STAGES OF FRACTURE

HEALING AND
FACTORS AFFECTING
FRACTURE HEALING
BY DR. PANKAJ KUMAR
PG-III
ORTHOPAEDICS,CIO
 FRACTURE
• Fracture is defined as a break in the continuity of bone
• Fracture results in loss of its mechanical stability and also partial destruction
of blood supply
• Healing means to make whole or sound again, to cure, leaving a scar behind.
But following fracture a scar is not formed, instead a bone has formed a new
at the original fracture site. So rather than bone healing the appropriate
nomenclature would be BONE REGENERATION
•
 TYPES OF FRACTURE
• ON BASIS OF ETIOLOGY
• - Traumatic fracture
• - pathologic fractures due to some
• diseases
• - stress fracture
• ON BASIS OF DISPLACEMENT
• - undisplaced
• - displaced
• translation ( shift )
• angulation ( tilt )
• rotation ( twist )
• ON BASIS OF RELATIONSHIP WITH EXTERNAL ENVIRONMENT
• - simple / closed fracture
• - open fracture
• ON BASIS OF PATTERN
• - transverse
• - oblique
• - spiral
• - comminuted
• - segmental
HEALING AFTER FRACTURE FIXATION

• 1. DIRECT/PRIMARY:
• Mechanism of bone healing seen when there is no motion at the fracture
site (i.e. rigid internal fixation).
• Does not involve formation of fracture callus.
• Osteoblasts originate from endothelial and perivascular cells.
2. INDIRECT/SECONDARY:
• Mechanism for healing in fractures that are not rigidly fixed.
• Bridging periosteal (soft) callus and medullary (hard) callus re-establish
structural continuity.
• Callus subsequently undergoes endochondral ossification
 TYPES OF BONE HEALING

1. PRIMARY
• CONTACT HEALING: When there is direct contact between the cortical
bone ends, lamellar bone forms directly across the fracture line , parallel
to long axis of the bone, by direct extension of osteons.
• GAP HEALING: Osteoblasts differentiate and start depositing osteoids on
the exposed surfaces of fragment ends, mostly without a preceding
osteoclastic resorption which is later converted into the lamellar bone
• 2. SECONDARY:
• It is usual type consisting of formation of callus either of cartilaginous or
fibrous. This callus is later replaced by lamellar bone.
• It is comparable to healing of soft tissue by filling of gaps with vascular
granulation tissue
 STAGES OF FRACTURE HEALING
There are 3 major phases with sub divisions:
A. Reactive Phase:
• i. Fracture and inflammatory phase.
• ii. Stage of hematoma formation.
• iii. Granulation tissue formation.
B. Reparative Phase:
• iv. Cartilage Callus formation.
• v. Lamellar bone deposition.
• C. Remodeling Phase:
• vi. Remodeling to original bone contour
 Components of Bone Formation

• Cortex
• Periosteum
• Bone marrow
• Soft tissue
A. REACTIVE PHASE

• I .Fracture & inflammatory phase :

After fracture the first change seen by
light and electron microscopy is the
presence of blood cells within the tissues
which are adjacent to the injury site. Soon after fracture, the blood vessels
constrict, stopping any further bleeding
ii. Stage of Hematoma formation:

• Within a few hours after fracture, the extravascular blood cells form a blood
clot, known as a hematoma. All of the cells within the blood clot degenerate
and die.
• The fracture hematoma immobilizes & splints the fracture.
• The fracture haematoma provides a fibrin scaffold that facilitates migration
of repair cells
iii. Granulation Tissue Formation:

• Within this same area, the fibroblasts survive and replicate. They form a
loose aggregate of cells, interspersed with small blood vessels, known as
granulation tissue which grows forward, outside and inside the bone to
bridge the fracture.
• They are stimulated by vasoactive mediators like serotonin and histamine
B. REPARATIVE PHASE

• iv. Cartilage Callus formation :

• Days after the # the periosteal cells proximal to the fracture gap and
fibroblasts develop into chondroblasts which form hyaline cartilage.
• The periosteal cells distal to the fracture gap develop into osteoblasts which
form woven bone. These 2 tissues unite with their counterparts and
culminate into new mass of heterogenous tissue called Fracture Callus
restoring some of its original strength.
v. Lamellar bone deposition:

• Or consolidation ..where hyaline cartilage and woven bone is replaced by

lamellar bone. This process is called Endochondral ossification.
• At this point, the mineralized matrix is penetrated by channels, each
containing a microvessel and numerous osteoblasts.
• This new lamellar bone is in the form of trabecular bone which restores
bone’s original strength
C. REMODELLING PHASE

vi. Remodelling to original bone contour:

• The remodeling process substitutes the trabecular bone with compact bone.
The trabecular bone is first resorbed by osteoclasts, creating a shallow
resorption pit known as a "Howship's lacuna".
• Then osteoblasts deposit compact bone within the resorption pit.
• Eventually, the fracture callus is remodelled
 FACTORS INFLUENCING BONE
HEALING

• LOCAL FACTORS
• CHEMICAL FACTORS.
• VASCULAR FACTORS.
• SYSTEMIC FACTORS
• ELECTROMAGNETIC FACTORS
• TREATMENT FACTORS
 1.LOCAL FACTORS

