BASIC SCIENCE
Finite element analysis in
trauma & orthopaedics e an
introduction to clinically
relevant simulation & its
limitations
Gareth Llewelyn Roberts
Ian Pallister
Abstract
Finite element analysis is a mathematical tool, used by engineers to simu-
late real life situations. It is widely used in the Aeronautical industry and
has led to considerable savings in development costs and improvements
in design. It has been used in the design of orthopaedic implants and
surgical techniques, both for elective and trauma surgery. Developing
a virtual simulation of orthopaedic interventions carries huge theoretical
advantages; however to appreciate the results of finite element analysis
a brief understanding of the process is required. The purpose of this
article is to provide an overview of finite element analysis, its possible
applications in orthopaedics and also it’s limitations.
Keywords biomechanics; finite element analysis
Background
Finite element analysis (FEA) is a powerful tool for the simula-
tion of a wide range of problems. Its origins can be traced back to
the 1940s; however developments in computer technology have
led to a rapid development of this technique in the past
decades.1,2 It was initially developed for structural analysis,
however; it is now widely used to perform deformation and
stress analysis of buildings, bridges and other structures as well
as the analysis of heat flux, fluid flow, magnetic flux and
seepage. It has been used in orthopaedic surgery in a variety of
situations, particularly in the assessment of both trauma and
elective surgical implants. The purpose of this article is to explain
to an orthopaedic surgeon the basics of FEA, and importantly its
limitations.
Finite element analysis
Finite element analysis is a mathematical tool, which relies on
the simplification of complex situations into a number of
discrete, smaller problems, which can be solved individually and
Gareth Llewelyn Roberts MSc MRCS ST6 Trauma and Orthopaedics,
Morriston Hospital, Swansea, Wales, UK. Conflict of interest: none.
Ian Pallister MD FRCS Consultant Trauma and Orthopaedics, Morriston
Hospital, Swansea, Wales, UK. Conflict of interest: none.
ORTHOPAEDICS AND TRAUMA 26:6
combined to give an approximation of the solution to the
complex problem. It works by dividing complex geometries into
a set of small simplexes in the shape of triangles in 2D or tetra-
hedrals in 3D, known as a mesh. The solution is then approxi-
mated over each element. This results in a large set of
simultaneous equations that are solved to approximate the
solution of the domain (object) of interest. Each element is
interconnected at specified points called nodes (Figure 1).
Figure 2 shows the surface mesh generated from data based
on the geometry of a femur. The triangular elements are used for
the generation of the volume mesh inside the femur, which is
made of tetrahedral elements.
A number of computer software packages have been devel-
oped for the solution of finite element models, including ELFEN,
ABAQUS, NASTRAN, and ANSYS. These vary in complexity and
in the assumptions made during the solving, mainly a result of
the fact that they were created with certain situations in mind.
For example ANSYS grew from the Nuclear Industry, and NAS-
TRAN (National Aeronautics and Space Administration Struc-
tural Analysis) was developed by NASA to assess the space
shuttle!
However, all FEA software uses a similar workflow:

Pre-processing

Numerical analysis

Post processing.
Pre-processing
This is the problem definition stage, as defined by the user. This
includes generation of the mesh representing the domain of
interest, starting from the geometric definition derived from
scanned images or CAD (Computer Aided Design) definition.
Also at this stage the material properties, loads and boundary
conditions are defined. (The boundary conditions are the rela-
tionships that exists between the nodes and space, i.e. if they are
fixed or can move in space.)
Numerical analysis
At this stage the discretized governing equations are solved on
the generated mesh under the specified boundary and load
Figure 1 An example of a tetrahedral element.
410 Ó 2012 Elsevier Ltd. All rights reserved.
 BASIC SCIENCE

Figure 2 An example of a meshed femur.

conditions. This normally results in a large set of simultaneous

equations for the quantities of interest at the nodal points (i.e.
deformations and velocities). These equations are then solved
either directly or iteratively to give the nodal quantities of interest
(deformation and velocity). Other quantities can then be derived
from these entities (stress and stains).

Post processing
At this stage graphical presentation of the results is used, often
in the forms of characteristic images such as that shown
below (Figure 3), which display strain/stress patterns or patterns
of displacement. This data can also be displayed in tabular
format. Figure 3 An example of the visualisation of a stress analysis of a femur.

Validating the results of FEA

It is extremely important to check the results given by FEA
software. This is often done by comparison with experimental
data, and comparison with other similar computation
techniques.
Orthopaedic examples
Numerous examples of the use of finite element analysis exist
within the orthopaedic literature. A search on PubMed with the
keywords ‘finite element analysis’ and ‘orthopaedics’ itself
produces 807 published papers. The volume of literature on the
subject is therefore vast. Everything from total hip replacement
to footwear has been analyzed by FEA.
FEA has two main uses in orthopaedics:

Static problems e such as the stress analysis of bone and
the load bearing capacity of implants and prosthetic
systems.

