Techniques in Orthopaedics®

22(3):167–172 © 2007 Lippincott Williams & Wilkins, Inc.

Locked Plating: Biomechanics and Biology

Chiara M. Bellini, MSEng.,*† Manuela T. Raimondi, Ph.D.,*‡ Riccardo Accetta, M.D.,*§

Giuseppe V. Mineo, M.D.*¶

Summary: Conventional plate techniques have been widely used in the treatment of
humeral fractures. The controversial clinical outcome is believed to be related to the
reduced blood supply and to the presence of osteoporotic bone substance. In fact, the
compressive force under the plate prevents periosteal perfusion resulting in periosteum
and bone necrosis deep to the plate and adjacent to the fracture site, localized bone
resorption at the screw threads, and loosening of the implant. Furthermore, in the
presence of osteoporotic bone, it may become impossible to develop sufficient screw
torque to generate sufficient screw force to prevent micromotion. In light of the
encouraging results achieved in the management of metaphyseal fractures of the tibia
and femur, locking plates have recently been introduced for the treatment of humeral
fractures. These systems allow the screws to rigidly lock into the plate hole. Locking
plate systems decrease gap strain by minimizing motion whereas tolerating an
increased gap length. Strain at the fracture site is optimized so that secondary bone
healing with callus formation is favored over fibrosus nonunion or primary bone
healing. As internal fixators, locking plates no longer rely on frictional force between
the plate and bone thus allowing the local blood supply. Promising initial clinical
results have been reported. Regarding proximal humerus, biomechanical tests have
shown better fatigue resistance and stiffness of locked plates as compared with
conventional ones. Interestingly, in the case of distal humerus, comparative tests have
shown that the biomechanical behavior depends more on plate configuration than plate
type. Anyway, further clinical and biomechanical investigations are needed to under-
stand the indications for locked plating as opposed to conventional plating in the
treatment of humeral fracture. Key Words: Locked plate—Humeral fracture—
Biomechanics.

Fracture of the proximal humerus is a common prob-
lem that occurs in 73 per 100,000 people.13 It is a typical
injury of elderly people with osteporotic bone. Most of
the proximal humerus fractures in older, osteoporotic
adults are because of a direct blow on the lateral aspect
of the shoulder, although the classic fall on outstretched
hand may produce this fracture as well.192 Even if many
proximal humerus fractures in this osteoporotic popula-
From the *Istituto Ortopedico Galeazzi, Milan, Italy; †Department
of Bioengineering, Politecnico di Milano, Milan, Italy; ‡Department of
Structural Engineering, Politecnico di Milano, Milan, Italy; §Trauma
Surgery, Istituto Ortopedico Galeazzi, Milan, Italy; ¶Department of
Clinical Sciences at L. Sacco Hospital, Università degli Studi di
Milano, Milan, Italy.
Address correspondence and reprint requests to Giuseppe V. Mineo,
IRCCS Istituto Ortopedico Galeazzi, via R. Galeazzi 4, 20161 Milan,
Italy. E-mail: giuseppe.mineo@unimi.it
tion are treated conservatively, there is a clear trend
toward surgical treatment. Various fixation techniques
for two-part fracture have been analyzed; however, non-
consensus has been reached. Closed reduction and per-
cutaneous fixation offer biologic advantages, but these
techniques have frequently led to poor clinical results
because of the difficulty in achieving and maintaining
satisfactory reduction.9,15 Conventional plate fixation of-
fers higher stability but has been criticized for several
reasons. The main problem of plate fixation in the
humeral head is the anchoring of the screws in osteopo-
rotic bone. A typical resulting complication is the loos-
ening of the implant with varus dislocation of the
head.6,14 In light of the encouraging results achieved in
the management of metaphyseal fractures of the tibia and
femur, locking plates have recently been introduced for

