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Combined finite element and multibody

musculoskeletal investigation of a fractured clavicle
with reconstruction plate
a b a
Marie Cronskär , John Rasmussen & Mats Tinnsten
a
Department of Technology and Sustainable Development, Mid Sweden University, 83125,
Östersund, Sweden
b
Department of Mechanical and Manufacturing Engineering, Aalborg University, DK-9000,
Aalborg, Denmark
Published online: 24 Oct 2013.

To cite this article: Marie Cronskär, John Rasmussen & Mats Tinnsten (2013): Combined finite element and multibody
musculoskeletal investigation of a fractured clavicle with reconstruction plate, Computer Methods in Biomechanics and
Biomedical Engineering, DOI: 10.1080/10255842.2013.845175

To link to this article: http://dx.doi.org/10.1080/10255842.2013.845175

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 Computer Methods in Biomechanics and Biomedical Engineering, 2013
http://dx.doi.org/10.1080/10255842.2013.845175

Combined finite element and multibody musculoskeletal investigation of a fractured clavicle with
reconstruction plate
Marie Cronskära*, John Rasmussenb1 and Mats Tinnstena2
a
Department of Technology and Sustainable Development, Mid Sweden University, 83125 Östersund, Sweden; bDepartment of
Mechanical and Manufacturing Engineering, Aalborg University, DK-9000 Aalborg, Denmark
(Received 11 September 2012; accepted 12 September 2013)

This paper addresses the evaluation of clavicle fixation devices, by means of computational models. The aim was to develop
a method for comparison of stress distribution in various fixation devices, to determine whether the use of multibody
musculoskeletal input in such model is applicable and to report the approach. The focus was on realistic loading and the
motivation for the work is that the treatment can be enhanced by a better understanding of the loading of the clavicle and
fixation device. The method can be used to confirm the strength of customised plates, for optimisation of new plates and to
complement experimental studies. A finite element (FE) mesh of the clavicle geometry was created from computed
tomography data and imported into the FE solver where the model was subjected to muscle forces and other boundary
conditions from a multibody musculoskeletal model performing a typical activity of daily life. A reconstruction plate and
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screws were also imported into the model. The combination models returned stresses and displacements of plausible
magnitudes in all included parts and the result, upon further development and validation, may serve as a design guideline for
improved clavicle fixation.
Keywords: clavicle; finite element analysis; multibody simulation; bone plate

Introduction responsible for the typical displacement seen in midshaft

The treatment of clavicle fractures varies greatly in fractures (Dines et al. 2008). Present options for operative
different countries (Dines et al. 2008). There are differing treatment are intramedullary devices, reconstruction plates
opinions with regard to the optimal treatment of the which require shaping during surgery to follow the bone
various types of fractures. Traditionally, non-operative contour and anatomically shaped plates which are pre-
treatment has been preferred for fresh fractures of the contoured to follow the shape of an average clavicle. The
clavicle, with few exceptions. The current research is intramedullary device is a less invasive alternative than
inconsistent in this aspect. Some studies indicate that non- plating but appears to be inadequate where rotational
operative treatment is preferable (Bostman et al. 1997; Hill stiffness is required (Golish et al. 2008; Renfree et al. 2010).
et al. 1997; Judd et al. 2009), while others show that the Huang et al. (2007) investigated the fit of a pre-contoured
occurrence of malunion, non-union and sequelae is the plate on 100 pairs of clavicle bones and found that these had a
consequence of non-operative treatment (McKee et al. poor fit on 38% of the female clavicles. The optimum
2003; Ledger et al. 2005; Alatamimi and McKee 2008). treatment for these types of fractures is still under
In a study involving around 200 patients Nowak found investigation but a better understanding of the loading of
that displaced fractures, particularly where there were no the clavicle and the stresses in the clavicle/plate is needed for
osseous contact and comminuted fractures, especially with the choice of fixation technique and as a basis when
transversally located fragments, were associated with a developing the fixation devices for clavicle fractures.
significantly increased risk of remaining symptoms when Even though the shoulder girdle is exposed to such a
treated traditionally (Nowak 2002). Although there are complex loading, previous biomechanical studies and
large differences in treatment practice, there are some plate failure studies on the clavicle use various and often
types of complex fractures and cases of non-union which greatly simplified load cases such as axial compression or
always require surgery. cantilever bending. There is an inconsistency in those
The clavicle is an s-shaped tubular bone which forms a results and, to a large extent, the inconsistency is probably
part of the complex shoulder girdle and acts like a strut to due to the difference in test modes (Taylor et al. 2011). In a
hold the upper limb away from the body. The muscles recent study by Iannolo et al. (2010), the forces across the
attached to the clavicle are the deltoid, trapezius, clavicle during glenohumeral motion are studied in detail.
sternocleidomastoid, pectoral and subclavius which are Taylor et al. also used a more realistic load case in their

