw produc es a small gain in purcha se (45 ).
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FIGURE 1 -31 Top. The decrease in pullout strength in various types of foam used to test bone sc rews demo nstrating the perce ntage in decre ase of pullo ut stren gth betwe en screws placed into h oles that were e ith er drille d only or dril led and ta pped. B ottom . The percent age in increa se in vo lume co mparing holes th at we re drilled only a nd th ose th at w ere drille d an d tapped . Tapping in cancello us bone increa se s hole v olume , whic h decreases pullo ut strength (45).
Screw Breakage by Cyclic Loading

A mechan ism exists th rough which cortical screws can fail due to cyclic bendin g, shown in Figure 13 2. This mo de of lo ading coul d occu r durin g function al use. I t is importan t tha t the screw is tigh te ned a gainst the plate to the maximum extent possible , and the tightening torque must be effectively tra nsferred to com pres sive force between plate an d bone (Fig. 1-2 9). The sc rew h olds th e pl ate a gainst bon e pa rtly by frictional co ntact, wh ich de pends on the friction al force genera ted betwee n th e u nder surf ace of the plat e and bon e. The fri ctio nal force de pend s di re ctly on t he compressive force g enerated by th e screws. If any sliding o ccurs between the plate and bon e, the ben ding l oad will be tra nsferred from the head of the screw into the plate, where scre w-plate co ntact oc cu rs. Bending l oads per pend icul ar to the axis of the screw, a long wit h possible stre ss corrosio n and fretting co rrosion , may cause the screw s to fa il rapi dly in fatigue. Zand et a l (51) showed th at screws tightened against a plate with only 10% to 15% less force than the maximum possible failed in fewer th an 1,0 00 loa ding cycle s, by be nding fati gue, compared with fully tightened screws th at were able to su sta in over 2.5 millio n l oading cycles . Screws th at sc rew into an d lock to the plate r educe th is p roblem.
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FIGURE 1 -32 A mecha nism fo r rapid failure of screws in cyclic ben ding occurs when the screw ha s no t bee n tigh te ned su ffic iently to keep th e pla te from sli ding a lon g the bo ne su rfac e (the plat e -bone gap sh own he re is exaggerat ed for cla ri ty) . Th e resul t is tha t ben ding loads are applied transve rse to the lon g axis of th e screw w hich, in co mbination with fretting corrosion caused by the screws rubbing against the plate, results in early failure of the screw (51).
C ann ula te d screws are commo nly used for fi xation , as th ey have the si gnif icant a dvanta ge tha t they ca n be precisely guided into po sitio n over a guidewire, which may aid in reduc ing a fracture fragment. Cannu lated screws follow the same me ch anical principles as solid screws, discu ssed p re viously; how ever, to create the ce ntral h ole , material must be remo ved from the ce nter of the screw. Manu facturers commonly increase the minor diameter (the diameter of the screw a t the base o f the thr ead) to a cco mm oda te lo ss of th is materia l. The same size can nula te d screws usu ally have l ess thread depth c ompared with solid screw s. T he re su lt is, de pendin g o n th e screw size , less pu llou t strength. For 4-mm-diameter screws, can nulate d screws, of th e same outside di ameter had abou t 1 6% lower pu llou t strength (5 2). Alterna tively, to keep the same thread depth, the outer diameter of th e screw may be increase d.
Breakage of Fracture Fixation Plates

Th e fracture fixation plate is designed to stabilize a fracture by driving the en ds of the fracture together, compressing th em. P.2 3 Th is is be nefici al to f racture healing be ca use i t improves stability, o penin g the po ssibil ity for pr ima ry b one hea ling with minimal c allu s fo rm atio n, and by enh ancin g the resistance of the plate to b endin g fatigue failure . Observing the cross section of an oval h ole in a dynamic compression fra ctu re pla te , F igur e 1-33 sh ows th at o ne border of the ho le actually ha s an in cli ned su rface. Wh en th e head of the sc rew displaces do wnwa rd to ward th e bo ne s urface, the screw an d the f ra gment of bo ne it is a tta ch ed to slide towa rd the center of the plate. This a ction, which occurs for both f ra ctu re compone nts, ca uses the f ra ctu re surfaces to be driven together (53), and it creates significant compressi ve forces a cross t he ends of the frac ture (54 ). Co mpres si ng th e en ds o f the f rac ture si gnifi ca ntly i mp roves th e stabi lity o f th e co nstr uct an d redu ce s bendi ng a nd to rs iona l stresses appl ied to the plat e, increasin g i ts life . Stability is impro ved beca use the bo ne ends re sist bend ing forces tha t close the fractur e gap, a nd tors ion al loads are re si sted by th e frictional force and interlock between the end s of the fracture co mp on ents. Also, t he frac tur e gap that mus t be heal ed is sma ller . It is importa nt to apprecia te that the plate is vul nerable to bending failure , as plates a re thin , re latively easy to ben d ( compa red to bo ne), a nd h ave low mome nts o f iner tia. Th ey a re des ign ed to a pply co mp ressiv e force to t h e en ds o f the fr actur e, and the stabi lized bo ne can then resist the
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b ending loads app lied du ring fun ctiona l use. I f a ga p is left on the s ide o ppo site the plate (Fig. 1 -3 4), th e frac tur e site bec ome s a ful cru m aro und whic h the plate bends under combin ed co mp re ssive an d b ending loads such as th ose which occur during ambu lation (if the compressive force is n ot located d ire ctly dow n th e tibia l sha ft, wh ich occurs durin g h eel strike and toeo ff, th en bending lo ads wil l be a pplied along w ith the compressive force). G apping can also occu r whe n a segmen t of b one is missing a t the fractu re site, or if th e plate is not properly c on toured during application. Figure 1 -3 5 d emonstrat es how a fla t, no nco ntou re d plat e tighten ed a gains t a flat bone surf ace wi ll cau se a gap to a ppear on the oppo sit e co rtex (55 ,56). T h is is wh y a pla te is pre bent suf fi cie ntly P.2 4 to create an in itial ga p betwe en it an d the bo ne su rface that it will be applied to (56,5 7,58 ). G apping a lso occ urs w hen t he plate is applie d to the predomin antly compressive instead of the tensio n side o f a lo ng bon e du ri ng fun ctio nal lo ading, whic h causes bend in g. F igur e 1-36 s ho ws tha t plac ing the plat e o n t he co mp ressive side will cause a gap to o pen unde r load.
FIGURE 1 -33 A. Cr oss se ctio n th rough t he he ad of a bon e screw and the hol e in a fra ctu re plate showing the geometry. B . As th e screw i s tightene d, the hea d slides down t he inclin ed border of the plate, which displaces the screw sideways, and therefore, the screw and the bone fra gment to w hich th e screw is attach ed a re displaced toward the opposite fragment (53).
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FIGURE 1 -34 Left. When a gap is left o n th e co rtex op posit e th at to wh ich the pla te is att ache d, ben ding o f the plat e at th e fractur e site can cause the plat e to f ail rapidly in bendin g. Rig ht. Compressin g the fra ctu re surf aces no t only allo ws the bo ne co rt ices to resist bendi ng loads, bu t the friction al contact and interdigitation helps to resist torsion.
FIGURE 1 -35 A demo nstr ation o f the gapping that occurs o n t he oppo si te cortex when a f lat plate is a pplied to a flat b one surfac e. Sligh tl y preben ding the pla te cau ses the ends of the opposite cor tice s to be driven to gether when the plate is a pplied (5 8).
P late stresses are significan tly increased by gappin g at the fracture (5 5). In comminuted fractures w here it is di fficu lt to approximate the fracture ends, screws sh ou ld be placed as close a s possible across the fracture gap to reduce strains in the plate (59). Torsional and bending stiffness of a frac tur e constr uct can be significantly increased and, therefore, plat e strain c an be r educ ed by increasing the number of cortices of fixation (i.e., screw-cortex contact). As shown in Figure 1-37,
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h owe ver, there is an optimum number of cortices eight for dyn amic compre ssion plates (DCP) and n ine for limited contact dyna mic compression pl ates (LC-DC P)beyon d wh ich there is little additional gain in torsional stiffness (60). Figure 1-38 shows several interesting aspects related to p late fixation with screws. First, plate stra ins are h ighest a t the two holes a djacent to th e fracture g ap a nd b ecome very small, five holes away. Second, this occurs regardle ss of whether th e screws w er e pla ced n ear th e f rac ture (lo cation s 2, 3, 4, 5 ), fa r f rom t h e f rac ture (lo cation s 7, 8, 9, 1 0), o r mixed (locations 2, 6, 9) (59). These data also indicate that not all holes of the plate need to be filled with screw s in order to provide similar fixatio n stiffness .
FIGURE 1 -36 The application of a plate on the compressive as opposed to the tensile side of a bo ne su bjected to be nding causes a ga p to open on the opposite side of the pla te durin g function al loa ding.
A sig nificant re ce nt deve lopmen t in plate des ign is the lo cki ng or le ss- inva si ve stabiliza tion syste m (LI SS ) plate, also called the no nconta ct plate or internal fixat or (6 1). Th e screw head has a m achine th read, separate from the bone thread, which locks it to the plate. The screws and plate form a rigid co nne ctio n. In addi tio n, the screws have been des igne d with a fin er thr e ad for unico rt ical fixatio n (61). The LISS plate functions differently biomechanically from the DCP. The DCP is compressed a gainst the bone fra gments by the screws and requires bone-to- plate co ntact to produce a stable fracture construct. Bu ttressing of the o pposite cortex is important in main ta ining fra ctu re stability a nd reduc ing plat e str esses w ith the DCP . Bendin g loads applied to th e screws in th e nonl ocking DCP ca use th e screws to rota te within th e plate resulting in fracture fragment motion, higher plate stresses, an d reduce d stability at the fracture site (62). Th e LISS pla te acts conceptua lly like an extern al fixator (62), where the pins are rigidl y con nected to th e side bar and bone-to-fixator contact is minimized. Th is produces less interferen ce with the b iological pro ces ses of fracture hea ling, espe cia lly h elping to pr eser ve th e blo od supply near the fracture si te . Also, the LISS plate provides mo re stabil ity in commin uted fractures w here cortica l b uttre ssin g an d co mpre ssio n are di fficu lt to ach ieve, a nd fractur e mechan ical stabil ity o ccurs mainly th rough the hardware. LISS pla tes do not a llow t he screw s to be directed obli quely, except when specifically designed into the implan t, and they do not permit interfra gmentary compression at the fracture si te . Bendi ng loads applied to the screws from bone a re resisted by the locking interface b etw een t he screw hea d an d the threa ds in t he plate. Th erefo re, the se p lates are not as de penden t on cortical buttressing for sta bility a s the DC P. Dyn amic fatigue testing has sh own tha t LISS plates have fatigue strengths similar to other systems and are able to support P.2 5 P.2 6 l oads compara ble to o ne body weight for 2 millio n cycl es, which sho uld be suf fi cie nt for no rma l fracture healing (6 1). Because screw pu llou t strength is related directly to th e le ngth of screw
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p urc hase in bone cortex, the unico rtical s crews, used in s ome system s, have low er pul lout stre ngth th an bicortical screws. More screws must be used to com pensate for the inherent lowe r pullout strength of the unicortical screw.
FIGURE 1 -37 Relati ve stiffness of a plate -bone construct in torsion (top) a nd bend ing (bottom) as a functi on of t h e number of cortices thro ugh wh ich screws h ave been plac ed (DCP , dyna mic compression p late; LC-DCP, limited contact dynamic compression plate) (60).
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FIGURE 1 -38 Di stribution of strain (measured in microstrain or strain 5; holes 7, 8, 9, and 10; holes 2, 6, and 9) (59).
10 - 6 ) at va rio us
locations along a plate regardless of screw placement in different locations (holes 2, 3, 4, and
Plate Failure Through a Screw Hole