• A. Type of bone:
• Cancellous (spongy) bone or cortical bone.
• B. Degree of Trauma:
• Extensive soft tissue injury and comminuted #‘s V/s Mild contusions
• C. Vascular Injury:
• Inadequate blood supply impairs healing. Especially vulnerable areas are the
femoral head, talus, and scaphoid bones.
• D. Degree of Immobilization:
• Immobilized for vascular ingrowth and bone healing to occur. Repeated disruptions
of repair tissue, especially to areas with marginal blood supply or heavy soft tissue
damage, will impair healing.
• E. Type of Fractures:
• Intraarticular fractures communicate with synovial fluid, which contains
collagenases that retard bone healing
Open fractures result in infections
Segmental fractures have disrupted blood supply.
• F. Soft Tissue Interposition:
• G. others: Bone death caused by radiation, thermal or chemical burns or infection.
2.GROWTH FACTORS:
A. Transforming growth factor(TGF):
• Superfamily of growth factors (~34 members)
• Act on serine/threonine kinase cell wall receptors
• Promotes proliferation and differentiation of osteoblasts, osteoclasts and chondrocytes
• Stimulates both endochondral and intramembranous bone formation and collagen type 2
synthesis.
B. Fibroblast growth factors(FGF):
• Both acidic (FGF-1) and basic (FGF-2) forms
• Increase proliferation of chondrocytes and osteoblasts
• Enhance callus formation & stimulates angiogenesis.
C. Platelet derived growth factor(PDGF):
• A dimer, genes PDGF-A and PDGF-B
• Stimulates bone cell growth
• Increases type I collagen synthesis by increasing the number of osteoblasts.
• PDGF-B stimulates bone resorption.
D. Insulin like growth factor(ILGF):
• Two types, IGF1 &IGF2, out of which IGF1 is produced in liver and stimulated by growth
hormone.
• Stimulates bone collagen & matrix synthesis and replicates osteoblasts . It also inhibits
collagen degradation.
E. Bone Morphogenic Proteins (BMP):
• BMP was discovered by Marshall Urist in 1965. They are Osteoinductive proteins
initially isolated from demineralized bone matrix
FUNCTIONS: 1. Induce cell differentiation : BMP 3(osteogenin).
2. Promote endochondral ossification: BMP 2 & 7.
3. Regulate extracellular matrix production :BMP1.
4.Increase fusion rates in Spinal fusions): BMP 2
5.Non unions: BMP 7 as good as bone grafting
• These are included in the TGF-β family except BMP 1. Must be applied locally
because of rapid systemic clearance .
3. PERMEABILITY FACTORS:
Protease – Plasmin , Kalikrein, Globulin permeability factor.
Polypeptides –leucotaxime, Bradykinin, Kallidin
Amines – Adrenalin, nor-adrenalin, Histamine
These factors work in ways that :
Increase capillary permeability
Alteration in diffusion mechanism in intracellular matrix
Cellular migration
Proliferation & differentiation
New blood vessel formation
Matrix synthesis
Growth & development
3. VASCULAR FACTORS
• Metalloproteinases
• Degrade cartilage and bones to allow invasion of vessels
• Angiogenic factors:
• Vascular-endothelial growth factors mediate neo-angiogenesis & endothelial-
cell specific mitogens
• C. Angiopoietin (І & ІІ)
• Regulate formation of larger vessels and branches.
•
4.SYSTEMIC FACTORS
A. Age:
Young patients heal rapidly and have a remarkable ability to remodel V/S old .
B. Nutrition:
• An adequate metabolic stage with sufficient carbohydrates and protein is necessary.
C. Systemic Diseases:
• And those causing an immunocompromised state will likely delay healing. Illnesses
like Marfan’s syndrome and Ehlers-Danlos syndrome cause abnormal
musculoskeletal healing
•
D.HORMONES:
• Estrogen
Stimulates fracture healing through receptor mediated mechanism.
• Thyroid hormones
Thyroxine and triiodothyronine stimulate osteoclastic bone resorption.
• Glucocorticoids
Inhibit calcium absorption from the gut causing increased PTH and therefore
increased osteoclastic bone resorption.
• Parathyroid Hormone
• Growth Hormone: Mediated through IGF-1 (Somatomedin-C)
Increases callus formation and fracture strength
5.ELECTROMAGNETIC FACTORS

• In vitro bone deformation produces piezoelectric currents and streaming

potentials.
• Electromagnetic (EM) devices are based on Wolff ’s Law that bone responds
to mechanical stress: Exogenous EM fields may simulate mechanical loading
and stimulate bone growth and repair
•
6. TREATMENT FACTORS :
• APPOSITION OF FRACTURE FRAGMENTS.
• LOADING AND MICROMOTION .
• FRACTURE STABILIZATION.
• RIGID FIXATION.
• BONE GRAFTING
 RECENT ADVANCES

• GROWTH FACTOR THERAPY(3)

Due to their ability to stimulate proliferation and differentiation of
mesenchymal and osteoprogenitor cells they have shown great promise for their ability to
promote fracture repair .
• APPLICATION OF PLATELET RICH PLASMA(4)
Injecting platelet rich plasma at fracture site helps in fracture healing .
• TISSUE ENGINEERING, STEM CELLS AND GENE THERAPIES(5)
In past decade tissue culture and stem cells have been implicated in enhancing
fracture healing and articular cartilage regeneration.
 Nanotechnology
Based on understanding cell-implant interactions. Cells do not interact directly
with an implant but instead interact through a layer of proteins that absorb
almost instantaneously to the implant after insertion. Scientists have improved
numerous implant materials, including titanium and titanium alloys, porous
polymers, bone cements and hydroxyapatite, by placing nanoscale features on
their surfaces. The bulk materials' properties remain unchanged, maintaining
their desirable mechanical properties, but the surface changes enhance the
interactions with proteins. This causes bone-forming cells to adhere to the
implant and activates them to grow more bone.
 COMPLICATIONS OF FRACTURE
HEALING