167
168 C. M. BELLINI ET AL.
the treatment of proximal humeral fracture, with initial
promising clinical reports.
Distal humerus fractures in adults are relatively uncom-
mon. They account for about 2% to 6% of all fractures25
and for about 30% of all elbow fractures.26 Peaks of
incidence were described in males age 12 to 19 years and
females age 80 and older.25 The most common causes of
these fractures are falls in the elderly population and sports
injuries or road traffic accidents in the younger patients.12
Although relatively uncommon among joint injuries, com-
plication associated with malunion, elbow stiffness, and
subsequent decreased function are still relatively com-
mon.28 Fixation of these fractures remains a challenge
because of the restrict space for instrumentation at the distal
segment, the proximity to nerves of the upper extremity,
and the need to maintain repair integrity under a large range
of motion.18 Double-plate ostesynthesis is believed to be the
treatment of choice for this kind of fractures. Nevertheless,
unsatisfactory outcomes have been described especially in
the presence of osteoporotic bone. The reported cases of
nonunion o malunion are believed to be caused by the
reduced blood supply, related to the use of conventional
plate osteosynthesis.8 Because locking plates no longer rely
on frictional force between the plate and bone they have
been proposed for the treatment of distal humerus fractures.
This review will focus on the biomechanics of locked
plate system, with reference to the humeral experience. As
biologic aspects, i.e., mechanical stability and vascularity,
are well-known crucial determinants in the fracture healing
process, they deserve to be discussed as well.
BRIEF SUMMARY ON BIOLOGIC ASPECTS IN
FRACTURE HEALING
Stability
Primary bone healing, also known as direct or osteonal
healing, occurs under an absolutely stable fixation condi-
tion. This is attained through a combination of anatomic
reduction and compression of the fracture segments. With
the compression load and the friction between the frag-
ments, relative movement between the fragments is
avoided. Primary healing involves intramembranous bone
formation and direct cortical remodeling without external
callus formation. An advantage of absolute stability is that
the blood vessels may cross the fracture site more easily and
lead to faster revascularization.17 In contrast to callus heal-
ing, there is no increased bone diameter under direct os-
teonal healing. This limits the load-bearing capacity of the
healing bone, which consequently requires a longer period
of contention by the implant.
In the presence of interfragmentary movements sec-
ondary bone healing occurs. Secondary bone healing
Techniques in Orthopaedics®, Vol. 22, No. 3, 2007
involves a sequence of tissue regeneration processes by
which the bone fragments are first stabilized by means of
an external callus. The process of bone repair by second-
ary healing can be divided into 4 stages16: inflammation,
soft callus, hard callus, and remodeling. The hard callus
formation begins in areas remote from the fracture and
progresses toward the fracture until the distal and prox-
imal callus wedges unite. The increase in callus diameter
gets the healing region stiffer.
Bone Vascularity
Blood supply is necessary for the nutrition of the
healing zone, and an insufficient blood supply is likely to
result in a delayed union or even atrophic nonunion.29
However, even a well-vascularized fracture healing zone
will lead to a hypertrophic nonunion if the mechanical
stability is insufficient.27,29 Some studies show the gen-
eral effect of larger interfragmentary motions on revas-
cularization. In his fundamental work, Rhinelander24
demonstrated different patterns of vascularization under
stable and unstable fixation. He speculated that under
unstable fixation, capillaries required for osseous repair
are constantly ruptured and delay the fracture healing
process, resulting in the development of fibrocartilagi-
nous tissue.24 It is well accepted that instability in the
fracture healing zone prevents vascularization in the area
of callus mineralization and leads to fibrocartilaginous
tissue in the fracture gap.27,29 The deposition of fibrocar-
tilage may partially result from insufficient blood supply
whereas bone formation indicates adequate vasculariza-
tion under stable condition.1,4 However, few studies
quantitatively describe the relationship between the de-
gree of instability, expressed as interfragmentary move-
ments and the amount of vascularization in the fracture
healing zone. Wallace et al.31 quantified the blood supply
in an ovine tibia osteotomy model. They found that in the
early healing phase larger interfragmentary movements
led to an increase in corticomedullary blood supply than
smaller ones. However, after 6 weeks, a higher blood
supply was found in the periosteal callus for the more
stable group. Claes et al.2,3 quantified the effect of
different axial movements and fracture gap sizes on
tissue differentiation and vascularization in an ovine
metatarsal model. They found that greater interfragmen-
tary movements as well as greater gap sizes of the sheep
metatarsal led to significantly more nonvascularized fi-
brocartilage, less bone formation, and a smaller number
of vessels close to the periosteum than under smaller
