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Locking Plates: Tips and Tricks

Wade R. Smith, Bruce H. Ziran, Jeff O. Anglen and Philip F. Stahel
J Bone Joint Surg Am. 2007;89:2298-2307.

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Selected
Instructional
Course Lectures
The American Academy of Orthopaedic Surgeons
PAUL J. D UWELIUS
EDITOR, VOL. 57

C OMMITTEE
PAUL J. D UWELIUS
CHAIRMAN
FREDERICK M. A ZAR
KENNETH A. E GOL
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E X -O FFICIO
D EMPSEY S. S PRINGFIELD
DEPUTY EDITOR OF THE JOURNAL OF B ONE AND JOINT SURGERY
FOR INSTRUCTIONAL COURSE LECTURES

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EDITOR-IN-CHIEF,
THE JOURNAL OF BONE AND JOINT SURGERY

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presented at the Academy’s Annual Meeting, will be available
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Locking Plates: Tips and Tricks

By Wade R. Smith, MD, Bruce H. Ziran, MD, Jeff O. Anglen, MD, and Philip F. Stahel, MD
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Locking plates are fracture fixation de- well as the general interest of the public main biomechanical difference from
vices with threaded screw holes, which in “minimally invasive” surgery. conventional plates is the fact that the
allow screws to thread to the plate and While locking plates have been latter require compression of the plate
function as a fixed-angle device1-3. These used for years in specialized research to the bone and rely on friction at the
plates may have a mixture of holes that trials, they have been available in North bone-plate interface. With increasing
allow placement of both locking and America for general orthopaedic appli- axial loading cycles, the screws can be-
traditional nonlocking screws (so- cations only in the last six or seven gin to toggle, which decreases the fric-
called combi plates)4,5. The first locking years13-15. Currently, numerous com- tion force and leads to plate loosening.
plates were introduced about two de- panies offer a variety of locking plate If this occurs prematurely, fracture in-
cades ago for use in spinal and maxillo- systems for treatment of extremity stability will occur, leading to implant
facial surgery6-8. In the late 1980s and fractures. Many of these systems have failure. Thus, the more difficult it is to
into the 1990s, experimentation with been on the market for only a couple achieve and maintain tight screw fixa-
various types of internal fixation de- of years. Given the increased expense tion (as for example, in metaphyseal
vices led to the development of locking of these plates compared with that of and osteoporotic bone), the more diffi-
plates for fracture care9-11. The initial traditional nonlocking equipment and cult it is to maintain stability.
emphasis was on developing stable the short time that they have been avail- This biomechanical prerequisite
fixation that would not require exten- able for general use, it would seem fair of conventional plates is associated
sive soft-tissue stripping or disruption12. to ask: What are the advantages and dis- with biological pitfalls due to compres-
The clinical care impetus for develop- advantages of locking plates? What are sion of periosteal blood supply and
ment of these plates has been a com- the indications and contraindications? compromise of the vascularity of the
bination of factors, including the How do we use them effectively? How fracture. Thus, conventional plate os-
increasing survival of patients with can failures be avoided? The objective teosynthesis with rigid fixation (e.g.,
high-energy injuries, aging Western of this review will be to address these interfragmentary compression and lag
European and North American pop- questions and provide practical infor- screws) has been associated with a sub-
ulations with an increasing rate of mation and tips for the practicing or- stantial complication rate, including
fragility fractures, and dissatisfaction thopaedic surgeon. infection, hardware failure, delayed
of patients and surgeons with the out- union, and nonunion12,16.
comes of treatment of specific periar- What is a Locking Plate? In contrast, locking plates follow
ticular fractures. Nonclinical factors Any plate that allows the insertion of the biomechanical principle of external
likely include a push by industry for fixed-angle/angular-stable screws or fixators and do not require friction be-
new technology and new markets as pegs can be used as a locking plate. The tween the plate and bone. They are con-

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor
a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a com-
mercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center,
clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or
associated.