• MALUNION
• DELAYED UNION
• NONUNION
PRINCIPLES OF
DCP,LCP,ILN
 HISTORY OF OSTEOSYNTHESIS
• • The term osteosynthesis was coined by Albin Lambotte a Belgian surgeon
regarded universally as the father of the modern internal and external
fixation. He devised an external fixator and numerous different plates and
screws.
• Robert Danis as surgeon in Brussel published two books on osteosynthesis
in 1932 and 1949.
A young swiss surgeon E. muller read his second book and he drew around
himself a group of interested swiss surgeons and in 1958, at an historical
weekend meeting in chur they decided to form a study group concerning issue
of internal fixation of bone- the Arbeitgemeinschaft fur Osteosynthesefragen,
or AO.
 Principles of AO :
• 1. Anatomical Reduction.
• 2. Stable internal fixation.
• 3. Preservation of Blood supply
• 4. Early active pain free mobilisation.
 BIOMECHANICAL ASPECTS OF
THE AO TECHNIQUE
• • Neutralization Plate or Protection Plate
• • Compression Plating
• • Lag screw
• • Tension Band Principle
• • Intra Medullary Nailing
• • External Fixation.
 PLATES
• Introduction :
• Bone plates are like internal splints holding together the fractured ends of a bone.
• A bone plate has two mechanical functions.

• It transmits forces from one end of a bone to the other, bypassing and thus

protecting the area of fractures.

• It also holds the fracture ends together while maintaining the proper alignment of

the fragments throughout the healing process.

 Standard Plates

• Narrow DCP-4.5 mm
• Broad DCP – 4.5 mm
• 3.5 mm DCP
• LC-DCP 3.5 & 4.5mm
• Reconstruction plate 3.5 & 4.5mm
• 1/3 tubular plate 2.7, 3.5 & 4.5 mm
 Special Plates
• • T Plates
• • T&L Buttress plates
• • Lateral Tibial head buttress plates
• • Condylar buttress plate
• • Narrow lenthening plates
• • Broad Lengthening plate
• • Spoon plate
• • Clover leaf plate
 CLASSIFICATION

• Regardless of their length, thickness,geometry, configuration or type of

holes,
• all pates may be classified in four groups according to their function.
• Neutralization Plates.
• Compression Plates.
• Buttress Plates.
 NEUTRALIZATION PLATE
• A neutralization plate acts as a ""bridge". It transmits various
forces from one end of the bone to the other, by passing the area
of the fracture.
• Its main function is to act as a mechanical link between the
healthy segments of bone above and below the fracture. Such a
plate does not produce any compression at the fracture site.
• The most common clinical application of the neutralization plate
is to protect the screw fixation of a short oblique fracture, a
butterfly fragment or a mildly comminuted fracture of a long
bone, or for the fixation of a segmental bone defect in
combination with bone grafting.
 COMPRESSION PLATE
• • A compression plate produces a locking force across a fracture site to
which it is applied.
• The effect occurs according to Newton's Third Law (action and reaction are
equal opposite).
• The plate is attached to a bone fragment. It is then pulled across the fracture
site by a device, producing tension in the plate. As a reaction to this tension,
compression is produced at the fracture site across which the plate is fixed
with the screws. The direction of the compression force is parallel to the
plate.
 BONE UNDER COMPRESSION
• • Superior stability
• Utilization of physiological forces.
• • Improved milieu for bone healing.
• • Early mobilization
 BUTTRESS PLATE
• • The mechanical function of this plate, as the name suggests, is to
strengthen (buttress) a weakened area of cortex. The plate prevents the bone
from collapsing during the healing process.
• It is usually designed with a large surface area to facilitate wider distribution
of the load.
• • A buttress plate applied a force to the bone which is perpendicular
(normal) to the flat surface of the plate.
• • The fixation to the bone should begin in the middle of the plate, i.e. closest
to the fracture site on the shaft. The screws should then be applied in an
orderly fashion, one after the other, towards both ends of the plate.
• • A representative clinical example of a buttress plate is the T-plate used for
the fixation of fractures of the distal radius and the tibial plateau.
 DCP (Dynamic Compression Plate):

• Principle :
- Its a self compression plate due to the special geometry of screw holes which
allow the axial compression.
 • Screw hole and the spherical gliding
principle.
Axial compression result from the an interplay between screw hole geometry
and eccentric placement of the screw in the screw hole. The screw hole is a
combination of incline and horizontal cylinder which permits the downward
and the horizontal movement of a sphere the screw hand. Sideway movement
of screw head is impossible. The aim is to position the screw head at the
intersection of inclined and the horizontal cylinder. At this point screw head
has a spherical contact in the screw hole which result in the maximum stability
without completely blocking the horizontal movement of the screw.
 Advantage of DCP :
1. Inclined insertion 25° longitudinal and 7°sideways.

2. Placement of a screw in neutral position without

the danger of distraction of fragments.

3. Insertion of a load screw for the compression.

4. Usage of two load screws in the main fragments for axial compression.

5. Compression of several fragments individually in comminuted fractures.

 Short Coming of DCP :

1. Flat under surface.

2. Inclination upto 25°
3. Plate hole distribution (extended middle segment)
 LC-DCP
• The LC-DCP (limited contact DCP) is a further development of the DCP is
used for the same indications as the DCP, but the improved design offers
additional advantage.
The evenly distributed undercuts reduces the contact area between bone and
plate to a minimum. This significantly reduces impairment of the blood supply
of the underlying cortical bone
• undercuts also allow for the formation of a small callusbridge.
The enlarged cross section at the plate holes and the reduced cross section
between holes offer a constant degree of stiffness along the long axis of the
plate
• The trapezoid cross section of the plate results in a smaller contact area
between plate and bone.