Ma ny plates a re lo ng with mu ltiple screw holes to provi de flexib ility of fixatio n of bo ne fract ures with complex geometries. It is not necessary to place screws in every hole in the plate (59), but the effects of screw placement on fixation stiffness should be understood. The screw hole w ill be an area o f eleva ted st resses o n th e pla te , unless the plate is made thicker nea r the holes to compen sate, a s i s the case wi th s o me pla te s. Pla cin g the pla te so that an emp ty screw hol e is locat ed ove r the fracture will sign ifica ntly in crease th e potential for f atigue fra cture of the plate. Th e pla te materia l a rou nd th e h oles will h ave high er material stresse s than oc cu rs in the solid region s of th e plate. Around the holes, the force a cts th rough a smaller cross-sectional area, so the material stresses mu st b e hi gher . A s econd c on side ra tion related to multiho le plat es i s that se parating the screw s so that th ere is a gre ater distan ce betwee n th em a cros s the fracture site resul ts in lower sti ffness of the p late-fracture construct (3 1). As wi th a ny be am (plate) (Fig. 1-39), the grea te r the distance between th e suppo rts (screw s), t h e grea te r t he bendin g dis pla ce me nt a nd th e h igher the stres ses will be fo r th e same applied load. It is best to a void placing s crew holes over or n ear th e fracture si te , and it is b eneficial, in terms of improvi ng fixation stiffn ess, to place screws as close together a cross the fracture si te as possible.
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FIGURE 1 -39 The greater th e span or distance of a beam is between its supports, the lower its st iffnes s w ill be, an d the more it wi ll deform unde r load in ben ding and tors io n. For th is rea so n, screws should be pl aced a s close together across the fracture site as possible.
The Problem With Fully Threaded Lag Screws

Th e lag screw i s a very effe ctive device for generating large compressive forces across fracture fragments, and these forces are applied directly a cros s the fracture site. The head and u pper pa rt of th e shaft of the scre w mu st be a llow ed to glide in one fracture component so that it pulls th e other fracture com ponent toward it to create compression across the tw o. As s how n in Figure 1-40 , a fu lly th readed lag screw blocks th e gl iding action between the two compo nen ts. Co mparing the compressi ve forces across the fra ctu re site u sing full y and partly threade d lag scre ws demonstrated th at the ave ra ge co mpressi ve force at the opposite cortex (i.e., th e force in th e screw itse lf) was a bou t 50 % gre ater wh en a partly threa ded screw was used (63 ).
Femoral Splitting Due to IM Rod Insertion

Insertio n of an I M ro d in to th e femur can lead to diff iculties be ca use th e femur has a sign ifican t a nterio r curvature (64 ), as s ho wn in Figu re 1 -41. Th e ro d, wh ich a lso has a cu rve d sha pe to a ccommodate the femoral bow , must conform to the curvatu re of the femur as insertion progresses. P lacing a r od, which is essentia lly a st eel curved sprin g, do wn th e femur ca uses th e rod to ben d, b eca use th e femur is generally much stiffe r than the rod. Figu re 1 -4 2 show s that rod contact with th e i nternal surfaces of th e femur generate s forc es with resist insertion. Th ese rod-femur contact force s, d ire cted per pend i cu lar to the surf ace of the medulla ry can al ca use th e femur to e xpand and will result i n splitting if they become too l arge (6 5). The factors P.2 7 th at go ver n t he amou nt of bendin g of the rod during insertion a nd th e resultin g in te rnal force s act ing w ithin the femu r are the pro xim al s tar ting hol e po sition, t he lengt h of th e pro xim al fragmen t, the i nitial curvatur e of th e IM ro d co mp ared wi th the curvatu re o f the femur , and the rod bend in g stiffn ess. Rod stiffness can vary con siderably (66). Figure 1-43 demonstrates ex amples where rod p ro ximal s tart ing hole po sitio n r esulted in femo ra l splitt ing durin g rod ins ertio n (6 5). So me n ewer IM n ails employ a valg us bend to be u se d with a fe mo ral troc han ter ic en try portal. The basic pr inciple s re garding nail geo metry, entr y portal locatio n, and excessive nail bendin g result in g in femoral splitting remain the same, however.
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FIGURE 1 -40 Using a fully th re aded lag sc rew causes th e threa ds to enga ge i n bone on bo th sides of the fra cture. This i nhibits th e screw from compressing the bon e fragments together (63).
FIGURE 1 -41 These cros s sections of va rious femora demon strate the curvature that an IM rod must conform to w hen it is fully inserted (64).
IM Rod and Locking Screw Breakage