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sult of the difference in the mechanics

of conventional plate and locking plate
fixation3,14,17,28-30. As mentioned above,
locking plates do not depend on the
bone-plate interface. Stability is main-
tained at the angular-stable screw-plate
interface. As a result of this stable mono-
block of the locking internal fixator, the
pullout strength of locking head screws
is substantially higher than that of con-
ventional screws3,14,17,28-30. Because the
screws are locked to the plate, it is dif-
ficult for one screw to pull out or fail
unless all adjacent screws fail.
The increase in stability provided
by locking plates is most helpful to sur-
geons treating a fracture in poor-quality
bone, a comminuted bicondylar frac-
ture, or any highly unstable fracture
for which a single plate may not pro-
vide adequate stability. Also, since only
a single plate is needed and the plate
Fig. 1 does not depend on a tight fit to the
Minimally invasive, percutaneous locking plate fixation. The locking drill sleeves are attached to bone for stability, substantially less soft
the proximal and distal ends of the locking plate through a skin incision and counterincision. tissue dissection may be required, thus
These drill sleeves serve as joysticks and provide a frame in which to move the plate into perfect preserving the local blood supply and
position under fluoroscopic control. The plate is attached to a strong suture (arrow) to pull it enhancing fracture-healing12,28,31.
through the submuscular plane and to help to remove it if that is required during surgery. The biomechanical and biologi-
cal advantages of locking plate systems,
compared with conventional plates,
sidered to be internal fixators from a cial features such as outriggers, jigs, and have led to a widespread use of these
biomechanical standpoint since the blunted ends to enhance the surgeon’s new implants in recent years23,26,32-41.
angular-stable interface between the ability to pass the plate in a submuscu- However, the effective and successful
screws and the plate allows placement lar or subcutaneous manner for mini- use of locking plates and of minimally
of the plate without any contact to the mally invasive application23-27 (Fig. 1). invasive techniques remains highly
bone1,3,14,15,17. In essence, however, lock- challenging and is associated with a
ing plates can be considered to be exter- Principles of Locking substantial learning curve. The uncri-
nal fixators placed underneath the skin Plate Fixation tical use of locking plates for a broad
envelope, although they are more sta- Comminuted intra-articular fractures, range of undifferentiated indications
ble as a result of the shorter distance be- such as bicondylar tibial plateau and is associated with substantial pitfalls
tween the plate and the bone. Many distal femoral fractures, are highly un- and has led to new patterns of failure
conventional plates now have locking stable. After an anatomic joint reduc- of fracture fixation in recent years42-46.
counterparts. There is an increasing trend tion is achieved, the articular segment Thus, the surgeon working with locking
by manufacturers to supply anatomy- must be reconnected to the shaft while plates must be well aware of the indica-
specific plates with locking options. appropriate alignment is maintained. tions and contraindications, technical
Examples include anatomically pre- Achieving adequate stability for fracture- tricks, advantages and limitations, and
shaped plates for the proximal and dis- healing is difficult in the presence of typical pitfalls and adverse events asso-
tal parts of the femur, proximal and metaphyseal or metaphyseal-diaphyseal ciated with these new implants2,13,28,47.
distal parts of the tibia, proximal and comminution. An additional medial
distal parts of the humerus, and cal- buttress in the form of a plate or an ex- Disadvantages
caneus18-22. In many cases, the design of ternal fixator may be required when a of Locking Plates
the plate allows substantially less con- conventional laterally based plate is Locking plates are substantially more
tact between the plate and bone, in an used. Locking plates potentially pro- expensive than conventional plates.
attempt to preserve the periosteal blood vide increased stability in these cases They are also unnecessary for many
supply and bone perfusion. Increas- to a degree that a second plate is not re- fractures. Locking plates are more diffi-
ingly, locking plate systems have spe- quired. The increased stability is the re- cult to use to help achieve an adequate
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higher risk of loss of reduction and plate