The plate holes are uniformaly spaced,which permits easy positioning of

the plate.

Undercuts plate holes; undercut at each end of the plate hole allows 40
tilting of screws both ways along the long axis of the plate.

Lag screw fixation of short oblique fractures is thereby possible.

 ADDITIONAL PRINCIPLES OF
PLATE FIXATION

• • The engineering principle of the tension band is widely used in fracture

fixation.
• It applies to the conversion of tensile forces to compression forces on the
convex side of an eccentrically loaded bone.
 PREBENDING PLATES

• Contour to fit the bone surface snugly.

Make a sharp bend opposite the fracture site; midsection is elevated.
• Fix to the bone, starting on either side of the fracture and then moving
outwards.
• Plate then compresses the far cortex also.
• Apply only to two fragment fractures.
 HOW MANY SCREWS ?
• • Hands-on experience suggests that, in the humerus, screws grip seven
cortices on each side of the fracture ; in the radius and the ulna,five; in the
tibia, six, and in the femur, seven.
 HOW CLOSE TO THE FRACTURE SITE?

• •Ascrew, as a result, should not be placed closer

than one centimeter from the fracture line
 Reconstruction Plates :

• Can be bent and twisted in two dimensions.

• Decrease stiffness than DCP.
• Should not be bent more than 15°.
• Used were the exact and complex
• contouring is required. eg. Pelvis, Distal Humerus, Clavicle.
 One Third Tubular Plates :

• Plates have the form of one third of the circumference of a cylinder.

• Low rigidity (1mm thick).
• Oval holes – Axial compression can be achieved.
• Uses – Lateral malleolus, distal ulna, metatarsals.
 LOCKING COMPRESSION PLATE (LCP)
• Principle :
• The basic principle of LCP is its angular stability whereas stability of
conventional plate osteosynthesis relies on the friction between the plate and
bone.
• The principle of fixation of LCP is screw locking.
• The functional LCP screw is like that of external fixator pins, that is why
they are called as internal fixator.
• LCP provides the relative stability.
• # heals by the callus formation (Secondary Healing)
Bridge/Locked Plating Using Locking Screws
• Screws lock to the plate, forming a fixed-angle construct.
Bone healing is achieved indirectly by callus formation
wMaintenance of primary reduction
Once the locking screws engage the plate, no further tightening is possible.
Therefore, the implant locks the bone segments in their relative positions
regardless of degree of reduction. Precontouring the plate minimizes the gap
between the plate and the bone, but an exact fit is not necessary for implant
stability. This feature is especially advantageous in minimally or less invasive
plating techniques because these techniques do not allow exact contouring of
the plate to the bone surface.hence using locking screws exclusively
Stability under load
• By locking the screws to the plate, the axial force is transmitted over the
length of the plate. The risk of a secondary loss of the intraoperative
reduction is reduced.
Blood supply to the bone
Locking the screw into the plate does not generate additional
compression. Therefore, the periosteum will be protected and the blood supply
to the bone preserved.
 Plate Design :

LC DCP features :
• Tapered end for sub muscular insertion.
• Locking holes
 Screw :

• Conical screw head

• Large core diameter.
• Self tapping.
• Star drive recess.
 Principle of internal fixation
using LCP
1. 1st reduced the # as anatomical as possible.
2. Cortical screw should be used 1st in a fracture
fragment.
3. If the locking screw have been put, use of the cortical screw in the same fragment
without loosening and retightening of the locking screw is not recommended.
4. If locking screw is used first avoid spinning of plates.
5. Unicortical screws causes no loss of stability.
6. Osteoporotic bones bicortical should be used.
7. In the comminuted # screw holes close to the fracture should be used
to reduce stain.
8. In the fracture with small or no gap the immediate screw holes should be
left unfilled to reduced the strain.
 Plate length and No. of Screws :
• Plate span ratio Plate length
• # length
• Comminuted # PSR 2
• Simple # PSR 8
• Plate Screw density No. of Screws
• No. of Plate holes
• PSD 0.5 to 0.4
• - At least 4 cortices per main fragment for
• comminuted fracture
• - At least 3 cortices per main fragment for simple
• fracture.
Indications :
1. Osteoporotic #
2. Periprosthetic #
3. Multifragmentry #
4. Delayed change from external fixation to internal fixation.
Advantages :
1. Angular stability
2. Axial stability
3. Plate contouring not required
4. Less damage to the blood supply of bone.
5. Decrease infection because of submuscular technique
6. Less soft tissue damage.
 Timing of Plate Removal,
Recommendations for removal of
• • Bone / Fracture
plates in the lower limb :
• • Time after implantation in months
• • Malleolar fractures
• • 8-12
• • The tibial pilon
• • 12-18
• • The tibial shaft
• • 12-18
• • The tibial head
• • 12-18
• The femoral condyles
• • 12-24
• • The femoral shaft: Single plate, Double Plate
• • 24-36
• • From month 18, in 2 steps ( Interval 06 months)
• • Pertrochanteric and femoral neck fractures Upper
• extremity
• • 12-18
• • Optional
• • Shaft of radius / ulna
• • 24-28
• • Distal radius
• • 8-12
• • Metacarpals
• • 4-6
 INTRAMEDULLARY NAILING