F rac tur es o f I M rod s and lo cki ng sc rews o ccur o cca siona lly during heal ing. T he wo rst mechan ical situation f or IM rod fixation of the f emur or tibia occu rs when the fra ctu re is very distal. Figu re 1 -4 4 compares th e forces acting on idealize d femora with more proximal and more distal fractu res. For a
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specif ic location o f the external lo ad (muscle load or bo dy weig ht), the m ore d istal fracture resu lts in a longer moment arm (th e perpen dicular distance from the loa d to the fra ctu re site), creating a g re ater moment, and th erefore, higher stresses in the rod. The highe st stresses in th e rod occu r ne ar th e fracture site. With a distal fracture, in addition to the greater moment, the locking holes, significant stress risers, are usually located just distal to the fracture site. It has been shown that the ma ximum stresses a cting in the rod increa se rapidly once the distance between the fra ctu re a nd th e mo st s uper io r o f the dis tal screw hol es is redu ced to less t h an abo ut 4 cm ( 6 7). I n addit io n, pla ci ng th e distal lo ckin g sc rews ca n be dif ficul t bec ause they mus t be inserted freeh and und er fluoro sco pic g uidan ce . It is po ss ible to n ick the corner of th e sc rew hole o f th e ro d w ith t he drill or while driving the screw, creati ng a n addition al stress riser, which can accentua te the fa tigue process. Awareness of th ese po tential proble ms ha s led to de si gn ch anges su ch as closin g the proxi mal sectio n of the rod, i ncreasing mat erial thicknes s arou nd th e screw hol es, an d cold form ing, whic h inc reases the ma terial's strength.
FIGURE 1 -42 M ismat ch o f the curvatur e between the I M rod an d the m edulla ry can al re su lts in bending stresses tha t cou ld cause splitting of the femur during insertion (65).
Sc rew bendin g a nd bre akage can also o ccur. Wh en dista l scr ews a re pla ce d into bo ne with relatively l ow bon e density, the cortices essentia lly support the screw. The distal end of the femur wi dens ra pidly (F ig. 1 -45), so the length o f the screws ca n be qu ite varia ble. F or the sa me dia met er a nd ma terial, th e stiffness and stre ngth of a scre w subjecte d to bendi ng de creases as th e th ird power of i ts length (the dista nce be tw een co rt ices). If one s cre w is tw ice as lon g as t he other, and assumin g
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th at the tr abec ul ar bo ne does no t con tribu te to s uppo rt of th e screw, one can expect th e stif fne ss and strength of the longe r scre w to be eight times less th an the sh orter screw and the deformation to be e ight times greater u nder the sa me load. Th is creates a trade -off in fixation of these fractures with re spect to screw P.2 8 P.2 9 p lacement. If the screws are too close to the fractu re , the stre sses in th e rod incre ase, wh ereas i f th ey a re within th e flair of the metaph ysi s, with poor trabecula r bone, th eir le ngth increases, d ecreasing screw sti ffness a nd strength.
FIGURE 1 -43 The starting position selected for rod entry into the medullary canal affects the degree to which it mu st bend an d, therefore, t he internal forces gen erated in th e femur. A starting posit io n offset from the a xis o f the me dullary cana l, cou pled wit h a stiff ro d a nd a longer pro ximal s egment, which requires th e ro d to ben d mor e du rin g ins ertion, genera te high er insertio n forces and intern al femo ra l forces. In this e xample of a mids ha ft femo ra l fr actur e ( left), th e st arting hole was selected medial relat ive to t he axis of the medulla ry can al ( mid dle ) , and posterior (right) . The me dullary cana l is outlin ed i n da shed lines . Th erefor e, the rod must be nd both medially an d posteriorly a s it is inserted into the ca nal and ha s created internal stresses, which have split the mid-shaft end of the femur (65).
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FIGURE 1 -44 If th e same force a cts on IM rods placed in femora with more proximal (l eft) o r more distal (right) frac tur es, th e mo ment arm o f the force will b e l onge r in the case o f the more distal fracture, and therefore the momen t, acting at th e fracture site, on the implant, will be larger. For the more dista l fracture, th e h igh stress region, cl ose to th e fracture site, is also significantly closer to th e distal locking screw hol es, which are significant stress risers.
FIGURE 1 -45 Because the distal end of the femur flares rapidly, the length of the locking screw requi re d to cross lock the rod can be quite variable. If th e screw is not wel l supported by trabecular bone but ma inly by co rtex, then its stiffness and s trength de crease with the third
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power of its length between cortice s. If th e screw length dou bles, the deformation of the screw un der the same loa d in cre ases by a fac tor of e ight .
Loosening of External Fixator Pins

Lo osen ing of fixat or pins in bone is th ough t to r esult fro m sever al causes. Beca use th e sh ape of the e nd of the pin is self -ta pping, i t can affect th e local heat genera te d in bo ne during insertion , p otentia lly cau sing th ermal necrosis a roun d the pin hole site (6 8), al ong with bon e micr o cra ckin g. In a ddition, high lo cal stresses ca n o cc ur in the pins and bon e if th e hole t hrou gh which t he pin is i nserted is undersized (69). A third mech ani sm (Fig. 1-46) is micromotion , whi ch in duces bone resorption at the pin/bone interface if the pin is a loose fit in the hole. To reduce these problems, sligh t under sizing of the bo ne hole , by approxima te ly 0.1 mm in diameter, has been advo ca ted. If the b one ho le is un dersi zed by 0.3 m m i n dia met er, the yield stre ngth of bo ne may be exceede d wh en th e p in is inserted (69).
Excessively Flexible External Fixation