or screw failure with subsequent non-
union. These are often termed “un-
solved” or “problem” fractures and
include comminuted intra-articular
fractures, short-segment periarticular
fractures, and fractures in osteopenic
bone. These injury patterns represent
the typical spectrum of indications for
locking plates.
However, decision-making regard-
ing the use of a locking plate must in-
clude precise preoperative consideration
of the exact principle by which the lock-
ing plate will be used. (“What’s your
plan?”) The main indications for the use
of a locking plate include four different
“classic” principles47: (1) the compres-
sion principle, for osteoporotic diaphy-
seal fractures; (2) the neutralization
principle, also for osteoporotic diaphy-
seal fractures; (3) the bridging principle
(“locked internal fixator” principle), for
comminuted diaphyseal or metaphyseal
extra-articular fractures; and (4) the
combination principle (“combi plate”
principle), for comminuted metaphy-
seal intra-articular fractures.
The surgeon using a locking
Fig. 2 plate for fracture fixation must be well
Primary malreduction with the use of a locking plate for fixation of a distal femoral fracture (A) aware of the exact indication, accord-
and a tibial shaft fracture (B). A fundamental biomechanical difference between locking plates ing to these four different principles, for
and conventional plates is that locking head screws do not pull the bone to the plate but lock which the angular-stable implant will
into the plate in the identical position. These two examples of malreduced fractures empha- be used (Table I). For simple, non-
size the notion that adequate reduction has to be achieved before a fracture is fixed with a
comminuted diaphyseal fractures in
locking plate.
osteoporotic bone requiring an open
reduction and rigid internal fixation,
locking plates offer the advantage of
reduction. Particularly with specialty they do not improve the fracture re- increased pullout resistance of the lock-
plates, which have only locking holes, duction and cannot help a poorly re- ing head screws compared with that of
fracture reduction must be achieved duced fracture to heal. For example, if conventional screws. Thus, for these
primarily, before plate fixation. Once a the final fracture construct is too stiff, fractures, locking plates can be applied
locking screw has been placed through particularly when a bridging technique according to the compression principle
the plate into bone, this particular bone is used, nonunion may occur. The com- through eccentric placement of screws
segment can no longer be manipulated bination of a stiff plate, stiff screws, and in the dynamic compression unit of the
by insertion of additional screws or by fracture distraction is a formula for “combi hole” or by the use of a com-
using compression devices. This makes nonunion (Fig. 3). pression device after initial placement
the sequence of screw placement critical of one locking head screw on the other
in order to avoid fracture malreduction Indications side of the fracture. On the basis of the
(Fig. 2). Surgeons who use locking Most fractures undergoing operative same rationale, locking plates can also
plates need a variety of reduction tech- treatment do not require a locking plate. be used according to the neutralization
niques such as “no-hands” traction, The majority heal with conventional principle to protect a lag screw in os-
femoral distractors, and percutaneous plates or intramedullary nails, provided teoporotic bone, with increased pullout
clamps48. The surgeon must keep in that the principles of safe surgery are resistance of the locking head screws.
mind that, despite the “advanced tech- followed. There are specific fractures, However, it is crucial to understand that
nology” of expensive locking plates, however, that are associated with a locking head screws can never provide
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TABLE I Indications for Locking Plates

Biomechanical Typical Anatomic

Indication Principle Technique Bone Quality Location
Comminuted Bridging Locked internal fixator Normal or osteopenic Femur, tibia, humeral shaft
shaft fractures

Comminuted Combination Combined (lag screws for articular fixation, Normal or osteopenic Distal part of femur, distal
metaphyseal intra- locking head screws for metaphyseal part of tibia
articular fractures bridging)
Short-segment Bridging or Locked internal fixator Normal or osteopenic Proximal part of humerus,
metaphyseal fractures combination distal part of humerus, distal
part of radius, proximal part
of tibia

Simple fractures in Compression Dynamic compression with eccentric Osteopenic Osteoporotic forearm
osteoporotic bone screw placement or a compression device,
locking head screws for shaft; tension de-
vice with locking head screws only

Simple fractures in Neutralization Conventional lag screw, locking head Osteopenic Osteoporotic ankle
osteoporotic bone screws for neutralization plate