interfragmentary and smaller gap sizes. Lienau et al.10
analyzed vascularization and tissue differentiation in an
ovine fracture healing model stabilized with either a rigid
or semirigid external fixator, differing in bending stiff-
 LOCKED PLATING
FIG. 1. Load bearing in a conventional plate construct: Fs, screw
force; Fc, compression force; Ff, friction force; Fl, longitudinal force.
ness. Stabilization performed by semirigid fixation dem-
onstrated larger interfragmentary movements and a re-
duced initial vascularization of the callus compared with
the rigid fixation. Apparently, these results are in con-
tradiction to those presented by Wallace et al.,31 probably
because of the different biomechanical conditions as-
sumed.10 Anyhow, further studies are required to deter-
mine the role and clinical relevance of stability for
vascularization and tissue differentiation, during the frac-
ture healing process.
Locking Plate Biomechanics
First, let us make some comments on conventional
plate biomechanics. With reference to Figure 1, when a
screw is inserted and tightened, a screw force normal to
the plate is generated. This force produces a compression
force (Fc) between the plate and the near cortex, which
multiplied by the coefficient of friction existing at the
bone/implant interface can give a maximum friction
FIG. 2. Newly designed distal humerus system: radial plate system
(a); ulnar plate system (b).
169
force (Ff). If a longitudinal force (Fl) applied to the plate
exceed the maximum friction force, the plate will slip on
the bone and a force equal to the difference between the
longitudinal force and friction force will be applied to the
screw head, resulting in micromotion between the screw
head and the plate, as well as the plate and the bone. In
the presence of osteoporotic bone, it becomes impossible
to develop sufficient screw torque to generate sufficient
screw force normal to prevent micromotion. Such motion
creates excessive gap strains that exceed the strains
conducive to bone healing. Furthermore, the compres-
sive force under the plate prevents periosteal perfusion
resulting in periosteum and bone necrosis deep to the
plate and adjacent to the fracture site.20 In turn, this can
lead to localized bone resorption at the screw threads and
result in loosening of the implant.
To avoid the ill effects of the plate/bone contact,
locking plates were introduced. These systems allow the
screws to rigidly lock into the plate hole. Locking plate
systems decrease gap strain by minimizing motion while
tolerating an increased gap length. Strain at the fracture
site is optimized so that secondary bone healing with
callus formation is favored over fibrosus nonunion or
primary bone healing. In a way similar in principle to the
external fixator, this quite different technique of applying
a plate has been termed the internal fixator system, as the
implant function more like a fixator than a plate, whereas
the whole construct is covered by soft tissues. As internal
fixators, locking plates no longer rely on frictional force
between the plate and bone to achieve compression and
absolute stability, thus allowing the local blood supply
under the plate to be preserved. The preserved periosteal
blood supply theoretically allows for more rapid bone
healing and decreased incidence of infection, bone re-
sorption, delayed union, nonunion, and secondary loss of
reduction. An additional theoretical advantage of the
locked plate system is the avoidance of stress shielding
below the plate.5 This prevents local bone necrosis and
improves the ability for resistance to infection.23
Biomechanical Evaluation Of Humeral Locking
Plates
The stability of a locking system is mainly determined
by the stiffness of the implant construct and the quality
of the connection between the screw and the bone. The
stiffness is described by the interfragmentary movements
occurring under external load. During fracture healing, if
the amount of interfragmentary movements is high, i.e.,
the amount of strain exceed 2% of fracture gap size,22 the
initial microstructure of the bridging tissue is repeatedly
disrupted. As a result, the contribution of the callus
formation to stabilizing the fracture is delayed.21 Preven-
Techniques in Orthopaedics®, Vol. 22, No. 3, 2007
170 C. M. BELLINI ET AL.
FIG. 3. Simplified free body diagram showing the forces acting on
the system (B, A, W), the lever arms (b, a, w) and the joint force (J).
tion of fragment movement are therefore thought to be
favorable for osteosyntesis and than for a given implant
the stiffer the better. Stiffness of locked plates as op-
posed to conventional plates has been evaluated in ex-
perimental tests as well as fatigue behavior under cycling
loading. Since the specimens used in these studies are
primarily from older individuals, the results might be of
considerable clinical relevance in patients with dimin-
ished bone mineral quality.
Biomechanics of locking plates in the treatment of
proximal humeral fracture has been evaluated in differ-
ent investigations. In an in vitro study, Lill et al.11
analyzed nonlocked and locked implants. The locked
screw plate was found to show the best results in osteo-
porotic bone anchoring. Walsh et al.32 compared a lock-
ing plate versus a standard plate in a cadaveric model.
They found that the locking plate displayed a greater