*Corresponding author. Email: [email protected]

q 2013 Taylor & Francis
 2 M. Cronskär et al.

biomechanical studies, based on the attached muscles and images were segmented using a dynamic region technique
ligaments, whose forces according to a biomechanical and a Hounsfield value of 102 and above. The model was
model were converted to section forces and moments then sliced at 0.8 mm reconstruction intervals.
across the fracture and used as loads in subsequent The CT data were imported into the Mimics 14.11
sawbone experiments. A mathematical simulation of the (Materialise, Leuven, Belgium) software for thresholding
early rehabilitation moments on the clavicle was used. between the Hounsfield values 111 and 2310 to achieve the
It was found that the simulation results corresponded outer contours of the bone. Subsequently, an approxi-
better to experimental results than traditional three-point mation of the inner spongious bone was created based on
and cantilever bending (Taylor et al. 2011). the grey-scale values of the bone. The dark, spongious part
To obtain a realistic load case for the finite element of the bone was marked in every 5th – 10th image
(FE) model, a musculoskeletal model similar to that used throughout the bone (Figure 1) and a stereolithography
in Taylor’s study was developed. The difference between (STL) file of the spongious bone was created from the
the two studies is that Taylor’s model focused on section interpolation of the slices and smoothed in the 3-matic
forces and moments in the fracture gap for the purpose of 14.11 (Materialise, Leuven, Belgium) software. A Boolean
constructing test equipment for the mechanical testing of a operation was performed to remove the spongious bone
clavicle with a fixation plate. In the present study, the from the bone model in order to create an STL-file which
model focused on muscle and ligament forces distributed represented only the cortical part of the bone. Hence, the
throughout the clavicle for use as boundary conditions for spongious part was left as a cavity without material
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an FE analysis. To the best of the author’s knowledge, no properties. As the task of the bone is to transfer forces from
FE model including bone with implant and a load case the muscle and ligaments to the plate and the centre of the
based on muscle and ligament forces has been previously bone has small impact on the bending resistance, it was
reported in the literature. assumed that leaving the cavity without spongious material
The aim of this study was to develop a method for the properties would not have much impact on the stresses in
comparison of different fixation devices for clavicle the plate. To confirm this assumption, a comparing stress
fractures. In a future work, the model will be further analysis was carried out. One model contains a solid bone
developed and used to compare the stress distribution in (cortical material properties through all) and one with a
customised plates with current commercial plates, in plates cavity which corresponds to the spongious part of the bone.
with different shape, in different positions and with The resulting maximum stresses and displacements in the
varying screw joints. plate in the solid and hollow models were 481 MPa, 0.
57 mm and 483 MPa, 0.59 mm, respectively, which means
that the resulting stresses would be even smaller comparing
the current model used in this study with a model with
Materials and methods
material properties for trabecular bone in the cavity.
Image data collection and bone modelling Therefore, the authors decided to simplify the bone
The clavicle bone model was created from a computed model by excluding the influence of the spongious part of
tomography (CT) scan of a left, healthy clavicle of a the bone.
36-year-old woman. The woman had a non-union fracture A simulated fracture was created in the Magics 16.0
on the right clavicle with a large degree of callus (Materialise, Leuven, Belgium) software by splitting the
formation. A fracture was simulated on a 3D model of the bone approximately in the same manner and position as
left clavicle and the fracture gap was oriented to the fracture of the right bone. A fracture gap of 0.5 mm
approximately reproduce the positioning of the fracture was created so that the fracture edges could later be
of the right clavicle. The reason for using the CT data on remeshed to obtain high-quality triangles, without
the left clavicle was the presence of callus on the right, generating any overlapping triangles between the two
which would have to be removed in order to be able to parts of the bone. The bone mesh, plate and screws were
simulate plating on a fresh fracture. imported into the Magics software, the plates and screws
The CT image acquisition was performed using a Light were oriented in the correct positions and a Boolean
Speed Pro 16 system (GE Medical Systems) and then operation on the mesh was used to create the screw holes
reconstructed from raw data using a slice thickness of in the bone mesh (see Figure 2).
0.6 mm and a 512 £ 512 image matrix resolution in a Bone To achieve a functional mesh for use in the FE
Plus algorithm. The CT scan was retrieved from the simulations, the mesh of the fractured cortical bone was
picture archiving and communication system station and refined using the 3-matic software to meet the requirements
anonymised. In the radiotherapy department, a 3D model for not having any angles less than 258 and a maximum edge
of the clavicle was reconstructed utilising a GE Advanced length of 2 mm. A volume mesh was created and exported
Workstation 4.6 (GE Medical Systems). The digital to the Abaqus 6.11 (Dassault Systemes, Vélizy-Villacou-
imaging and communications in medicine (DICOM) blay, France) input format.
 Computer Methods in Biomechanics and Biomedical Engineering 3
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Figure 1. Above: cross section of the various parts of the clavicle (Nowak 2002). Below: markings of the spongious bone, based on
grey-scale values, in different parts of the clavicle.