interfragmentary compression. Com- The classic and ideal indications tion—either high-energy fractures in
pression can be achieved only by the use for fracture fixation with locking plates young patients or low-energy osteo-
of a compression device or by eccentric are represented by the bridging princi- porotic fractures in elderly patients.
placement of conventional screws in the ple and the combination principle (Ta- The bridging principle is typically rep-
“combi hole” of a combination locking ble I). Both concepts apply to fixation resented by the concept of minimally
plate (lag first, then lock)5,28,30,47. of fractures with substantial comminu- invasive percutaneous plate fixation
(also referred to as the “MIPO” or
“MIPPO” technique), whereby the
angular-stable plate is used as an inter-
nal splint that bridges the comminuted
fracture. With this method, indirect
reduction is performed by ensuring
adequate axial alignment, length, and
rotation of the extremity while the
fracture fragments are not exposed
or directly reduced. In contrast to the
compression and neutralization prin-
ciples, which provide absolute rigid
stability leading to primary (direct)
fracture-healing, the bridging concept
provides relative, elastic fixation that
leads to secondary (indirect) fracture-
healing by callus formation. For ade-
quate bridge plate fixation, three or
four holes of the plate should be left
empty at the level of the fracture, as
discussed below (in the Tips, Tricks,
and Pitfalls section).
The combination principle refers
Fig. 3 to a biomechanical mixture of compres-
Locking plate fixation of a simple fracture of the radial shaft, leading to nonunion. The use of sion and bridging with only one im-
locking plates is contraindicated for simple fractures that require interfragmentary compression. plant. Although the original locking
In this case, three locking head screws were used on each side of the fracture (arrows in panel plates available for fracture fixation,
C), whereas the dynamic compression holes of the combi plate were left empty. This stiff con- such as the point contact fixator (PC-
struct led to a nonunion within a few months after the surgery. Fix) and the less invasive stabilization
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TABLE II Contraindications for Locking Plates

Expected
Contraindication Wrong Technique Example Adverse Outcome
Simple fractures Locked internal fixator Simple forearm or humeral shaft Nonunion
fracture

Simple fractures Minimally invasive percutaneous Simple distal tibial fracture Nonunion
plate fixation

Displaced intra-articular fractures Locked internal fixator Tibial pilon fracture Malunion, arthritis

system (LISS), provided all of the in- ing compression plate (LCP), which (e.g., metaphyseal-diaphyseal commi-
novative biomechanical and biological was designed by Robert Frigg (Bettlach, nution) at a different level. Under these
properties of angular-stable devices, Switzerland) on the basis of an idea circumstances, the plate can be used to
surgeons expressed the desire to use a from Prof. Michael Wagner (Vienna, achieve interfragmentary compression
combination of both concepts, locking Austria)4,5,15,28. of the simple fracture pattern by means
and compression plate fixation, with The combination technique is in- of a dynamic compression technique or
only one implant. This option was dicated for fixation of fractures with a placement of a lag screw through the
made available for the first time in the simple pattern (e.g., an intra-articular dynamic compression unit of the plate.
early twenty-first century by the lock- split) at one level and comminution Thereafter, the plate can be used as a

Fig. 4
Typical patterns of failure of locking plate fixation of prox-
imal humeral fractures. Although the locking plate tech-
nique has revolutionized the surgical fixation of this
fracture in recent years, typical failure patterns occur
with locking plates whenever basic concepts and techni-
cal principles are not respected. Secondary loss of reduc-
tion with varus collapse can occur as a result of use of
screws of inadequate length in the humeral head frag-
ment and inappropriate fixation of locking head screws in
the plate (arrows in panels A and B). The interfaces be-
tween the locking head screws and the threaded plate
holes should not fail if the screws are inserted at the per-
fect angle and attached with a torque-limiting screw
driver. Increased strain in a construct with too much stiff-
ness and exposure to high rotational forces will lead ei-
ther to breakage of the plate in the dynamic compression
part of the combi hole, which is the weakest part of this
construct (panels C and D) or, more rarely, to a failure at
the screw-plate interface with breakage of the screws (as-
terisks in panel B). If the locking screws in the head part
of the fracture are too long, they may protrude into the
glenohumeral joint, since locking head screws cannot re-
cede backward, as conventional screws can. This failure
pattern is particularly frequent if the fracture is malre-
duced in varus, as demonstrated in panel E.
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locked internal fixator to align the ar-

ticular fragment to the shaft in a bridg-
ing manner. The combination principle
is feasible only with plates that allow
placement of both locking head screws
and conventional compression screws
in one implant47.

