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The use of plates for internal fixation gains more and more importance and
acceptance due to the introduction of new implants offering the possibility to lock
the screw head with the plate. With this new plate generation, different fixation
concepts can be considered and in addition the indication for plating is spread out
to the diaphyseal segment of bone. For proper application of the implants—and
to avoid technical or mechanical complications—a thorough understanding of
the basic concepts of fixation, the bone biology and biomechanics, remains of
outstanding importance.

Emanuel Gautier

Bridge plating

Refections useful for the adapted use of plates and screws in to be inserted, as well as the type of screws (standard cortical
internal fixation screws or locking head screws, mono- or bicortical screws, self
More or less all implant systems used in internal fixation con- drilling or self tapping screws) remain under debate. Thus, a
sist of two main elements—a longitudinal element for the load lot of additional decisions have to be taken by the surgeon
transfer from one main fragment to the other and a transverse when planning and performing plate osteosynthesis. It is also
element to assure the coupling of the implant system to bone evident that plating is intellectually and technically much more
(Table 1). When comparing internal fixation with intramedul- demanding than nailing (Table 2).
lary nails or internal fixation with plates some major differences
appear. Using an intramedullary nail for a diaphyseal fracture The three following main factors influence the stability of the
the mechanical concept is more or less independent from the fixation and the loading conditions of the plate bone construct:
fracture pattern—simple fracture, wedge fracture, comminuted The overall length of the plate, the overspan length of the plate,
fracture. In addition, the position of the nail, the length and and the number, position and design of the screws.
diameter of the nail as well as the position of the locking bolts
are more or less given and standardised by the local anatomy of Length of the plate
the broken bone segment as well as the implant design. Utilizing the newer minimally invasive techniques of indirect
reduction, subcutaneous or submuscular plate insertion and
In contrast to nailing, plating offers two different fixation con- splinting as a stabilization concept, the plate length can be
cepts—splinting and interfragmentary compression. Comminut- chosen to be very long without the need of additional soft tissue
ed fractures are best treated using a splinting technique, because section and devascularization.
local bone and soft tissue devascularization can be minimized;
while in simple fractures the application of interfragmentary Theoretically the plate can equal the whole length of the broken
compression can be considered as a stabilization tool. bone. But, at least the minimal length of the internal plate can be
determined by means of the two factors: The plate span width and
Plate position is chosen mainly according to the local anatomy the plate screw density. Plate span width is defined as the quotient
and the surgical approach chosen. But, depending on mechani- of the plate length and overall fracture length. Empirically we find
cal demands, the plate position can be altered (tension side, that the plate length should be two to three times higher than
compression side). In addition, the length of the plate itself, the overall fracture length in comminuted fractures and eight
the number and the relative position of screws which need to ten times higher in simple fractures. The second factor is the

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1a 1b 1c

Fig 1a–c  Plate span ratio and plate screw density

In comminuted fracture the plate length should be 2 to 3 times higher than the overall fracture length (a). In simple fractures this ratio should be
raised to a value of 8 to 10 (b). In addition the plate screw density should be kept below a value of 0.5, indicating that less than half of the plate
holes are occupied by screws (c).

plate screw density which is the quotient formed by the number

Orientation of elements and mechanical function
Technique of screws inserted and the total number of plate holes. Empiric
Longitudinal load transfer Transverse coupling ally we recommend values below 0.5, indicating that less than
external fixation Bar Schanz screw half of the plate holes are occupied by screws (Fig 1a–c).
Nailing Nail Locking bolt
Plating Plate Screw Number of screws
From the mechanical point of view, two screws (monocortical
Table 1
or bicortical) on each main fragment, is the minimum number
of screws needed to keep the plate bone construction stable
Characteristics of
Nailing Plating (Fig 2a–c). Unfortunately, such a construction will fail if one
fixation and implants
Concept of fixation Mainly splinting Splinting screw breaks to due overload or when the interface between
Compression bone cortex and screw is threatened due to bone resorption
Load transfer Locking Locking with subsequent screw loosening. Thus, for safety reasons we
Friction
recommend a minimum of three screws in each the proximal
Position Intramedullary Tension side
Compression side and the distal main fragment.
Insertion Intramedullary Open
MIPO Adjusting the plate screw density to a maximum value of 0.5 the
Length Whole length of bone To decide
plate length should not be chosen below a 12-hole plate for treat-
Dimension Inner diameter of bone In relation with bone
and bone segment
ment of a diaphyseal fracture. But, to increase the leverage of the
Number of screws Minimum  0 Minimum  4 screws the use of a 14- to 22-hole plate would even be better.
Maximum  6 Maximum  ?
Position of screws Given by nail design To decide Effect of plate length on screw loading
Design of screws Bicortical Monocortical The length of the plate and the position of the screws modify
ASLS Bicortical
Self tapping the loading conditions of the screws. Increasing the length of
Self drilling the plate decreases the pullout force acting on the screw due
Standard cortical to an improvement of the active lever arm of each screw (Fig
Locking head
3a–b). This argument points to the use of long plates (nearly as
Table 2
long as the bone itself).