Muscle and ligament forces on the clavicle file. The Abaqus input mesh and the xml-file of the load case
The adapted clavicle geometrical model was imported into were converted into a new Abaqus input file (inp) using a
the AnyBody Modeling System (AnyBody Technology, converter tool included in the AnyBody suite. The input file
Aalborg, Denmark) and subjected to a multibody was then imported into the Abaqus software. The surface
musculoskeletal analysis based on inverse dynamics areas representing the muscle and ligament attachments were
assuming a third-order muscle recruitment criterion. For manually adjusted to provide a better representation of the
details on the musculoskeletal simulation method, please real areas of attachment. The parts of the muscular
refer to Damsgaard et al. (2006). The simulations were attachments were later removed where the plate was
based on the eating motion, more precisely the static attached, in accordance with surgical practice (see Figure 4).
position when holding a cup of tea weighting 0.5 kg, in
front of the mouth (see Figure 3).
The reaction forces on the clavicle, derived from the Reconstruction plate and screws
muscles and ligaments were exported from the AnyBody The plate used in this study is a locking compression plate
Modeling software as an Extensible Markup Language (xml) (LCP) Reco-Plate 3.5 straight, 6 holes (Synthes, West Chester,

Figure 2. Mesh of the cortical bone with screw holes seen from below. Enlargement with plate, screw and constraints between screw and
cortical part of bone mesh.
 4 M. Cronskär et al.

geometry of the LCP Reco-Plate was scanned with a

FARO Titanium measurement arm with laser scanner and
modelled in Rhinoceros 4.0 (McNeal , Seattle, WA, USA)
and Solid Works 2010 (Dassault Systemes, Waltham, MA,
USA) using the data from the 3D scan. The screw holes
were modelled without threads and countersinks. The plate
was modelled as a straight reconstruction plate and later
bent in the Solid Works software using the ‘flex’ command
to follow the bone contour. The 3D model of the plate was
later imported into the FE model in the universal Initial
Graphics Exchange Specification (IGES) file format. The
screws were simplified and modelled in the Solid Works
software without threads and heads. The focus in this
article is on stresses in the plate. The authors have not
found any reported problems with high stresses in the
screws and the clavicle is a bone with good bone quality not
primarily known for screw loosening; hence, the screws –
bone – plate interfaces are simplified in this model.
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FE model of bone with plate