Contraindications
Despite the widespread use of locking
plates and their wide range of indica-
tions, a few contraindications must be
acknowledged and respected (Table II).
The uncritical use of locking plates
may lead to failure of fixation and to
nonunion, particularly if the above-
mentioned standard principles for use
of locking plates are violated. A typical
contraindication to the use of a locking
plate as a locked internal fixator is a
simple fracture pattern that requires in-
terfragmentary compression. For exam-
ple, simple diaphyseal fractures of the
forearm fixed with a plate with a locked Fig. 5
internal fixation technique are prone to Relationship of working length and strain at the level of the fracture for the locked internal fixator
nonunion (Fig. 3). Similarly contrain- principle. When a fracture is bridged with a locking plate, three or four plate holes should be
dicated is percutaneous locking plate left empty at the level of the fracture in order to increase the working length and decrease the
fixation of simple fractures with use of strain and stress concentration on the plate (A). In contrast, if a locking construct is made too
a minimally invasive technique. This stiff with too many screws at the level of the fracture (B), the short working length will lead to
concept violates the principle of the increased strain and stress concentration with loading and torsional forces, causing the plate
fracture gap width in relation to strain to break42,47,49.
and thus leads to nonunion, as de-
scribed in an excellent review article
by Stephan Perren12. Finally, indirect Tips, Tricks, and Pitfalls of technical success. The preoperative
reduction and locking-plate fixation Successful use of locking plates de- plan also ensures that the surgeon will
are contraindicated for displaced intra- pends on adherence to established prin- have all necessary implants available at
articular fractures, since these injuries ciples of operative fracture care and the time of surgery.
require anatomic open reduction and learning the tricks of the specific tech- Correct positioning of the pa-
rigid interfragmentary compression. nology. Gautier and Sommer recently tient is vital, particularly if the plan calls
Because of their cost, locking presented prudent guidelines that may for minimally invasive or percutaneous
plates are relatively contraindicated improve the individual learning curve insertion of the implant. The surgeon
for fractures that can be stabilized of surgeons who are less familiar with should ensure that all necessary images
satisfactorily with conventional plates. these new implants47. are obtainable prior to preparation and
For example, diaphyseal forearm frac- In general, successful use begins draping of the patient. A radiolucent ta-
tures have healing rates in excess of 90% with a formal preoperative drawing. ble is very helpful. Tightly rolled bumps
with conventional plates. While there The advent of digitized radiography at of different sizes fashioned prior to the
are some claims that, theoretically, the many centers requires that digital tem- operation can aid in fracture reduction
use of unicortical locking plates should plates be available. If plain radiographs as well as visualization, particularly in
increase healing rates because of the are used, utilization of tracing paper is the lateral plane. Fracture reduction can
lack of soft-tissue stripping, this has not still the most effective way to draw a be challenging with locking plates be-
been validated in any type of controlled preoperative plan. The sequence of cause the locking screws do not pull the
trial, to our knowledge. Overuse of screw placement, the length and posi- plate to the bone in the manner of con-
these plates in some health-care systems tion of the plate, and the surgical ap- ventional screws. Therefore, it is essen-
may negatively impact overall patient proach are all critical to success. A tial that the surgeon have a preoperative
care by consuming resources that could precise preoperative plan reduces the plan for fracture reduction. Combina-
be better used elsewhere. guesswork and increases the likelihood tions of traction to correct length and
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TABLE III Decision-Making for the Use of Unicortical or Bicortical Locking Head Screws

Screw Bone Fracture Working

Placement Quality Location Length Comments
Unicortical Normal Diaphysis Adequate Except for fractures exposed to high rotational forces;
e.g., in humerus

Bicortical Normal and Diaphysis and metaphysis Adequate Use self-tapping but not self-drilling screws for
osteopenic bicortical fixation

Unicortical Normal Metaphysis Inadequate Except for minimally invasive use of self-drilling/self-
tapping screws or short-segment metaphyseal frac-
tures (e.g., in proximal part of humerus)