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3a 4a

2a 2b 2c 3b 4b

6a 7a 7b

6b 7c 7d

5a 5b 5c 6c 7e

Fig 2a–c  Minimal requirements for internal fixation using plates. Fig 5a-c  Submuscular splinting of a simple femoral shaft fracture.
Two screws to couple each main fragment to the plate is sufficient from Spreading out the two innermost screws leads to a sound strain dis­t ribution
the mechanical point of view. But, the construct becomes to be unstable if within the implant and a sound bone healing documented by radiographs
one screw fails due to fatigue failure or due to resorption at the bone-screw taken postoperatively (a) at 4 months and 3 years (b and c).
interface with subsequent screw loosening. Thus, for safety reasons 3 screws
Fig 6a–c  In the case of a comminuted diaphyseal fracture spreading out
for each main fragment can be recommended.
the innermost screws is dictated by the fracture pattern leading to low implant
Example of plate fixation of a humeral shaft fracture using a minimal number strain under the prerequisite that the overall deformation and angulation is
of screws showing the undisturbed course of bone healing—postoperative limited by partial contact of intercalated fragments at the opposite cortex (a).
radiograph (a), situation at 3 months (b), and 6 months (c). In case of no distance limitation plate angulation is not hindered (b) and can
equal the critical strain values seen in the schematic drawing with splinting
Fig 3a–b  Influence of lever arm on pull out of screws. a simple fracture by means of a plate leaving a small gap between the main
Using a long plate improves the lever arm of the screws. This leads to a low fragments and positioning the screw as close as possible to the fracture (c).
pull out force acting on each screw. A short plate creates higher pull out of the Fig 7a–d  Working length of the screws.
screw (a) compared with a long plate creating lower pull out of the screws (b).
The screw threads need to be engaged in the bone cortex over a certain
Fig 4a–b  Decreasing the implant deformation and strain with adaptation distance to assure sound anchorage of the plate. A normal cortex is sufficiently
of screw positioning. thick to allow good anchorage. Even a monocortical screw can withstand the
Bending the plate over a short segment increases the strain within the plate torque potentially acting between two fragments and thus loading the screw
(a). To decrease the relative plate deformation the distance between the thread bone interface (a, b). In case of osteoporosis the cortex is thin reducing
innermost screws should be increased (b). This distributes the implant the working length of the screw (c). In this situation even low interfragmental
deformation over a longer distance and reduces the strain within the implant torque can damage the screw bone interface with subsequent loosening and
—as long as the overall plate angulation remains unchanged due to a distance instability (d). Thus in osteoporosis it is mandatory to use bicortical screws
limitation of the opposite bone cortex. with improvement of the working langth of he screws (e).

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Effect of plate length and screw position on plate loading Effects of the internal fixator concept on bone healing
When using the concept of interfragmentary compression in a Using plates as internal fixators with locking head screws has the
simple fracture pattern, load sharing conditions between plate advantage that a certain distance is present under the implant.
and bone are present and in this way the screws in the middle This enables the cortex underneath the plate to form bone callus
of the plate can be inserted as close as possible to the fracture. allowing faster and stronger bone healing.
When using the concept of splinting in a simple fracture pat-
tern, the middle plate segment is bent over a short distance Take home messages for plating:
enhancing the local strain within the implant. To avoid high • Splinting is a sound stabilization principle for fixation of
implant strain, the innermost screws should be spread apart, comminuted fractures.
which increases the length of the plate segment bending, thus • Splinting can be used for stabilization of simple fractures—
decreasing the implant strain. This protects the plate against when, on the one hand, a long plate is used to improve the
fatigue failure (Fig 4a–b). Figures 5a–c show a clinical case of lever arm of each screw, decreasing the screw pullout and,
a femoral shaft fracture stabilized according to the previously on the other hand, the two innermost screws are spread
described principles. apart leaving at least two to three plate holes unoccupied at
the fracture site to decrease plate loading.
In the case of comminuted diaphyseal fractures, the plate spans • Interfragmentary compression remains a sound stabilization
over the fracture like a non gliding splint. A longer distance tool for fixation of simple fractures under the prerequisite
between the two screws adjacent to the fracture is dictated on of careful soft tissue section and handling.
the one hand, by the fracture pattern itself and on the other • The use of locking head screws is advantageous from the
hand, for mechanical reasons, by the spreading out of the in- biological point of view. Such an internal fixator does not
nermost screws thus decreasing the implant loading—but only compress the periosteum and thus reduces the amount of
when there is a distance limitation on the opposite cortex. With- avascularity of the bone cortex adjacent to the plate. In ad-
out distance limitation the deformation of each plate segment dition callus formation is possible in the gap between plate
in the middle depends on the acting bending moment. Each and bone cortex.
plate segment is deformed according to the external loading •  Monocortical screws should only be used in case of good
condition—thus, the overall deformation is much higher and bone quality and sufficient cortical thickness, as well as in
the implant strain can become high and critical, as in the situ- bone segment not loaded with high torque.
ation where it is bridging a small gap with a short plate segment •  Self drilling screws are exclusively used as monocortical screws
between the two innermost screws (Fig 6a–c). in the diaphyseal bone segment to avoid harm to the soft
tissue due to the long sticking out length of a bicortical self
Appropriate screw selection drilling screw.
The selection of the screws is dependent on the bone qual-
ity, cortical thickness, and external loading conditions of the
bone segment. We have the choice between monocortical and
bicortical screws, self tapping and self drilling screws, as well
as standard and locking head screws. The use of locking head
screws has advantages where bad bone quality is found as screw
loading is no longer only pure pullout but also bending, altering
the loading condition at the interface bone-screw thread. The
choice between self tapping and self drilling screws should be
made according to the anatomy of the segment. Self tapping
screws can be used as bicortical screws, whereas self drilling
screws should exclusively be used as monocortical screws be-
cause the stick out length for anchoring in the opposite cortex
is too long which increases possible harm to the soft tissues on Emanuel Gautier
Orthopedic Clinic
the opposite cortex. In very osteoporotic bones, which typically
(Orthopädische Klinik)
present a thin cortex or a bone segment under high torsional Freiburg, Switzerland
loading, the use of bicortical screws is mandatory to enhance [email protected]
the working length of the screws and to avoid torsional displace-
ment of the fractured fragments (Fig 7a–e).

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