An ext ern al fixato r is an assembly o f pins att ached to bon e fragm ents, a lon g with clamps and side bars tha t cou ple the p in s. This a ssem bly allows co nsider able varia tion in fra me co nstru ction to a ccommoda te the fracture. Alt ho ugh the optim al stiff ness o f a fixa tor i s no t s pec ifi ca lly kn own , an d th e stif fne ss necessary to s tabili ze the fra ctu re a nd crea te hea ling chan ges as the fractur e co nsol idates , it must be rigid en ough to in itially support th e fo rces applied by th e pa tie nt du ring a mb ulatio n witho ut cau sing ma l-alignme nt of the fractur e. On th e o ther han d, the fixa tor sh oul d not b e so stiff tha t the fractu re is sh ielded from the stre sses required to stimulate h ealin g. Some basic me ch anica l gu idelines in frame con str uctio n will e nsure th at fram es are a deq uatel y con stru cted for th e lo ads they a re subj ec ted to . Fi gure 1 -47 dem on stra te s t hat when the diame te r of a pin o r s idebar i ncreases, its stiffnes s and strength increase to the fourth po wer of the relative chan ge in dia meter (a ctua lly th e ra tio o f the larger to th e small er dia me te r), and as its length (dis ta nce be tw een bon e su rface and sidebar) de creases, stiffness a nd strength in crease to the t hird power of the len gth ch ange. This prin ci ple a lso holds for the pins spann ing th e fr actur e, w hich affect the un supported length of the sidebar across the fracture. In construction of a frame, it is beneficial to decrease the side bar to bo ne dis ta nce, w hich decre ases the un su pported lengths of the pin s to increase the pin d iameter, a nd de crea se the dis tanc e bet ween the pins that spa n th e frac tur e. Increa sin g the nu mb er o f pins applied also increa ses fra me stif fne ss (7 0,71). Usin g a partly threaded pin and burying the pin th read co mp letely wit hin the cortex enha nces the stiffness of the pin, as the smaller diam eter of the root of the pin threa d is not exposed. Th e previous com ments p erta in to unipla ne fixators , which are constructed to resi st the major loads, a xial compression , an d a nterior-posterio r ben ding, a ctin g on a long bon e su ch a s the tibia during w alking, with t he side bar u su ally align ed wi th t he an te rior-post erior plan e. To r esist torsio n and outo f-pla ne (medi al-lateral) bending , the fixa to r can be as sembled wit h addit io nal pins and si debars in o ther plane s. A co mparison of th e rela tive stiffne sses of differe nt fixator assem blies is given in F igure 1 -48. T he unila ter al half p in f rame with sideba rs mounted at righ t angles pro vides overall, th e g re atest resistance to bending, compression , an d torsiona l loads (7 2). Hybrid fixa tion devices h ave a dopted components of both u nilateral ba r fi xators a nd ri ng fixators with wire tra nsfixin g pins. Both a xial compression a nd to rsio na l P.3 0 P.3 1 stiffnesse s have been f ou nd to in cre ase sign ifican tly with in crea se s in t he number and diam e te r of th e transfixing wires, a nd pretension ing th e w ires (73 ). M ore anterior wire placement or adding an a nterome dial half pin h as bee n fou nd to i ncrease a nterio r-po sterio r be nding sti ffness (74 ). Testin g a n umber of different con figuration s (Fig. 1-49 ) showed that the bo x type (two rin gs above a nd tw o b elow the fractur e, alo ng wit h a nterio r half pins, two c o nnecting rods, and a unila teral ba r) was th e stiffest co nfigur atio n, co mpared wit h a unilatera l fram e alon e or a un ilateral fra me wi th rin gs on ly p ro ximal to the fracture site . Adding an an ter ior half pin signi fican tly incr ea se d fixation s tif fness (75).
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FIGURE 1 -46 A pro posed mechan ism for lo osen ing external fi xation pin s invo lves u nder- or o versi zi ng th e dia meter o f t he p in rel ative to the bo ne hole. A. If the pin and bon e h ole ar e the same diameter, micromotion ca n occur w ith bone resorption . B . If the pin is more than 0.3 mm sm aller in diameter th an the ho le in bo ne, microfra ctu re m ay occur during insertio n. C . If the bo ne hol e dia meter is a bou t 0.1 mm sma ller th an the pin di ameter , the bo ne is pres tresse d but do es no t f racture, mic ro motion is elimina ted, an d pin stability is ma intaine d (56 ).
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FIGURE 1 -47 T o produce more rigidity i n co nstructi on of an external fixator, th e ba sic principles that sh ou ld be con side re d are that for pin- a nd-rod-type sidebars; stiffn ess increase s with the fourth power of the cross-sectional area (the momen t of inertia, Fig. 1-7) a nd decreases with th e th ird po wer o f their span o r unsupporte d length (F ig. 1 -4 5). This explain s wh y it i s bene ficial to dec reas e sid ebar to bo ne dis ta nce, i ncrease pin di amet er, pla ce pin s as close together across the fracture site a s possible, and use larger-diameter or mu ltiple sidebars in frame constru cti on (70,7 1).
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FIGURE 1 -48 A comparison of th e be nding, compression , an d torsional stiffnesses of different ext erna l fixatio n co nstr ucts f or mu ltiplane lo ad re sistan ce (72 ).
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FIGURE 1 -49 A comparison of displacement of the proximal fragment in a simulated tibia f ra ctu re u nder 1 00 N loa d with vario us u nila te ra l a nd h ybrid extern al fixa to rs ( the box type uses both a large unila teral frame conn ecting bar a nd two smal ler-dia meter co nnecting rods) (75).
Fixation in Osteoporotic Bone

Be ca use attachment to bone, by a screw for exam ple, is directly related to bon e density, and a d omina nt mech anical characteristic of o steoporotic bone is low den si ty, several strate gies can be u sed when osteoporotic bon e is encou ntered. Th ese a pproache s include cortical buttressing by i mpaction, wide buttressing, which sprea ds the load over a larger surfa ce area, long spl intage, i mpro ved ancho ring, and incr easin g the lo ca l bo ne density by inj ection o f, for example , h ydroxyapatite or meth ylmethacrylate ( Fig. 1-50) (7 6). Impaction ca n be appli ed to fra ctu res of th e d ista l radiu s, fe moral neck, and lumbar ver tebrae. Th e dyn amic P.3 2 h ip screw is an exa mple o f a devic e that a llow s c on tro lled frac ture im pac tion o f the fem o ral n ec k. An a ngled blade plate applie d to supraco ndylar femu r fra ctu res, as co mpared with a co ndyla r scre w, p rovides w ider buttressing; th at is, a larger surface area of contact with bo ne. Th e ra fter plate tha t p ermi ts placemen t of numerous can ce llou s scre ws for tibial pla teau fractu re s is anoth er exa mple of th e applic ation o f this prin ci ple (77 ). Lon g splin tin g wi th a lo nger, mo re flexible plate ha s been a pplied in humeru s fra ctu re s, and the interlo cke d IM ro d is a seco nd exam ple of lo ng splinting. E nha nced ancho ring of pedic le screws usin g au gm entin g lamin ar h ooks is an exam ple of augm en ta tion o f an ch orin g (78). The locking plate, where t he s crews are th readed into t he plate and fi xed so they ca nnot rota te , can be usefu l for sta bilizing osteoporoti c fra ctu re s whe re cortical buttressing i s not p ra ctica l becau se of low bo ne dens ity, an d the fixat io n hardware mus t suppo rt m o re o f the load. H ydroxyapa ti te -co ated e xtern al fixa ti on pins have been sho wn to enha nce th e sc rew-bon e in ter face (7 9). Interlocki ng screws, wh ere a standard screw has a 4 5 hole drilled i nto the sh aft to accept a n i nterlocking pin, can be used to redu ce screw bac kout (8 0).
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FIGURE 1 -50 Some basic strategies to augment fixation strength in osteoporotic bon e inclu ding impaction o f the fr acture co mponents u sing a dev ice tha t allo ws slidin g, buttressing wit h a wide plate, i ncreasing the plat e l engt h, and augm e nting th e bo ne lo ca lly by inj ecti on of methymeth acrylate or a calcium phosphate cement (5 8).
E nha ncem ent of lo cal bon e den sity usin g eithe r pol ymethylmetha cryla te (PMM A) o r mo re rec ently, a bs orbable hydro xyapa tite cement, has been stu died, pa rticu larly in rel ation to fi xation o f femo ral a nd vertebral os teoporotic fractures. P MMA inj ecti on has been widely employed in ve rtebroplasty th rough a transpedicu lar a pproach (81 ) and has been shown to re store stiffness of fractu red v erte bra e to in ta ct levels. Biomechanical studies h ave show n sign ifican tly improved strength of th e fixatio n of f emora l ne ck fra ctu res, up to 170 % (8 2), a nd sim ila r findings , includin g decrea sed sh ortening and greater stability were noted when h ydroxyapa tite cement was applied to unstable th ree-part intertroch anteric fractures fixed with a dynamic hip screw (83). Calcium phos phate ceme nts used in vertebroplasty instead of PMMA also restored the sti ffness of fractured vertebrae to i ntac t leve ls (84 ). Calciu m pho sphate cement inje ctio n into the ped icle (85) h as bee n sh own to i mpro ve th e be nding stiffness of pedicle screws by u p to 125%.
BIOMECHANICAL ASPECTS OF FRACTURE FIXATION IN SPECIFIC LOCATIONS