The FE analysis program Abaqus 6.11 (Dassault
Systemes) was used for the simulation work. Initially,
the input file containing the bone mesh with loads from the
biomechanical model was imported. In this file, the muscle
and ligament forces are modelled as concentrated forces at
a point which is coupled (in all 6 degrees of freedom) to a
surface representing the muscle or ligament attachment to
the bone. The bone mesh was refined from linear (4 nodes)
tetrahedral to quadratic (10 nodes) tetrahedral and the total
number of elements in the bone mesh was 63,021 (100,045
Figure 3. The position of the arm in the biomechanical model. nodes). The plate and screws were imported as IGES files
and later the plate was meshed with 41,681 quadratic
PA, USA). This is a plate which is sometimes used for the tetrahedral elements of type C3D10 (Abaqus) and 66,613
fixation of clavicle non-unions and the plate which was nodes. Each screw was meshed with , 3000 quadratic
used for fixation in the patient from which the CT data tetrahedral elements (5000 nodes). The plate and screws
were received for the FE model in this study. The were assembled and oriented to fit the bone mesh. The

Figure 4. FE model of bone with plate and screws and muscle and ligament attachment areas. For labels A– F, see Table 1. The labels
with arrows are muscle and ligament attachments not visible in current view.
 Computer Methods in Biomechanics and Biomedical Engineering 5

screws were divided into three sections. The upper end, there is a small surface where the linear translations
sections were modelled with coupling constraints to the are locked in the transverse directions. The largest reaction
inner surfaces of the plate holes, simulating locked screws. force in the boundary conditions was 2.6 N, demonstrating
The two lower sections of the screws were coupled to that the muscle and ligament forces are almost in
upper and lower cortical bone segments of the screw holes equilibrium. A surface-to-surface contact interaction was
made in the bone mesh (see Figure 2). A boundary modelled in the fracture gap. The FE model is shown in
condition, locking all linear translations and the rotation Figure 4.
around the axis along the clavicle bone, was assigned to a The material properties used for the cortical bone
small surface of the medial end of the bone. At the distal differ in the literature (Wirtz et al. 2000; Atac et al. 2009;
Pérez et al. 2011; Wong et al. 2011; Kunze et al. 2012).
In this case, an anisotropic material was used for the
CT scan of bone cortical bone with a Young’s modulus of E ¼ 18 GPa in
the longitudinal direction of the bone and E ¼ 8 GPa in the
transversal direction (Kim et al. 2011). The Poisson’s ratio
was 0.3. The influence of the inner spongious bone is
STL file of
STL file of outer
spongious part of
excluded in this model. The plate and screws were
contour of bone (1) assigned as a stainless steel (316 L) material,
bone (2)
E ¼ 186.4 GPa and a Poison’s ratio of 0.3 (Disegi 2009).
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The procedure for creating the FE model including the

Boolean operation bone mesh generated from CT data and a load case based
subtracting (2) from (1)
on a multibody musculoskeletal model generated in the
AnyBody software is presented step by step in Figure 5.
Creating fracture gap

Rescaling and Results

reorientation to fit into the
musculoskeletal model The forces resulting from the musculoskeletal model are
(3) shown in Table 1. For muscle and ligament attachments
(see Figure 4). For the current arm position, the largest
Modelling of plates and forces come from the conoid ligament, the acromion
screws based on (3) contact and the deltoid muscle.
The procedure for simulating the stresses in a
Boolean operations using reconstruction plate placed on a clavicle bone model with a
the screws to create screw load case based on the muscle and ligament forces was
holes in (3) successful and showed plausible results. The maximal Von
Mises stress in the middle of the plate was in the order of
Refine mesh (3) to be of 150–220 MPa with a maximal stress of 460 MPa on the edge
FE analysis quality (4) of tapering reconstruction segment (Figure 6). In the stress
concentrated areas of the screws, the stresses were around

Use (4) in the Export (4) to an

Table 1. Muscle and ligament forces on the clavicle from the
musculoskeletal model Abaqus input file (6)
for generation of load
multibody musculoskeletal simulation (for coordinate system and
case in xml-format (5) muscle attachment areas, see Figure 4).