significantly holding power than did the traditional plate.
A comparison between locked and unlocked screws was
also performed by Seide et al.30 in a cadaveric model.
The authors concluded that locking screws increase the
stiffness and the fatigue load of plate osteosynthesis for
the proximal human region. Weinstein et al.33 in a
cadaveric model studied locking plate versus angled
blade plate. They found that locking plate provided better
torsional fatigue resistance and stiffness than the blade
plate. Thus, it can be concluded from the literature that
locked systems are biomechanically favorable in the
region of the humeral head.
Few comparative biomechanical data of locking plates
applied to the distal humerus are currently available. In a
human cadaveric model, Korner et al.7 examined the
Techniques in Orthopaedics®, Vol. 22, No. 3, 2007
FIG. 4. Loading and boundary conditions assumed in the finite
element model for both the radial (a) and the ulnar plate (b): a
concentrated force acting on the proximal screw (J); no displacement
allowed to the nodes belonging to the distal screw (encastre).
biomechanical behavior of two standard techniques of
double-plate osteosynthesis (dorsal or 90 degree config-
uration) using conventional plates and locking plates.
Stiffness testing in anterior/posterior bending, torsion,
and axial rotation loading was carried out as well as
cycling loading and strength testing under posterior
bending. The results showed that anterior/posterior bend-
ing and torsional stiffness were greatest for the speci-
mens 90-degree locking plates. No significant differ-
ences were found in axial compression. Under cycling
loading no statistically significant differences were
found although locking plates demonstrated a trend to-
ward less settling. Finally, strength testing did not dem-
onstrate any difference between types of implant, but
confirmed the results of previous studies indicating that
plate position is important. In fact, 90-degree plates
demonstrated significantly higher load-to-failure than
dorsal plates. Interestingly, a difference in the mode of
failure was detected: specimens implanted with standard
 LOCKED PLATING
FIG. 5. Results in terms of Von Mises stress acting in the radial plate.
plates tended to fail by loosening of the implant and
fractures of the bone, whereas most failures with locking
plates occurred by plastic deformation of the plate itself.
From the results of this study, advantages of locking
plate seem significant if compared with dorsal plate
application techniques.
FIG. 6. Results in terms of Von Mises stress acting in the ulnar plate.
171
Recently, a new locking plate system to treat distal
humerus fractures, particularly suitable for both intratro-
clear supracondilar and multifragmentary fractures was
designed at the Istituto Ortopedico Galeazzi in collabo-
ration with Politecnico di Milano. The system included a
precontoured radial plate and a precontoured ulnar plate
(Fig. 2). Both plates presented a tubular shape to be
placed on the lateral and medial edges of the distal
humerus. To allow the screws to reach a wider volume of
the distal humerus, a double set of staggered holes was
designed. From a surgical point of view, such a plate
system shows several advantages. First, to treat a wide
range of distal fractures only one plate is required: the
anatomic contour, the number, and position of the holes
in the distal area allow the humeral epicondyles to be
both controlled. To achieve fracture fixation, a single
step without multiple reduction is required. Furthermore,
a single surgical approach (lateral approach or medial
approach) is needed. A bilateral approach is required if
both the plates are used. To evaluate the designed plates,
a biomechanical analysis was conducted. For this pur-
pose, a 3-dimensional finite element model of both the
ulnar and the radial plate was developed. Stainless steel
material properties were assumed as follows: Youn’s
Modulus 210 GPa, Poisson’s ratio 0.3. A worst-case
scenario was considered, thus assuming the plate to be
fixed with only a distal screw and a proximal screw.
Setting the kinematics and boundary conditions, the
nodes belonging to the distal screw were kept fixed
during all the simulation steps, while a concentrated
force equal to 180 N was applied at the end of the
proximal screw (Fig. 3). The value of this force was
obtained from the equilibrium equations, taking into
account all the forces acting on the system (Fig. 4).
Favorable results in terms of Von Mises stress were
predicted (Figs. 5 and 6). Anyway, further modification
could be required to improve the design and then the
clinical performance of the system.
CONCLUSIONS
Locked plates and compression plates rely on com-
pletely different mechanical principles to provide frac-
ture fixation and consequently create a different biologic
environment for bone union. Locking plate systems have
recently been introduced in the treatment of humeral
fractures. Promising initial clinical results as well as
biomechanical tests have been reported. However, fur-
ther clinical and biomechanical investigations are needed
to understand the indications of locked plates as opposed
to conventional plates.
Techniques in Orthopaedics®, Vol. 22, No. 3, 2007
172 C. M. BELLINI ET AL.
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