• The intramedullary nail is commonly used for long-bone fracture fixation

and has become the standard treatment of most long-bone diaphyseal and
selected metaphyseal fractures
• To understand the intramedullary nail, knowledge of evolution and
biomechanics are helpful
 HISTORY
• In 16 th Century In Mexico Aztec physicians have placed wooden sticks into
the medullary canals of patients with long bone non-union.
• In Mid 1800’s Ivory pegs were inserted into the medullary canal for non-
union.
• In1917 ‘s Hoglund of United States reported the use of autogenous bone as
a intramedullary implant.1930’s In the Unit
• 1930’s In the United States, Rush and Rush described the use of Steinman pins
placed in the medullary canal -to treat fractures of the proximal ulna and proximal
femur.
• 1931 : Smith-Petersen reported the success of stainless steel nails for the treatment
of NOF #s
• 1940 ‘s : The Evolution of Kűntscher Nailing Gerhard Kűntscher was born in
Germany in 1900
• 1940’s:
• Gerard Küntscher developed ‘V’nail, Cloverleaf shaped and
the ‘Y’ nail.
• His methods were based on two principles: stable fixation and closed nailing
• 1950’s Interlocking Screws :Modny and Bambara introduced the transfixion
intramedullary
nail in 1953
• Nailing of tibia is introduced by herzog in 1950.
• Livingston bar,introduced a short I-beam pattern pointed nail at both
ends,which had short slots for cross-pinning with screws.
 INTRODUCTION
• Today any fracture is stabilized by one of the two systems of fracture fixation .
1. compression system
2. splinting system
• Intramedullary fixation belongs to internal splinting system.
• Splintage may be defined as a construct in which micromotion can occur between
bone & implant, providing only relative stability without interfragmentary
compression.
• Depending on the anatomy the insertion can be antegrade and retrograde.
• The entry point depends on the anatomy of the bone but is distant from the
fracture site.
• Intramedullary fixation techniques offer the advantages of closed reduction
and closed fixation
 INTRAMEDULLARY DEVICES ARE
BROADLY CLASSIFIED INTO:

• A.) CENTROMEDULLARY- K NAIL,FIRST GENERATION IM

NAIL
• B.) CEPHALOMEDULLARY- GAMMA NAIL,RUSSELL TAYLOR
NAIL,UNIFLEX, PFN
• C.) CONDYLOCEPHALIC NAIL- ENDER
• NAIL,LOTTES ETC
CONDYLOCEPHALIC FIXAT
ION

• Also known as elastic stable intramedullary nailing(ESIN), is a primary

definitvie fracture care (PDFC) in paediatric orthopaedic practice.
• This method works by 3 – point fixation or bundle nailing.
• The elasticity of the construct allows for ideal cirumstances of micro-motion
for rapid fracture healing
• Nonreamed nails are actually not nails but pins.Their mechanical characteristics and use are
different from IM nails. They are of smaller diameter and are more elastic.
• Their flexibility allows insertion through a cortical window. There are many different types of
flexible nails, the best known are:-
• Lottes nails - Tibia
• Rush pins – for all the long bones of the body
• Ender nails
• Morote nails
• Nancy nails
• Prevot nails
• Bundle nails
 RUSH NAIL
• RUSH NAILS
SOLID, CIRCULAR IN CROSS SECTION,
STRAIGHT,WITH A SHARP BEVELLED TIPS
AND A HOOK AT THE DRIVING END.
 ENDERS NAIL.
• Ender Nails, which are
solid pins with an
oblique tip and an eye in
flange at the other end,
were originally designed
for percutaneous, closed
treatment of extracapsular hip fractures
 BIOMECHANICS
• Each nail is precurved to achieve 3-point fixation where the required precurve should
be approximately 3 times the diameter of a long bone at its narrowest point.
Part of the biomechanical stability is provided by the intact muscle envelope surrounding
the long bone.
• All currently available nails have beaked or hooked ends to allow
satisfactory sliding down on insertion along inner surface of
the diaphysis without impacting
the opposite cortex
• •Insertion points that do not lie opposite to one another produce
differing internal tension and imbalance of the fracture stability
and fixation.
•The apex of the curvature should be at the level of the fracture site.
•The nail diameter should be 40% of the narrowest medullary space
diameter.
•Two nails of the same diameter and similarly prebent to be
used.
•Commonest biomechanical error is lack of internal support.
• There are two basic methods of IM pinning, they are:
1. Three point compression.
2. Bundle nailing.
Most pins stabilize fracture by three point
compression.
These pins are C- or S – Shaped, they act like a
spring.
The equilibrium between the tensioned pin and the
bone with its attached soft tissues will hold the
alignment.
• The principle of bundle nailing was introduced by Hackethal.

• He inserted many pins into the bone until they jammed within the
medullary cavity to provide compression between the nails and
the bone.
Both techniques should be seen more as IM
splinting than rigid fixation.
Bending movements are neutralized, but telescoping and rotational torsion
are not prevented with this technique
BUNDLE PINNING
• Flexible nail are usually simpler to use and can be inserted
more quickly.
If infection intervenes, the complication of likely less severe.
So can be used in tibia open fracture because of its less blood
supply and its subcutaneous location.
Because of small size of forearm bones reaming is technically
difficult, so unreamed nail have generally been used.
 INTRAMEDULLARY
INTERLOCKING
NAILS:
• •They are usually reamed nails in which interlocking is
its newer modification.
•The classic reamed nail is the hollow, open – section
nail of Küntscher.
•Most other reamed nails are variations of the
Küntscher nail such as the AO nail, and the various
interlocking nails, such as the Grosse – kempf, Klemm
Alta, Russell – Taylor, Uniflex, AO Universal and
others.
 VARIOUS GENERATIONS OF NAILS
• Consecutive advancements of nails over years Can be
grouped under three generations
• 1 st generation:
primarily act as splints ,rotational stability is minimal , primarly
relies on close fit
Eg –K nail , V nail
• 2 nd generation :
Improved rotational stability due to locking screw
Eg-Russel taylor nail
• 3 rd generation:
Nails with various designs to fit anatomocally as much as
possible ,to aid the insertion and stability
Eg -Nails with multiple curves ,multiple fixation systems Tibial
nail with malleolar fixation
• Russell – Taylor nail:
This is a second generation nail.
Proximal locking into the
femoral head enhances its
stability in hip fractures
 Brooker – Wills nail