Unicortical Osteopenic Diaphysis and metaphysis Inadequate Contraindication for unicortical screws

alignment in the anteroposterior plane tribution on the plate (Fig. 5). In tapping screws is the selection of an in-
and placement of bumps under the ex- contrast to conventional plates, which adequate screw length. If the screw is
tremity to correct lateral plane deformi- fail at the interface between the screws too short, the threads in the near cortex
ties can successfully permit reductions and the plate—often leading to break- will not have enough purchase and the
with minimal direct manipulation of age of conventional screw heads—the locking monoblock frame is prone to
the fracture fragments. Specialized re- interface of the locking head screw with failure by pullout with cyclic loading
duction clamps can be used judiciously the threaded locking hole is the stron- (Fig. 6). In contrast, if the unicortical
with percutaneous long-bone and peri- gest part of the locking plate system. screw is slightly too long, the nondrill-
articular reductions. Conventional Locking screw heads are less likely to ing screw tip will push off from the far
screws or “whirlybird” push-pull types break since the difference between the cortex, thus destroying the tapped
of devices can be used to pull the bone core diameters of the screw shaft and thread in the near cortex.
to the plate initially to secure fracture head is much smaller than it is with The pullout resistance of uni-
reduction. Once the fracture is re- conventional screws. Nevertheless, cortical locking head screws is almost
duced, then locking screws can be locking head screws can break in cases identical to that of similar-diameter
added as needed to provide stability. of chronic instability and increased bicortical conventional screws and
Effective use of locking plates re- strain as a result of rotational forces, about 70% of that of bicortical locking
quires an understanding of the poten- as is exemplified by proximal humeral head screws. Thus, how much pullout
tial pitfalls of usage. Locking holes offer nonunion shown in Figure 4 (panel B). strength is needed? There is no way to
minimal opportunity for screw angula- Locking plates allow the use of objectively judge this, nor is it neces-
tion. More than 5° of angulation be- both bicortical and unicortical locking sarily important, because these con-
tween the screw and the locking hole head screws. The choice of screw type structs rarely fail through pullout per
can cause the screw to eventually fail. (self-drilling/self-tapping or self-tapping se. Two factors are essential for deci-
Careful technique is necessary to en- only) and screw length (unicortical or sion-making with regard to the use of
sure that the screw is perfectly lined up bicortical) needs to be based on de- unicortical or bicortical locking head
with the axis of the screw threads in the fined principles in order to avoid screws. These are, first, the quality of
plate. This may be quite difficult in a complications. As a general rule, self- the cortical bone and, second, the ex-
minimally invasive procedure. Mala- drilling/self-tapping screws, as are used tent of rotational forces applied to the
ligned screw threads can lead to loose in minimally invasive locking plates fractured bone. Cortical thickness is of
screws and loss of reduction (Fig. 4). (such as the LISS), should be employed great importance in determining the
The weakest part of the combi locking exclusively in a unicortical fashion. adequacy of the working length of uni-
plate (e.g., the LCP) is the dynamic The main reason is that self-drilling cortical screws47. The working length of
compression unit. This is the part of the screws have sharp tips that may cause a unicortical screw in good-quality cor-
plate that should be used for bending, if neurovascular and/or soft-tissue dam- tical bone usually provides sufficient
required, and it is the part that breaks age across the far cortex. Furthermore, pullout resistance equaling the pullout
when there is increased stress concen- drilling of the far cortex with self- strength of a bicortical conventional
tration and strain on the plate17,42. For drilling/self-tapping screws may lead screw, as mentioned above. In contrast,
this reason, when a bridge plate is used to simultaneous disruption of the in metaphyseal bone and osteoporotic
to fix a comminuted fracture, at least tapped thread in the near cortex and cortical bone, the cortex is usually very
three or four plate holes should be left thus reduce the overall purchase of the thin, thus rendering the working length
empty at the level of the fracture, in or- locking head screws. Similarly, a pitfall of unicortical screws insufficient. This
der to achieve a larger area of stress dis- with unicortical placement of self- reduction in pullout strength is of par-
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ticular importance when osteoporotic healing. Additionally, unicortical by overtightening or cross-threading