In the previou s discussion , common problems su ch a s screw pullou t an d pla te break age (common to fracture fixa ti on, mainl y in the lon g bones) we re discussed. In this section, the focus is pla ced o n specif ic cha llengin g pro blems in fixatio n, in cl uding the femoral neck, tibia l pla te au, pelvis , a nd spin e.
Fixation of the Proximal Femur

F ixatio n of pro ximal femo ral fractures is partic ula rl y cha llengin g becau se the compressive force actin g th rough the f emoral hea d can range from four to eight times th e body weight during norma l a ctivitie s (8 6). T his force acts t hro ugh a s ignificant moment arm ( the len gth o f the femo ral neck) , whi ch ca uses la rge ben ding loa ds on the fixat ion h ardware. In addi tio n, many of th ese frac tur es o ccu r in the e lderly w ho are likely to have trabecula r bo ne o f lo w den sity an d po or mechan ica l qu ality (8 7). Also, i t is n ot possible to ga in screw purcha se in the cortical bone o f the fem o ral h ead. Th e ma jor fo rce ac ting in, fo r exa mple, a bas ic er vic al fracture o f the fem o ral neck, f ixed wit h a slidi ng h ip sc rew is the jo int rea ctio n forc e thro ugh the femo ral head, whic h der ives fro m bo dy wei ght a nd force s genera te d by mus cle actio n during amb u lation . The jo int rea cti on forc e can be divided into two compon ents. One (Fig. 1-5 1) is perpendicular to the axis of the sliding screw an d cau ses sheari ng o f the fra ctu re surf aces al ong the fractur e line , whi ch results in i nfe ri or di spla cement a nd varus a ngul ation o f th e fem o ra l head, and incr eases th e resis tan ce o f th e scr ew to sl iding. Th e ot her co mpon ent is parallel to the scre w, driving the surfa ces toge th er, enhancing stability by friction al a nd me ch anical in te rl ocking of the fracture. The aim of femora l n eck fixation systems is to use th e p arallel compo nen t of th e joint force to all ow the su rfaces to slide toge th er. This is the basic pri nciple b ehind selecting a higher- an gle h ip screw when po ssible . The actual s tiff ness pr o vided by the sliding h ip screw, th e reconstruction nail, a nd mu ltiple pi n co nstructs are quite simi lar, except that th e
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re construction na il offers sign ifican tl y greater torsion al stiffn ess tha n th e other forms of fixation , b eca use of its tu bular shape (88,8 9,90 ,91) . W hen u sin g th e co mpressio n (or slidin g) hip screw , or a nail with a sl iding lag screw, it is important to e nsure that the P.3 3 sc rew can slide freely in the ba rrel o f the si de pla te o r the ho le i n the na il. The following comm en ts re lated to sliding hip screws a pply a s well to nail/lag screw constructs. When screw sliding occurs, th e ba rre l supports the screw against inferior bending of the fe moral head becau se the con stru ct is b uttre ssed by f rac tur e interdigitatio n. Adh erence to t wo ba sic mecha nical principles w ill en han ce the sc rew's a bility to slide in t he side pla te or nail. As me ntion ed, the hi gher- angle hip sc re w is more e ffecti ve a t accommo dating sliding. Also, th e screw sh ou ld be enga ged a s deeply as possible within th e ba rre l. For th e same forc e a cting at the femoral end of the screw, the internal force where the screw contacts th e barre l is increased if less of th e screw remains in the barrel. This occurs be ca use th e mo ment (ben ding loa d) c aused by th e f orce tra ns ver se to the axis of the screw (F h in F ig. 1 -52) (at the femoral head) acts over a longer moment arm or perpendicular distance (Le) (force p erpend icula r distanc e to the edg e o f the barrel, w hich is the fulcru m). The balan cing mo ment arm , Lb, is shorter becau se less of the scre w remains in the barrel. Because Fh acts over a longer moment a rm wh ile F e acts ove r a shorter momen t arm, Fb i ncreases. The intern al force, Fb, where t he screw contacts the barrel, causes a greater fri ctional resistance force that requires more force to ove rcome i n order to permit sl iding (9 2). Slidin g hip screws with eith er two- or four-hol e side plates a ppear to p ro vide equiva lent re sistan ce to phys io logi c compress ive load ing (9 3).
FIGURE 1 -51 The joi nt rea ctio n force in the femo ral head can be divided i nto t wo majo r compo nen ts. The comp on ent th at is paralle l to the axis of the fe moral neck produces sliding and impaction of the fra ctu re componen ts and the oth er, transverse to the femora l n eck, causes the screw compone nt of the femoral hip screw to bind and resist sliding. Th e h igher -an gle h ip screw has a screw axi s more c losely aligned with the joint reaction f orce so the f orce co mpon ent that produc es sliding is l arger, while th e tran sve rse force component tha t resists sliding is smaller.
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FIGURE 1 -52 The greater th e len gth of the sliding screw within the barrel is, the lower its resistanc e to sl iding will be . In th is diagra m, F h is the co mp on ent of the jo int re acti on forc e per pen dic ular to t h e a xis o f the screw. Th e in fer io r edge o f the proxim al end of th e ba rrel is th e location of the fulcrum in bending. An internal force, Fb, from the surface of the barrel acts aga inst the screw to co unterac t Fh. For equ ilibrium, th e mo ments pro duc ed by F h (Fh and Fb (Fb Le) Lb) must be equal. If Lb, the distance from the point of application of internal
force Fb to the f ulcrum decre ases, Fb must increase to produce th e sa me moment. If Fb is larger, the friction al force and, therefore, the re sistan ce to screw sliding wi ll increase (128). (L e is the length of th e screw b eyon d the barrel.)
Se ver al fac tors af fec t the strength of fem o ral n ec k f ixation u si ng mu lt iple screws. T h e n um ber o f screws used (three or four) is not a significa nt factor ( 91). Factors th at do i ncrease th e strength of th is type of fixation include a more horizontal fra cture lin e with respect to the lon g axes of the screws (94), placement of the screw s in areas of greater femoral head bone density (90,95), fractures w ith le ss comminu tion (95,9 6), and a shorter mo ment arm for th e j oint load (shorte r d ista nce from the ce nter of the femoral h ead to th e fracture line) (9 5). The most importan t fa ctor has b een found to be th e qu ality of the reduction du e to the importance of cortical buttressing in reducing fracture d isplacement (9 7). U nder phys iol ogical loa d, severa l mecha nism s of fixa tion failure have b een observed (Fig. 1- 53). In some cases, the screws ben d inferiorly, especial ly if bu ttressing of the fracture su rfa ces inferior to th e screws is not possible becau se of fracture comminution . If no w ashers a re u se d to d istribute th e scr ew load aga inst bo ne, th e fixatio n scr ew hea ds ha ve be en found to pull th rough cortex nea r the greater troc han te r, when the cortex is thin. Finall y, if the scre ws are n ot well su pported inferiorly where they cros s the fra ctu re , they may rotate inferiorly carrying th e femo ra l h ead into a varus orienta tion (82). Supporting at least one scre w a gainst the inferior cortex ma y help prevent thi s occurren ce.
Fixation Around the Metaphyseal Region of the Knee