Muscle force components (N)

Muscle/ligament Fx Fy Fz
Combine (5) and (6) to a new
input file (7), with the Lig. conoid (F) 2 86.8 2 84.8 211.5
AnyBody converter tool Lig. trapezoid 0 0 0
M. deltoid (E) 59.2 2 46.8 225.8
M. pect. major 0 0 0
Load (7) into Abaqus CAE
M. sternocleidomastoid (B) 24.2 14.2 2 1.5
and modify the contact
M. trapezius (C) 22.8 22.4 30.5
surfaces of the muscular
attachments.
Sternum contact force (A) 11.1 13.4 210.1
M. trapezius (C) 22.8 22.4 30.5
Sternum contact force (A) 11.1 13.4 210.1
Figure 5. Procedure for combining the bone/implant FE model Acromion contact force (D) 23.4 86.5 18.3
with a multibody musculoskeletal load case.
 6 M. Cronskär et al.
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Figure 6. Stresses in the reconstruction plate.

100–200 MPa with a maximum of 330 MPa in the spacing Discussion

between the plate and bone, in one of the screws in the To our knowledge, this is the first FE study to use a
middle of the plate. The resulting displacement (U) in the validated musculoskeletal model to estimate realistic loads
plate varies between 0.3 and 0.6 mm (Figure 7). The for a clavicle in an arm position which represents early
fracture is in such a position that, together with a plate in rehabilitation after clavicle fixation surgery. Previous FE
current position, the load case caused by the studied arm analyses of clavicles mainly concern injury predictions
position tends to open up the fracture. Hence, the contact (Astier et al. 2008; Arregui-Dalmases et al. 2010) and the
interaction in the fracture gap was not activated and the authors have not found any clavicle FE models including
plate is subjected to the entire load. The maximal Von implants with which to compare their results. Similar
Mises stress in the bone is around 20 MPa (Figure 8). For studies with bone and implant but with simplified load
comparison, a second FE analysis was performed in order cases have been shown to be usable for implant analysis in
to investigate the stress pattern in the bone without fracture other parts of the body, for example, on the proximal
and plate. The results are shown in Figure 9. humerus (Young et al. 2010), the maxilla (Atac et al. 2008;

Figure 7. Displacements in the reconstruction plate.

 Computer Methods in Biomechanics and Biomedical Engineering 7

Figure 8. Stresses in bone with plate (the plate and screws are hidden in the picture).
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Atac et al. 2009; Lin et al. 2010), the femur (Peleg et al. relatively crude in the interest of computational
2006), the tibia (Raja Izaham et al. 2012) and for dental performance.
implants (Pérez et al. 2011). Contrary to the musculoskeletal model, the FE model
The musculoskeletal model is based on rigid body relies on the actual geometry of the clavicle bone and its
dynamics meaning that it technically is constructed from a accuracy is therefore more important in the FE model than
number of moving reference frames with mass and inertia in the multibody dynamics model. Consequently, the
properties and points and surfaces in these local reference original clavicle bone from the musculoskeletal model was
frames forming joint centres to which muscles attach. The replaced by a new clavicle model of similar shape but with
anatomical data, i.e. mass properties and local point much higher resolution based on a CT-scan reconstruction.
coordinates, originate from published cadaver data. The This new model was oriented to match the sternoclavicular
bone geometries in the original musculoskeletal model and acromioclavicular joints. Small shape differences
only serve graphical purposes and have no influence on the between the original and the new bone models mean that
computational model. These bone geometries originate the muscle attachment points do not perfectly match the
from various sources, typically CT scans, and have in new bone. This has an unknown impact on the
some cases been morphed to fit the point coordinates of the computational result, which can only be quantified by
musculoskeletal model. These bone models are also further analysis work. Alternatively, the muscle attachment

Figure 9. Stresses in bone without plate.