bone is mainly loaded by torsional screws are less stiff than bicortical lock- (“cold-welding”) into the plate can
forces such as occurs in the humerus. ing screws. Unicortical screws are indi- make hardware removal very difficult.
Under these conditions, an adequate cated for periarticular fractures in This happens more often with the mini-
working length must be achieved by which the screws are placed in the di- mally invasive technique, which can re-
using bicortical locking head screws, rection of an articular surface, such as sult in stripping of the screw heads and
as outlined in Table III. in the proximal part of the humerus. angulation of the screws because of the
For these reasons, bicortical fixa- Locking head screws have some difficulty in judging orientation with-
tion is recommended for osteoporotic peculiar differences from conventional out direct visualization. In contrast to
bone in general and for metaphyseal screws. While these differences may the situation with conventional screws,
fractures in bone of normal quality. seem intuitively obvious, they have im- the purchase of the screw in the bone
Also, unicortical screws should not be plications with regard to clinical appli- cannot be felt, since locking head screws
used in anatomic locations exposed to cation. The first difference is that a always feel tight. Unfortunately, the
high rotational forces, such as the hu- torque-limiting screwdriver is useful tight feel is deceptive. Many fracture
meral shaft. In fact, the only advantage during placement of the locking head surgeons, through years of experience
of using unicortical screws may be the screw. The advantage of the use of a and training, have developed a tactile
lack of penetration of the bone and pe- torque-limiting device is that, as long as feedback loop based on how the screw
riosteum on the far side of the bone, the screw is centered in the hole, the “feels” as it tightens down. The fixation
and this advantage is highly debatable thread cannot be stripped or overtight- can still fail despite “tightness” of the
as far as its true impact on fracture- ened. Deformation of the screw heads screws, particularly if there is substan-
tial malreduction (Fig. 2) or if the
screws are cross-threaded or not ade-
quately locked in the plate (Fig. 4, pan-
els A and B).
One strategy that is used to over-
come this problem is to carefully place
perpendicular 2.0-mm Kirschner wires
in the most distal and proximal plate
holes prior to screw insertion. To ensure
that the wires are truly perpendicular,
they should be placed through the lock-
ing drill guides. Alignment can then be
checked by looking for the round “bull’s-
eye” of the drill guide in the locking
hole on the lateral radiograph. These
wires will maintain length and can also
serve as a reference for subsequent
placement of screws. Alternatively, a
drill bit can be left in place through the
drill sleeve to hold the plate in place
temporarily, until an adequate reduc-
tion is achieved.
Although minimally invasive
techniques have been improved in re-
Fig. 6
cent years by the introduction of lock-
Inappropriate use of unicortical locking head screws. Several errors in concept and technique
ing plates, achieving and maintaining
led to failure of the fixation of this simple humeral shaft fracture. The plate was used as a bridg-
an adequate reduction remain sources
ing locked internal fixator, holding the fracture in distraction and rendering it prone to nonunion
of pitfalls and failures. Sliding any mini-
(A). Furthermore, the fracture was fixed by only two unicortical locking head screws on each side, mally invasive plate in the submuscular
which is insufficient for fixation of a humeral shaft fracture exposed to high rotational forces (Ta- plane along the bone can be challeng-
ble II). Finally, some unicortical screws that were placed without sufficient purchase in the near ing. There are a number of strategies
cortex had no pullout resistance at all (C). This inadequate locking plate fixation failed early after for aligning the plate along the bone
the surgery (B) and was revised with use of a conventional compression plate. The fracture percutaneously. Kirschner wires can
healed fully within three months. It is important to emphasize that locking plates usually fail as a be inserted manually just anterior
monoblock if the locking head screws are properly attached to the threaded plate holes, as de- and posterior to the bone to mark the
picted in panel D. boundaries for plate passage. The plate
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VO L U M E 89-A · N U M B E R 10 · O C T O B E R 2007