Bo th su pracon dylar f emur and tibial plat ea u fractur es a re cha llengin g to stabiliz e becau se they may i nvol ve fixatio n of mult iple sm all fragme nts o f prim arily ca ncello us bo ne. Supracondylar fixatio n
Page 53 of 69
a lternatives have been mech anicall y compa red, in clu ding condyl ar pla te s, plates with lag sc rews a cross the fra ctu re site, a nd blade plates. All devices tested appea re d to provi de similar con struct stiffn esse s. The mos t importa nt factor identified was ma intain ing co ntact at the cortex opposite that o n whic h the fixa tion devic e was applied. Fixa tio n constr uct s wi th out cortical c ontact were o nly abo ut 2 0% as stiff as th ose with cortical bu ttressing (98). Th e retrograde IM su pracon dylar n ail was found to 1 4% les s stif f in a xial c ompress ion an d 17% less stiff in to rsion, compared with a fixed-an gle side p late (9 9). Several ne wer fixation systems have been descri bed for femo ral su pracon dylar fracture stabi lization . On e sys tem co nsists of a bla de pla te with P.3 4 a screw th readed throu gh th e plate to trian gulate it (Fig. 1-54 ). This h as be en found to be sign ifica ntly st if fer th an c onventio nal c onstr uct s (10 0). The L ISS uses a l ow-prof ile plate with monocortical screws dista lly, w hich also lock to th e pl ate. LISS pla te s ha ve more ela sti c deformation a nd less subsiden ce than a con dylar screw or buttress plate (101 ).
FIGURE 1 -53 A. S ome factors that decrease th e strength of femoral n eck fracture fixation include decrease d bone density, a mo re vertical fra ctu re s urface th at facilitates sliding of the fra ctu re co mponents, comminution at the inferior cortex that reduces buttressi ng a gainst bending, a nd a longer moment arm or dista nce of the center of the fe moral head to the fracture lin e. B. Obs erved me ch anisms of failure of femo ral n eck fixat io n u sing screws include bend i ng of th e pi ns, displacement of the screw heads throu gh th e th in cortex of the greater troch anter, especially if wash ers are not used, an d rota tion of th e screws in feriorly through the low-density can cel lous bon e o f the Ward's tria ngle area un til t hey s ettle a gainst th e in ferior co rtex (95 ).
Tibia l pla teau fra ctu re s are challe nging to fix fo r the same reason s tha t make supraco ndylar fractur es d iff ic ult. D iff er ent fixa tion met ho ds inclu de screws a lon e o r s crews pla ced thro ugh an L- o r T -shaped p late th at bu ttresses th e co rtex. Fixation with T-plates an d screws h as been found to provide the
Page 54 of 69
g re atest resistance to an axial compressive loa d (102). As Figure 1-55 shows, fixation with screws a lone requ ires tha t the screw resist ben ding forces, as the t ibial fra gment is loaded dista lly in compression through the joint. With the addition of a plate, not only is the load distributed to the p late, but additional sc rews can be placed in th e stron ger cortica l bo ne dista l to the metaphysis of th e tibia . The disadvan tage of addi ng a bu ttressing plate is the greater invasiven ess that it requires fo r installa tion. An alterna tive to t ibial fra ctu re f ixatio n wi th s crews is multiple Kirschner wires , wh ich i n e ssen ce form a ra ft u nder the fragmen t. Variou s c on figu ration s ha ve bee n tes ted (103 ) an d sho w th at the con stru ct's stiffn ess is most increased by adding more wires, regardl ess of their specific o rienta ti ons. Th e fractured p atella is cha llengin g to st abilize bec au se o f P.3 5 th e la rge ten sil e a nd be nding forces gener ated by contra ctin g the qua dri ce ps muscles (104). Th e ten sile force causes sign ifica nt ben ding in th e pa tella with th e kn ee flexe d, whi ch tends to open the a nterior surfa ce of the fracture. A varie ty of screw, wire, or comb ination screw and wire fixati on co nstructs have been de velope d. Screw fixation ca n generate greater com pression across th e fracture sit e, but w ir e can wit h stan d h igher te ns ile fo rces bec ause it do es n ot de pend upo n th e pu rch as e o f th reads in the can cel lous bon e o f the patella fo r f ixatio n as do screws ( 10 5).
FIGURE 1 -54 T he tria ngula ted bla de pla te is a simple con stru ct that has been s hown t o significantly improve the stiffness of supracon dylar fractures (100).
Fixation of Pelvic Fractures

Th e pel vis can be co nsidered, in genera l term s, as the str uctur a l ba se o f th e spin al co lumn , with a flexible an terior join t, the s ymphysis pu bis, an d two sem irigid posterior hin ges, the sacroiliac joints , w hich ar e su bjec ted to la rge ben ding loa ds. The majo r externa l loads include the weight of the torso
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a cti ng th rough the sacrum, th e a bductor and gluteus muscle forces, a nd th e j oint reactions acting th rough the acetabu li. Because th ese force vectors do not align, both anterior-pos terior and mediall ater al bendin g loads a ct on the pelvis alo ng w ith c o mpre ssio n t hrou gh th e sacr um and tens ile str esses a ro un d the pelvic ring th at ten d to ope n th e symp hysis. Whe n th e sacro iliac ( SI ) jo int is no t co mpletely disru pted, anterior plating of th e symphysis pubis a lone pro vides stability sim ilar to a nterio r platin g combi ned with po sterior fixatio n using as a n SI plate or iliac sc rews (1 06,107). With co mp lete disru pti on of th e SI j oin t or with frac tur e thr ou gh th e sa cru m, using a s ingle-legged stanc e mo del, the u se o f two anter io r pla te s c ombin ed wi th a single SI screw w as mo st eff ec tive at redu cin g SI join t gappi ng, ro tation , and pu bis symphysis ga pping. This con stru ct was fol lowed in order of i ncreased joint motions by two SI screws, two anterior SI plates, a nd variou s combinations of p osterior tension ba nd pl ates, sacral bars, and iliosacral s crew s (108 ,10 9). Another co nstruct tha t mi ght be considere d for sa cra l fractures is a triangulated combi nation of a sacroiliac screw, a screw p laced in to th e iliac wi ng, a nd a ver tic al bar attached to th e iliac sc rew with fixatio n into L5. This setup resists the vertical compression component of the loads applied throu gh th e spine in to th e sacrum (110).
Fixation of the Spine