 8 M. Cronskär et al.

points could be relocated to fit the new bone, but this Integrating muscle forces in the FE analysis is a step
strategy was discarded in the interest of preserving the towards more realistic simulations of clavicle plates. This
original data-set, which is well-known and frequently used combination of a multibody musculoskeletal analysis with
in the literature. an FE analysis of a bone with implant can be used to
Earlier FE models in the literature, which contain a supplement physical and clinical testing for the comparison
bone mesh generated from CT data, uses various methods of various fixation methods for clavicle fractures. For
to define the cortical section of the bone. Some are example, it can be used initially when choosing what types of
simplified with an even cortical thickness throughout the physical tests to perform. Other applications would be to
bone and some use the grey-scale values from the CT data simulate different types of fractures, various stages of the
as the basis for defining the cortical thickness. The best healing process, different loads and positions of the body,
approximation of the bone materials properties is likely to and combinations of the factors mentioned above. Hence, it
be achieved by setting bone material properties which vary can be used to study fixation methods, suitable body
with the CT image density of the bone (Li et al. 2012). movements during rehabilitation, optimisation of new plates,
At the present time, this was not compatible with verification of the strength of customised implants, etc.
importing the load case from the AnyBody software. As described in the methods chapter, the loading case
In order to apply the load case to the STL mesh, the latter (xml) has to be combined with a mesh file (STL) to form the
needs to be slightly rescaled and reoriented to match the input file to the FE solver (at least while using a standard FE
biomechanical model. However, when applying the solver). A conclusion of the work is that this way of
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material properties based on the CT density, the STL combining the bone mesh file (STL) with the loading case
mesh cannot be rescaled and must be in the origin position. (xml) and working with a so-called orphan mesh in the FE
Furthermore, since it turned out that the influence of the solver is time consuming and not suitable for quick analysis
material definition in the inner part of the bone had small of many different fixation devises. After importing the mesh
impact on the resulting stresses in the plate; it was assumed together with the muscle and ligament forces, the mesh
that detailed bone material definition is not the most should be replaced by a solid model of the bone, and then it is
crucial part in this type of study. possible to create new screw holes in the solid model and
The stresses at the holes edges and the edge of the hence quickly simulate different fixation devices and plate
reconstruction segment were in the order of 400 – positioning. This will be a first part of the further work.
460 MPa. The yield stress limit for the stainless steel Another important continuation of this work is to do more
(316 L) used in these plates differs between 190 and sensitivity analyses of the model and to compare stress
690 MPa depending on the model of plate used (Disegi distribution between superior and anterior plate position,
2009). These maximum stresses are local edge stresses plating with and without lag screw in the fracture gap and in
which may seem high for lifting a load of 0.5 kg; however, plates with different shape. The screw–bone interaction is
the forces on the clavicle from the muscle and ligaments in also interesting and could be modelled in better detail. It is
this position of the arm are in fact relatively high (Table 1) especially interesting for the fixation of fractures in
and hence will result in high stresses in a small cancellous (osteoporotic) bone. That is usually not the case
reconstruction plate with tapering reconstruction seg- for midshaft clavicle fixation, but in other areas, primarily in
ments. Furthermore, the fracture is in such a position that, proximity to joints, that is of high interest for the surgeons
together with a plate in current position, the present load and will be dealt with in further similar studies.
case tends to open up the fracture and the fracture edges do
not come into contact. The maximum stress in the bone
without fracture, screw holes and plate was 16 MPa, and Acknowledgements
when the smallest cross-sectional area on the plate is The authors thank Joakim Asklund at Abaqus for the support with
Abaqus CAE, the physicians Börje Samuelsson and Tryggve
subjected to the same load, it seems reasonable to assume Ericsson at Östersund Hospital and the assistant tutors Lars-Erik
that stresses in this magnitude will occur. Rännar and Mikael Bäckström, for their contribution to the study.
Based on the stress analysis of the plate, the areas
exposed to the highest stresses are the edges of the holes
and the reconstruction segments in the middle of the plate. Funding
According to these results, it is favourable to use a plate This work was funded by Swedish Agency for Economic and
without reconstruction segments in the middle section. Regional Growth – Tillväxtverket, European Regional Devel-
Furthermore, the plate could be designed with a reduced opment Fund.
thickness at the outer ends, where the stresses are low,
in order to make it smoother and less intrusive under the
skin. As this is an initial model, which has not yet been Notes
validated, more work is needed before it can be used to 1. [email protected]
draw applicable conclusions. 2. [email protected]
 Computer Methods in Biomechanics and Biomedical Engineering 9

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