• Brooker – Wills nail fixing a

fracture of the femur, an AP
roentgenogram. This nail has
flanges deployed through slots
in the tip of the nail for distal
stability.
 LOCKING NAILS :
• Except for the Brooker – Wills nail with its flanges and the expandable tip
of the Seidel nail, which is used exclusively for the humerus, all current
designs use two distal transverse cross – locking screws, as in the
Alta intramedullary rod
Proximal fixation includes inclined screws as in the Grosse Kempf nail,
two transverse screws, as in the Alta, and specialized screws
though the nail designed to secure fixation in
the femoral head, as in the Russell – Taylor
• Gamma nail: This intramedullary
device is designed for proximal
intramedullary fixation of
intertrochanteric and some
subtrochanterc fractues.
 BIOMECHANICS
• When placed in a fractured longbone, IM nails act as internal
splints with load-sharing
characteristics.

• Various types of load act on an IM

nail: torsion, compression, tension
and bending
Physiologic loading is a
combination of all these force
• Nail cross section
is round resisting
loads equally in all
directions.
• Plate cross-section
is rectangular
resisting greater
loads in one plane
versus the other.
The amount of load borne by the nail depends on the stability of the fracture/implant
construct.

• This stability is determined by

1.Nail Characteristics
2.Number and orientation of locking screws
3.Distance of the locking screw from the fracture site
4.Reaming or non reaming
5.Quality of the bone
IM nails are assumed to bear most of the load initially, then
gradually transfer it to the bone as the fracture heals
• Several factors contribute to the overall biomechanical profile
and resulting structural stiffness of an IM nail.
Chief among them are
a)Material properties
b)Cross-sectional shape
c)Diameter Curves
d)Length and working length
e)Extreme ends of the nail
f) Supplementary fixation devices
 MATERIAL PROPERTIES
• Metallurgy less important than other parameters for
stiffness of an IM Nail.
• Most of them are fabricated from stainless steel, with a small number from titanium.
• The material must be stiff . Titanium are 1.6 times stiffer and elastic modulus is 50% lower
than steel nail.
• Titanium alloy has a modulus of elasticity closely approximates that of cortical
bone(Modulus is ability to resist deformation in tension).
• The cross-sectional shape of the nail ,Diameter determines
its bending and torsional strengths( Resistance of a
structure to torsion or twisting force is called polar
movement of inertia )
Circular nail has polar movement of inertia proportional to
its diameter, in square nail its proportional to the edge
length
Nails with Sharp corners or fluted edges has more polar
movement inertia
Cloverleaf design resist bending most effectively .Presence
of slot reduces the torsional strength . It is more rigid when
slot is placed in tensile side
 CROSS SECTIONAL SHAPES
• A-Schneider
B-Diamond
C-Sampson fluted
D- Kuntscher
E-Rush
F-Ender
G- Mondy
H-Halloran
I- Huckstep
J-AO/ASIF
K-Grosse – Kempf
L-Russell-Taylor
 DIAMETER
• Nail diameter affects bending rigidity of nail.
For a solid circular nail, the bending rigidity is proportional
to the third power of nail diameter
Torsional rigidity is proportional to the fourth power of
diameter .
Large diameter with same cross-section are both stiffer and
stronger than smaller ones.
•Some nails are designed in a such a way that stiffness
doesn’t vary with diameter.
• •The diameter of a nail should always be measured with a circular guage

• In reamed nailing, the width of nail is better determined by the feel of the
reamers than by radiographic measurements, although the approximate size
to be used can be determined from preoperative radiographs.
• Obtain preoperative radiographs of the
fractured long bone, including the proximal
and distal joints.
If there is any question, obtain an
anteroposterior radiograph of the opposite
normal limb at a tube distance of 1meter. A
nail of the appropriate size should be taped to
the side of the limb for reference, or a
radiographic ruler can be used, alternatively a
Kuntscher measuring device – the ossimeter
may be used to measure length and width.
The ossimeter has two scales, one of which
takes into account the magnification caused
by the X-ray at a 1 – m tube distance.
-In most cases, a nail reaching to within 1 to 2
cm of the subchondral bone distally is
indicated.
• CURVES

• Longitudinal (Anterior) bow

•Governs how easily a nail can be inserted as well as bone/ nail
mismatch, in turn influences the stability of fixation of the nail
in the bone.

• Complete congruency minimizes normal forces and hence

little frictional component to nail’s fixation.

• Conversely, gross mismatch increases frictional component of

fixation and inadequate fracture reduction.
Femoral nail designs have considerably less curve, with
radius ranging from 186 to 300 cm
• Herzog bend
Tibial nail also has a smooth 11*
bend in the anterioposterior
direction at junction of upper one
third and lower two third .
• When inserting nail , axial force is necessary as the nail must
bend to fit the curvature of the medularly canal .

• The insertion force generates

hoop stress in the bone
( Circumferential expansion stress )

• Greater the insertion force higher the hoop stress.