is then passed between the wires, and Malreduction can result in failure ficult than the placement of conven-
the wires will prevent posterior or ante- regardless of whether the plate is con- tional plates. Fracture reductions are
rior deviation of the plate. Another tac- ventional or locking. Common prob- often done indirectly, the locking screw
tic is to make 4 to 6-cm incisions at the lems include varus in the proximal part must be carefully aligned along the axis
proximal and distal sites of the plate. of the humerus and distal part of the fe- of the receiving hole to ensure proper
With use of blunt dissection down to mur and distraction in diaphyseal frac- tightness, and the length of the plate
bone, the plate can be directly visual- tures (Figs. 2, 3, and 4). In many cases, must be selected carefully. Despite the
ized as it passes into the wound. Lock- locking plates are used as bridge plates necessity of mastering these nuances,
ing drill sleeves should be attached to in the presence of substantial commi- the use of locking plates will likely in-
the most proximal and distal holes of nution. Plates that are very stiff or stiff crease, particularly with the increasing
the plate to form a frame for easier po- fracture constructs with too many prevalence of fragility fractures in our
sitioning of the plate on the bone as de- screws can lead to nonunion and even- aging population and the increase in
picted in Figure 1. This way, the plate tually plate failure (Fig. 5). Bridge plates high-energy fractures in younger pa-
can be centered on the bone at each end must be longer, and fewer screws are tients surviving severe trauma. While a
and anchoring screws can be placed un- needed. For the treatment of periarticu- substantial amount of biomechanical
der direct visualization. If the fracture lar fractures, few screws are needed in and animal data have been published,
is well reduced with regard to length, the diaphysis but more screws may be few series have validated the long-term
alignment, and rotation, then the plate required near the articular surface. The advantages of fixation with locking
will be appropriately positioned along precise length of the bridge plate and plates. The initial results in series that
the entire length of bone when it is cen- the number of screws needed for a spe- included a variety of fractures are en-
tered at each end. The plate must be cific fracture remain controversial. In couraging, although it is increasingly
held to the bone by first placing a con- general, the length of the plate should apparent that failures do occur. The
ventional screw or a “whirlybird” tool, be more than two times the length of causes of failure should be examined
since the placement of a self-drilling/ the fracture zone. Screws should be carefully in both the literature and one’s
self-tapping screw will push the plate spread evenly, and ideally there should own practice in order to learn from
away from the bone and may cold-weld be at least one empty hole between each mistakes and refine our techniques.
the screw head to the plate. Since the pair of holes filled with screws. As
incisions are distant to the fracture site, mentioned above, when the bridging
the principle of minimally invasive fixa- principle is used, three or four screw
tion is preserved, as the fracture frag- holes should be left empty at the level Wade R. Smith, MD
ments and soft-tissue attachments are of the fracture to avoid a local stress Philip F. Stahel, MD
undisturbed. concentration, which may lead to Department of Orthopedic Surgery, Denver
Locking plates, particularly the breakage of the plate42. The even dis- Health Medical Center, University of Colorado
School of Medicine, 777 Bannock Street, Den-
specialized so-called all-locking plates, tribution of force over a long working
ver, CO 80204. E-mail address for W.R. Smith:
require an approach to fracture reduc- plate length with relatively few screws [email protected]
tion that is completely different from appears to provide a stable stimulus
what most of us have practiced. When for indirect bone-healing and callus Bruce H. Ziran, MD
one begins to use locking plates, a good formation. Department of Orthopaedic Surgery, St. Eliza-
approach is to “start easy.” One should beth Health Center, Youngstown, OH 44501
consider initially using combination Overview
Jeff O. Anglen, MD
plates that permit the use of traditional Locking plate technology offers im-
Department of Orthopaedics, Indiana Uni-
reduction techniques. Lost in the cur- proved fixation stability in osteopenic versity School of Medicine, Indianapolis, IN
rent enthusiasm for this new technol- bone and for comminuted and periar- 46202
ogy is the recollection that ten years ago ticular fractures. The additional stabil-
almost no surgeons in the world were ity per screw compared with that of Printed with permission of the American
using locking plates routinely. Most of conventional nonlocking fixation en- Academy of Orthopaedic Surgeons. This arti-
the current high-volume experts in this hances the application of minimally in- cle, as well as other lectures presented at the
Academy’s Annual Meeting, will be available in
field started by practicing on Sawbones vasive fracture techniques such as use March 2008 in Instructional Course Lectures,
and attending workshops. This is a of bridge plates and percutaneous frac- Volume 57. The complete volume can be or-
good approach for anyone starting to ture stabilization. The application of dered online at www.aaos.org, or by calling
use these techniques. locking plates is somewhat more dif- 800-626-6726 (8 A.M.-5 P.M., Central time).

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