Th e h alo appa ratus is an externa l fixatio n de vice for ce rvica l spine in juries with spec if ic mecha nical ch aracteristics that P.3 6 a llow it to s tabil ize the inj ured ce rv ica l spin e against be nding, but n ot co mpressive loads. T h ese featu re s inclu de the fit of th e jacket o n t he to rs o and the friction al ch arac teristics of the lin ing (Fig. 1 -56). High- friction lin ings decre ase slip at th e vest linin g/torso in terface, more rigid ve sts re duce d eflectio n u nder loa ds, and less-flexibl e super str uctur es all decre ase cervic al s pine motio n at the i nju ry level. Alt hough stif fe ning t he vest enh ances its abili ty t o stabiliz e the i njury, this pro perty must be balanced with enough flexibility to provide reasonable comfort for the wearer and to a cco mm oda te ches t expansio n and con tra ctio n. Th e in jured cervic al se gme nt is relatively dis tant fro m th e ve st, so small moti ons of the vest can result in relatively large displacements at th e injury site (1 11). A very ri gid halo superstructure a tta ching the vest to the halo ring may not in crease injury stability if it is con nected to a po orly fitting vest.
FIGURE 1 -55 T wo alternative methods of fi xation of tibial plateau fractures. Transverse screws combined w ith a buttress pla te (A), and transverse screws alon e ( B). The buttress plate provi des addit io na l suppo rt in bend i ng a s the tibial fractur e compo nen t is lo aded in an inf erio r direction a nd a llow s the screws to engage the thicker, mo re di sta l cortical bone.
A nu mber of m ethods are availa ble to rec o nstruct cervical spi ne inju ri es. The m ajor differen ces b etw een these approa ch es rela te to the loca tion of the f ixation (eithe r an te ri or, lateral, or poste rior) a nd to th e meth od by wh ich th e fixatio n is att ached to bon e. Gene ra lly, th e mo st rigid f ixat io n is the one with the lon gest mome nt a rm from the center of rota tion of th e i njured segment. For a specific a pplied momen t (e.g., flexion ), posterior fixation , bein g located further from the center of rota tion , re su lts in greater rigidity. Fi gure 1 -57 shows the approximate locations of the ce nters of rotation a t d ifferent cervic a l spine level s when the po sterio r el ements h ave been disrupted (1 12). A fter co rpectomy, testing has shown th at pos terior rods provide th e greate st sta bility, wh ich i s un ch anged
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a fter augmentation with an anterior plate, w hereas anterior plati ng a lon e offers the lea st sta bility (1 13). Si mi larly, a noth er test showed that after corpectomy, sagittal plane motion was mos t rigid a fter su pplemen ta tion with later al mass pla tes , was less rigid with an anterio r pla te alo ne, an d P.3 7 l east rigid with strut grafting a lon e (114). An terior plates provi de rela tively simila r stability, e spe ci ally if augm en ted with a bon e gra ft; howeve r, with multilevel corpect o my , an te rio r pla te constructs were more prone to fatigue loosenin g than single level corpectomies (1 15). Some of the n ewer se miconstrain ed a nterior plates a llow s crew rotation that results in more load sharing with the g ra ft. By compari son, th e compressive load estimated to be tra nsmitted through the graft increased from abo ut 40% wit h a ful ly con stra ined device to a bou t 80% w hen a se mico nstr ain ed devi ce was u sed (116). W iring or plating with lateral mass screws ge nerally reduces anterior-po ste rior motion a cross the fixed segm en t by 20% to 70%, so n one o f th e tech niques can be co nsidered as en tirely rigid (117).
FIGURE 1 -56 A sc hema ti c diagram sho wing possible sourc es of def ormatio n in th e h alo appa ratus. The large distance from the vest-to- ch est con tact points to the cervical injury site results i n rela tively large mot ion s at the injury s ite for small motions of th e ve st (111 ).
Page 57 of 69
FIGURE 1 -57 T he ra tios, i n terms of anterior-posterior vertebra diameter of the loca ti on of the center of rota tion at each vertebral level, from the anterior and posterior su rfaces. A fixation device must resist be nding momen ts caused by flexion, e xte nsion , lateral ben ding, and torsion . The resisting moment in the fixation is the product of the force acting in the fixation (e.g., at the scre w-plate j unction ) an d the distance of th at point on the fixati on to the ce nter of rotation of th e motion segment. The lon ger the mome nt arm for the same bending load is, the smaller the force o n th e fixatio n co mponents w ill be. Poste ri or fixatio n, by its lo catio n, wil l have l ower mome nts in its compone nts (112).
Th e type of atta ch ment of the fi xation system to the vertebra is funda mental to its performance. Wires, hooks, screws, or combinations of these three items all produce different types of force tra nsfer between the fixation an d the vertebra (Fig. 1 -58) (118). A wire can resist on ly tensi on, w hereas a screw can resist forces in all direction s (tension , compression, be nding transverse to the a xis of the screw), e xce pt for rotation a bout its longitudinal a xis. A hook only resists force s that drive i ts surfa ce aga inst bo ne and dep en ds als o o n i ts shape and the bon e surface it rests aga inst. F or th is re ason, scre ws are biome ch anically superior to other forms of vertebral attachme nts. In gene ral, pedi cle screws resist pullou t in the same ma nne r as bone screws described elsewhere; th erefore, pu llou t stre ngth increases w ith incre ased de nsity of the bone it is embedded into (4 5,46 ,47,48,11 9,120), a greater insertion depth (1 21), engageme nt of the anterior cortex (1 22 ), a nd a larger screw diam eter. Sin gle screws plac ed i nto pedic les a nd l oade d in a cauda l-ceph alad d ire ctio n, whic h occurs du ring flexio n and ext ensio n of the ver tebra, are vulnera ble to to ggling and e vent ua l loosen ing, e ven under relatively small force s. As s ho wn in Figure 1-5 9, th e screw ten ds to toggle about the base of the pedicle, which is the stiffest region and is mainly composed of cortical b one. Togglin g ten ds to open the sc rew h ole in a win dshield wiper v er te bra o ver a wide area (12 4). C onsider some funda mental principles when applyin g lu mbar spin al fixatio n. Longe r fi xation , attac h ed fashio n (1 23,124). To gglin g ca n be reduced if the scre w h ead is locke d to the plate or rod and if the plate or rod contacts the
Page 58 of 69
to a grea te r nu mb er o f ver te brae r e duc es forces a ctin g o n the screws, be ca us e o f the eff ec t o f the g re ater leve r arm of a lo nger p late o r ro d. A longe r fusion, alth ough b io mechan ically advan ta geou s, P.3 8 i s no t ne ce ssarily ben eficial from a clin ica l pe rspec tive. Adding an anter io r s trut gra ft o r a fus ion cage i s importan t, as it buttresses a posterior fixation system against flexion moments, reducing forces in th e fixation (125,126 ). Coupler bars, which connect th e fixation rods to form a n H con figuration , p re vent th e rods from rotating m edial and lateral when torsion is applied to th e mot ion segment (Fig. 1 -60). Th is con stru ct sig nifica ntly enha nces the im pla nt's torsio nal and later a l ben ding sta bilit y.
FIGURE 1 -58 Comparison s of th e forces that can be resiste d by different method s of attachme nt of the fixation to the verte bra . A su blaminar wire resists on ly tensi on, wherea s a screw can resist forces in a ll di re ctions e xce pt for rotation a bout its long a xis. A h ook resists o nly forces that dri ve it ag ain st the bon e surf aces.
Page 59 of 69
FIGURE 1 -59 A. The mechanism of toggling of a single pedicle screw subjected to a cau docephalad loadi ng. B . T he fu lcru m is at the base of th e pedicle , the narrowest region with little ca ncellous bone. The screw toggle compresses bone within the vertebral body. C. To ggling is red uced if the plate o r rod to which the screw connects co ntacts the vertebra over a w ide surface, wh ich prev ents it from rotatin g wh ile th e screw head is locked to th e plate o r rod (124).
E xtensive testing has been pe rformed on a va rie ty o f posterior and anterior th oracolumbar fixation d evices as they continu e to be developed. Testin g anterior fixation systems with and without a n a ugmente d strut graft showed that loa d sharing with the graft ranged from 63% to 89% for six sys tems tested three were pl ates a nd th re e were based on lo cked ro ds. These tests demonstrated th e sign ifican t effect of the graf t in sagit tal plane s tability of the f ixation . The m ost rig id syst ems , n ot si gnifica ntly different in pe rformance, relie d on either a thi ck rigid pl ate or large rods (127 ). In ca se s of de layed or non unio n, the cyclic per form ance of the impla nt can be ver y i mp ortant, more so
Page 60 of 69
th an its static stiffness or ma ximum loa d to fa ilure. A comparison test of 12 fixa tion systems showed th at o nly t hree co uld withstan d 2 millio n loa d cycles with 6 00 N of compress ive force. The two fixat io ns wit h grea test bendin g strength also did no t fail after cycli ng; ho wever, there was n o co rr elatio n be tw een bend in g strength and cyclic f ailure for the o ther 1 0 s ystem s, indicating that p art icular desi gn aspec ts co uld cause fatigue fai lure, rega rdless of static stren gth (12 8). Th re e d evices failed in less than 10,000 cycl es. Currently, most posterior devices use e ssenti ally th e same p rinciples: pedicle screw s, an adjustable screw to rod or plate interface to enhance fixation assembly, i nterconn ecting rods, (or less fre quently, plates), a low-profile assembly, and crosslinks. Th ese compon ents provide similar fixation stiffne ss. Lumbosa cral fixation u si ng sacral screws was most rigi d, demonstra ted the least screw strain when supplemented with iliac screws, a nd was more e ffecti ve tha n using screws at S1 supple mented wit h screws at S2 (12 9). Th e bio mec han ical propert ies o f fusion cages have been in ves tiga ted. A fusio n c age i s a ho llow th readed insert that can be applied from anterior, lateral, or posterior directions in single or doubl e u nits. A wide variety of fu sion c ages are availa ble for the ce rvi ca l spin e. The devic es fall into o ne of th ree categories: screw de signs with a horizontal cylind er an d external threads, box shapes, an d v ertica l cylin ders. In gen eral, all ca ge de sign s in crea se d flexio n stif fne ss by 1 30% to 1 80% . Onl y a few box or cylinder designs incre ased e xte nsion stiffness, a nd box designs w ere most effective in i ncreasing axia l rota ti on an d later a l ben ding stiffnesses, r angin g fr om 14 0% to 180% of inta ct value s (1 26). Te stin g lumba r fusion cage s has show n th at pla ci ng fusio n ca ges in latera l, po ster o lateral, or p osterior orienta tion s had little effect on stiffn ess, except for th e e ffect of posterior placement in to rs iona l lo adin g, as insertion da maged th e la mina or face ts, reducing the motio n segmen t's inh erent to rs ional stabili ty. Fixa tion with cages alone di d not signi fican tl y increa se lu mba r mo ti on s egm ent stabi lity, so augme ntation wi th po ste rio r fixatio n in ca se s of mo tion s egmen t instabil ity is n eces sa ry. Be ca use ca ge fixat io n re lies o n th e co mb inatio n of so ft tissue dis tr action an d the stre ngth of the v er te bral can cellou s bo ne, th e pro per ties o f these tis sues will have a signific ant eff ec t o n th e p erforma nce of cage implan ts (130).
FIGURE 1 -60 With out a coupler bar between two lon gitudina l rods ( left), th ey can ro tate wh en a later al mo me nt or a xial to rs ion is a pplied (rig ht) . A coupler connecting the rods to form an H con figuration reduces this effect.
P.3 9
SUMMARY
E ffec tive fracture fixa tio n r equires a bi omecha nical appr eciatio n of the for ces appl ied to a dama ged b one o r joint and th e ba sic mecha nisms by whic h these load s are tra nsferred thr ou gh th e bridgi ng fixat io n and at th e impla nt- bon e inte rface. In particula r, the importan ce of the co ntr ibut io n of c o rtex-
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to-cortex contact a cross the fracture site in resisting both compressive and bending forces mu st be e mphasized. Th is buttress contributes significantly to the construct's stability and the implan t's fun ctio na l life. Ma ny of the observa tio ns used to f ormul ate th ese basic principles h ave been made u sing ca daveric bo ne in experimen ta l sim u lation s. It is impo rtant to co rrelate th ese findin gs to clin ical observatio ns of the mechan ics of fixatio n during fracture hea ling.
REFERENCES
1. Bla ck J, Orthopedic Bi omaterials in Resea rch and Practise . Ch urchill Livingst one: New York, 198 8.
2. C art er D R, Hayes W C. Th e co mpressi ve beh avio r o f bone as a tw o-phase poro us str uctur e. J Bone J t Surg 19 77:59 A:954 9 62 .
3. Bu rstein AH, Zika IM, H eiple KG, Klein L. Cont ribution of colla gen and mineral to t he elast icplastic prope rtie s of bo ne. J Bone Jt Surg 1 975 ;57A:95 6 96 1.
4. Curr ey JD . The mecha nical consequ ences o f var ia ti on in the mineral con te nt of bon e. J Biomech 19 69 ;2 :1 1 1.
5. Ascenzi A, Bonucci E. The compressive properties of singl e osteons. An at R ec 196 8;16 1:37 7 392 .
6. Ascenzi A, Bonucci E. The shearing p roperties of single osteons. Ana t Rec 197 2;17 2:49 9 510 .
7. Ascenzi A, Bonucci E. The tensile prope rties of single osteon s. Anat Rec 1 96 7; 15 8: 375 3 86 .
8. Ascenzi A, Bonucci E, Simkin A. An a pproach to the mechani ca l properties of si ngle osteon ic lamella e. J Biomech 19 73;6:2 27 23 5.
9. E vans FG. R elatio ns betwe en th e micro sco pic s tr uctur e and te nsile str en gth o f huma n bone . Acta A nat 19 58;3 5:285 3 01 .
10. Evan s FG, Bang S. Differences and r elatio nships bet ween the physical properties and t he str uctur e of h uman femora l, tibial, and fi bular co rt ical bone . Am J An at 1 96 7;12 0:79 88 .
11. Evan s FG, Vinc entell i R. Rela ti on of co llagen fiber o rientatio n t o som e me ch ani ca l pro perti es of hu man cortical b on e. J Biomech 196 9;2:6 3 71.
12. Bartley MH Jr, Arno ld JS, Ha sl am R K, et al. Th e rela tions h ip o f bon e strength an d bo ne quan tity in hea lth , disea se , an d agin g. J Gero ntol 19 96 ;21:51 7 52 1.
13. Bell GH, Dunbar O, Beck JS, Gibb A. Va riation s in strength of vertebra e with age and the ir re l at ion t o o st eo por o sis . Ca lcif Ti ssue Re s 19 67 ;1 :7 5 86 .
14. Co dy D D, Goldstein SA , Flynn MJ, Brown E B. Co rr elatio ns betwe en ver te bral regio na l bo ne mineral density (rBM D) an d wh ole bon e frac tur e load. Spine 19 91;1 6:14 6 154 .
15. Galante J, Rostoker W, Ray RD. Physical properties of trabecular bone. C alcif T issue R es 197 0;5:23 6 24 6.