• Larger hoop
stress can split the bone
• Over reaming the entry hole by 0.5-
1mm ,selecting entry point
posterior to the central axis reduce
the hoop stress
Example :The ideal starting
point for insertion of an
antegrade femoral nail is in the
posterior portion of the
piriformis fossa . It reduces the
hoop stress
 Length and working length
• A-Total nail length- total anatomical length

• B-Working length-
-Length of a nail spanning the fracture site
from its distal point of fixation in the
proximal fragment to proximal point of
fixation in the distal fragment
-Length between proximal and distal point
of firm fixation to the bone
-Un supported portion of the nail between
two major fragments
• Working length is affected by various factors

• Type of force (Bending ,Torsion )

• Type of fracture

• Interlocking

• Reaming
 WORKING LENGTH
The bending stiffness of a nail is inversely proportional to
the square of its working Length.
The torsional stiffness is inversely proportional to its
working length.
Shorter the working length stronger the fixation
Medullary reaming prepares a uniform canal and improves
nail- bone fixation Towards the fracture,thus reducing the working length
 INTERLOCKING
• Interlocking screws are recommended for most cases of IM nailing.
The number of interlocks used is based on fracture location, amount of fracture
comminution , and the fit of the nail within the canal.
• Placing screws in multiple planes may lead to a reduction
of minor movement
The principle of interlocking nailing is different. The nail is locked to the bone by inserting
screws through the bone and the screw holes.
• The resistance to axial and torsional forces is mainly dependent on the screw – bone
interface,and the length of the bone is maintained even if there is a
bone defect.
•
STATIC
when screws placed proximal and distal
LOCKING
to the fracture site. This restrict translation and rotation at the fracture
site.

• Indications – comminuted ,
spiral, pathological fractures Fractures
with bone loss lengthening or
shortening osteotomies , Athropic non
union

• It achieves BRIDGING FIXATION

through which fracture is often held in
distraction , a favourable environment
for periosteal callus formation exists and
healing rather than nonunion is rule.
 DYNAMIC LOCKING
It achieves additional rotational
control of a fragment with large
medullary canal or short epimetaphyseal fragment.
It is effective only when the contact
area between the major fragments is
atleast 50% of the cortical
circumference.
With axial loading, working length in
bending and torsion is reduced as
nail bends and abuts against the
cortex near the fracture, improving
the nail-bone contact
 DYNAMISATION:
•No longer std. practice to dynamize an interlocked
nail by removing the locked screws .
•It is indicated when there is a risk of development of
nonunion or established pseudoarthrosis.
•The screws are then removed from the longer
fragments, maintaining adequate control of shorter
fragment. Premature removal may cause shortening,
instability and nonunion
 Screw
strength
• •Characterised by an outer
diameter, root diameter and
pitch.
•Shape of the threads at their
base determines stress
concentration (sharp v/s
rounded).
• Pullout strength is dependent on
the outer diameter.

• •The largest diameter of the screw

which can be used is limited by the
diameter of the nail.

• •Increasing the diameter of the

screws reduces the cross section of
the nail at its hole and their by
predisposes to failure
• Stability depends on the locking screw diameter for a given
nail diameter. In general, 4 to 5 mm for humeral nails and 5
to 6 mm for tibial and femoral nails.

• Nail hole size should not exceed 50% of the nail diameter.
Interlocking screws undergo four-point bending loads, with
higher screw stresses seen at the most distal locking sites

• The number of locking screws is determined based on

fracture location and stability.
In general, one proximal one distal screw is sufficient for
stable fractures.
• The location of the distal locking screws
affects the biomechanics of the fracture .

• The closer the fracture to the distal

locking screws, the nail has less cortical
contact , which leads to increased stress
on the locking screws.

• More distal the locking screw is from

fracture site, the fracture becomes more
rotationally stable
• Oblique ( angled to nail axis, not 90°) proximal locking
screws appear to increase the stability of proximal tibia
fractures compared with transverse ( 90° to nail axis)
locking screws.

• However, oblique or transverse orientation of the distal

screws in distal-third tibia fractures has minimal effect on
stability
• Orientation of the proximal femur locking screws has little
effect on fixation stability, with both oblique and transverse
proximal locking screws showing equal axial load to failure.
 EXTREME ENDS OF NAILS
• K-nail has slot/eye in the either ends for attachment of
extraction hook .one end is tapered to facilitate the insertion.
• Present version of cannulated locking screw contains
cylinderical proximal end with internally threaded core to
allow firm attachment of driver and extracter.

• Holes for interlocking screws present either ends .

Some nails have slots near the distal end for placement of
anti rotation screw
• Slot
- Anterior slot - improved
flexibility
- Posterior slot - increased
bending strength

• Non-slotted - increased
torsional stiffness, increased
strength in smaller sizes.
Unknown if its of any clinical
advantage.
 BIOMECHANICS OF IM REAMING
• IM reaming can act to increase the contact area between the nail and cortical bone
by smoothing internal surfaces.
When the nail is the same size as the reamer, 1 mm of reaming can increase the
contact area by 38% .
Reaming reduces the working length and increase the stability.
More reaming allows insertion of a larger-diameter nail, which provides more
rigidity in bending and torsion.
Biomechanically, reamed nails provide better fixation stability
than do unreamed nails.
• Medullary canal is more or less like an hour-glass than a perfect cylinder. Reaming is
an attempt to make the canal of uniform size to adapt the bone to the nail. The
size of the canal limits the size of the nail
 LOCAL CHANGES:
• Both reamed and unreamed nails cause damage to the endosteal blood supply.