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Ovid: Rockwood & Green's Fractures in Adults

Edi tors : Tit le:

Buchol z, Robe rt W.; Heckm an, J ames D.; Court-Brown , Charl es M.

C opyright 2006 Lippincott Willia ms & Wilki ns

Chapter 1 Biomechanics of Fixation and Fractures

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

TABLE 1-1 Basic Engineering Properties of Common Engineering Materials

Ovid: Rockwood & Green's Fractures in Adults

Acrylic bone cem ent

Titani um ( pure, cold wo rked)

Titani um ( Al-4V) ( allo y F 1 36 )

Stain less steel (31 6 L) (ann ealed)

Stain less steel (cold worked)

Co balt chrome (cast)

Co balt chrome (wrou ght, an neal ed)

Co balt chrome (wrou ght, cold wor k)

Ovid: Rockwood & Green's Fractures in Adults

Super allo ys (Co NiM o)

Ovid: Rockwood & Green's Fractures in Adults

4 is farther away from the central axis when the load is

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

BIOMECHANICS OF INTACT AND HEALING BONE

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults

BIOMECHANICS OF BONE FRACTURE

Cu r ry 19 84 , Princeton University Pre ss Y am ada 1 970 , W illiams a nd W ilkins, Ba ltimore

Ovid: Rockwood & Green's Fractures in Adults

Gala nte C alcif Tis sue Res 19 70 ;5:236

Loa ding Di rectio n and Typ e

Axial compressive impact

Nah um Acciden ta l I nju r y 1 993 , Springer -Ver lag

Nah um Acciden ta l I nju r y 1 993 , Springer -Ver lag

Lat eral ben ding

Nah um Acciden ta l I nju r y 1 993 , Springer -Ver lag

Axial compressive impact

Sac roi liac Join t

Axial compressive impact

F as ola 1 955 ; W rig ht Patterson AFB

Lat eral to medial at trochanter

Smith J Bone Jt Surg 19 53 ;3 5A: 36 7

Ovid: Rockwood & Green's Fractures in Adults

Vert ical impac t at femo ral he ad

Alho C lin Orthop 19 88 ;2 27 :2 92 Leic he r Clin Orthop 19 82 ;1 63 :2 72 Stanke witz J Orthop R es 19 96 ;1 4: 78 6

fro m i mpa ct at knee alo ng axis

Pa tri ck 9th S TAPP car cra sh co nf 19 66 :237 Vian o J B io me ch 19 80 ;1 3: 70 1

Three poin t bending, po st er io r

Mather J Biomech 19 68 ;1:331

Impact perpendicular to anterior

Pa tri ck 9th S TAPP car cra sh co nf 19 66 :237

Impact perpendicular to sole

Ovid: Rockwood & Green's Fractures in Adults

Ovid: Rockwood & Green's Fractures in Adults