• Experimental data suggest that reamed nailing deleteriously affects nutrient artery blood
flow, but cortical
blood supply is significantly reduced after reamed nailing compared with unreamed nailing.
• Reaming is also associated with the potential risk of fat
necrosis
Blunt reamers and the use of reamers larger in diameter than the medullary canal Lead to
increased temperature , therefore it suggested that long bones with very narrow
canals should first be reamed manually or an alternative
treatment method should be used.
• Some surgeons believe that unreamed nailing is
advantageous in the treatment of Gustilo III B open
fractures, citing higher infection rates.

• Clinical studies of both tibial and femoral fractures

show that reamed nailing of fractures with low –
grade soft tissue injuries significantly reduces the
rates of nonunion and implant failure in comparison
with unreamed nailing. In fractures with an intact soft
tissue envelope, reaming of the medullary cavity
increases significantly the circulation within the
surrounding muscles. This increased circulation may
improve fracture healing

• Reaming does not increase the risk of compartment

syndrome
 SYSTEMIC CHANGES
• Fat embolism due to IM reaming was described by
Kuntscher. Fat embolism due to passage of IM contents
into the bloodstream can occur only in the IM pressure
associated with instrumentation exceeds the physiologic
IM pressure and out weighs the effects of the normal
blood flow.
The incidence of fat embolism is more with femoral
reaming,. Reaming of the tibia does not lead to a
significant increase of IM pressure, and intraoperative
echocardiography does not show significant fat embolism
in reamed tibial fractures.
The use of a venting hole to reduce the IM pressure
increase during reaming is controversial
• Advantages
• Allows insertion of larger-sized implants which helps in weight bearing
and joint function during the healing process.
- Improves nail-bone cortical contact across the working length of the
implant and directs fracture fragments into a more anatomical position.
- From a biologic standpoint, provides systemic factors to promote
mitosis of osteogenic stem cells and to stimulate osteogenesis.
Disadvantages
Eccentric reaming may lead to malreduction of the fracture.
- Destroys all medullary vessels, resulting in a initial decrease in
endosteal blood flow and in turn decreased immune response and delay
in early healing of the involved cortices.
- In open fractures, avascular and nonviable fragments causes increased
susceptibility to infections
• side effects
- Heat: a rise in temperature upto 44.6⁰ C had
a negative effect on fracture healing.
•Cell enzymes get damaged and cannot fullfill
their function.
•The threshold value of heat induced
osteonecrosis is 47⁰C.
- Pressure: hydraulic pressure builds up in the
cavity which far exceeds that of blood
pressure and is independent of the size of the
reamer.
•It acts as a piston in sleeve which is filled
with a mixture of medullary fat, blood, blood
clots and bone debris.
•High intramedullary pressure forces contents
into the cortical bone and systemic
circulation.
 WEIGHT BEARING AFTER IM NAILING
• Segmentally comminuted diaphyseal fracture without bony
contact and nails with a 12-mm diameter and two distal
locking bolts could with stand the typical biomechanical
forces of weight bearing.

• In patients who retain diaphyseal bony contact after fracture

fixation, nails with a diameter <12 mm or nails with a single
distal interlock may provide adequate stability for weight
bearing because the bony contact reduces the load
encountered by the distal interlocking screws.
Weight bearing through a locked IM nail could be allowed in
fractures in which 50% cortical contact is p
 IM NAIL REMOVAL
• It is not necessary to remove a nail in a weight bearing limb
unlike a plate.
If needed can be removed after 18 months.
Indications for removal-
- Patient request, pain swelling secondary to backing out of
the implant.
- Nail removal should not be undertaken lightly ,specialized
extraction equipment fitting the nail must be available.
- Full weight bearing can commence immediately after the
removal of nail
 Z-effect of im nails
• Z-Effect is an unfortunate by-product of most intramedually
nails that utilize two screws placed up into the femoral neck
and head. Typically, the superior screw is of smaller diameter
than the inferior and bears a disproportionate amount of load
during weight bearing. Excessive varus forces placed on the
smaller screw at the lateral cortex cause it to toggle and either
back out or migrate through the femoral head into the
acetabulum. The larger inferior screw is neither keyed in
rotation nor locked in place, and it too will either back out or
migrate medially. The resultant Z-Effect where the two screws
move in opposite directions is one mode of failure for the
conventional two screw reconstruction device
 IM NAIL FAILURE

• With all metallic implants, there is a relative race between

bone healing and implant failure.
Occasionally, an implant will break when fracture healing is
delayed or when nonunion occurs.
IM nails usually fail in predictable patterns. Unlocked nails
typically fail either at the fracture site or through a screw hole
or slot.
Locked nails fail by screw breakage or fracturing of the nail at
locking hole sites, most commonly at the proximal hole of the
distal interlocks.
• applications of im nailing
Anatomic alignment, early weight bearing, early unrestricted joint &
muscle rehabilitation are of advantage to the patient.
ARDS can be prevented in multiple injuries by stabilizing and mobilizing
the patient immediately.
Floating hip, floating knee, floating elbow.
To protect the vascular repair following injuries by a fracture.
Aseptic and septic non-union.
Pathological fractures.
Malunions.
High proximal and low distal fractures of long bones
Open tibial and femoral grade I and II fractures
• REFERENCES:
1.CAMPBELL OPERATIVE ORTHOPAEDICS 11TH EDITION
2.The science and practice of Intramedullary Nailing – Bruce
D. Brown
3.ROCKWOOD AND GREENS
4.INTERLOCKING NAILING-DD.TANNA
5. The elements of fracture fixation – Anand J Thakur
6.Prospective study of distal end radius
fracture by an intramedullary nailing JBJS
aug3 2011
7.Textbook of orthopaedics and trauma –GS KULKARNI
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