Dynamics problems e such as fall analysis or the dynamic
simulation of anatomical structures.
Despite the fact that the use of FEA in engineering design
and analysis has become routine in such industries, its use
for modelling orthopaedic problems is not a straightforward
extension. Various specific issues associated with the use of finite
element analysis need first to be addressed.
The generation of FEA models of bone
Most of the objects analyzed using FEA are defined using CAD
systems. The vast majority of FEA bones are generated from
imaging data, be it computed tomography (CT) or magnetic
resonance (MR) data. A CT works on the same principle as
X-rays, i.e. electromagnetic waves travel through objects/speci-
mens and are attenuated to different degrees, this difference
being analyzed to give rise to images. Within a CT scanner the
source of the X-ray beam and the detector change position,
therefore allowing the generation of a matrix of attenuation
levels. The size of each pixel is dependent upon the field of view
and the size of the matrix.
field of view
Pixel size ¼
size of matrix
Modern CT scanners scan in volume cuts, therefore generating
a matrix of cubes, each cube of the matrix grid being called
a voxel.

ORTHOPAEDICS AND TRAUMA 26:6 411 Ó 2012 Elsevier Ltd. All rights reserved.
 BASIC SCIENCE
Figure 4 An illustration of the partial volume effect. The circle on the left is
scanned, and is recorded as a matrix of attenuation levels. Since the
recorded attenuation levels within each individual square is an average
attenuation of that square data is lost.
However trying to fit a curve into a square never works,
therefore problems arise at the boundaries between high atten-
uation (e.g. bone), and low attenuation (e.g. air). This leads to
the partial volume effect, which occurs due to the CT scanner
recording the average attenuation across each voxel, meaning
that at the edges voxels may have abnormally low or high values,
depending on the material of interest (Figure 4).
The only method to reduce this effect is to increase the size of
the matrix or reduce the field of view, which is dependent upon
the CT scanner’s abilities.
Creating bone geometries from CT scan data
Bone geometries are created from CT scan data by segmentation,
i.e. selecting what is needed. Various software programmes are
available for this, e.g. MIMICS (Materialise, Leuven), 3D Doctor
(Able Software Corp, Lexington), ScanIP (Simpleware, Exeter).
The degree of automation is variable. However, irrespective of
the method of segmentation, the raw data remains cubic
matrices of attenuation values. Therefore the accuracy of the
geometric models generated is controlled by the size of the CT
voxels.
Shape of the elements
Creating bone surfaces from tetrahedral elements is difficult,
as simple tetrahedral elements have straight edges whereas
bone, obviously, has curved edges. There are two methods to
compensate for this.
Figure 5 An illustration of the effect of reducing the size of the elements. The smaller elements in (b) resemble the actual curve much better than the large
element in (a).
ORTHOPAEDICS AND TRAUMA 26:6
Figure 6 An example of a 10 node tetrahedral element.

Reduce the size of the elements e the smaller the elements
the closer the final solution will be to the actual problem,
as shown in Figure 5. However reducing the size of an
element will in turn increase the number of elements,
therefore increasing the number of simultaneous equations
and the computational power required.

Using isoparametric elements e isoparametric elements have
the ability to be designated curved sides due to the addition of
mid-side nodes, for example a 10 node tetrahedral instead of
a four node tetrahedral (Figure 6). However, despite the fact
that this will reduce the number of elements required to
accurately discretize the geometry, it increases the solution
time due to the increase in the number of degrees of freedom
and the number of quadrature rules required to perform the
numerical integration. In addition, not all software has the
ability to implement isoparametric elements.
Interpolation
The basis of the finite element method is the piecewise approx-
imation of a complex problem e that is, the solution of
412 Ó 2012 Elsevier Ltd. All rights reserved.
 BASIC SCIENCE

a complicated problem is obtained by dividing the region of

interest into small regions (finite elements) and approximating
the solution over each sub-region by a simple function. Thus
a necessary and important step is that of choosing a simple
function for the solution of each element. The functions used to
represent the behaviour of the solution within an element are
called interpolation functions or approximating or interpolation
models. These are normally polynomial-type interpolation func-
tions, as they are easy to formulate and computerize and it is
possible to improve the accuracy of the results by increasing the
order of the polynomial.
When the interpolation polynomial is of the order of one the
element is termed a linear element. If the interpolation poly-
nomial is of the order of two or more the element is known as
a higher order element. In higher order elements, some
secondary (mid-sided and/or interior) nodes are introduced in
addition to the primary (corner) nodes in order to match the
number of nodal degrees of freedom with the number of
constants (generalize coordinates) in the interpolation poly-
nomial. In general, fewer higher order elements are needed to
achieve the same degree of accuracy in the final results.
Since the actual variation of the field variable inside the Figure 7 An example of the distribution of material properties across an
continuum is not known, we assume that the variation of the axial cut of a diaphysis, following assignment based on attenuation. Red
field variable inside a finite element can be approximated by representing high density and blue representing low density.
a simple function. These approximating functions (also called
interpolation models) are defined in terms of the values of the
E integration e firstly the Young’s modulus for each voxel
field variables at the nodes. When the filled equations (like is calculated based on the attenuation of each voxel and
equilibrium equations) for the whole continuum are written, the then this is averaged on each element.
new unknowns will be the nodal values of the field variable. By Taddei et al. compared both mapping strategies with experi-
solving the finite element equations, which are generally in the mentally derived measurements.10 They found that HU integra-
form of matrix equations, the nodal values of the filed variable tion produced a statistically significant different model than that
will be known. Once these are known, the approximating func- with E integration with, on average, lower values. They
tions define the field variable throughout the assemblage of concluded that both methods were able to predict superficial
elements. stress but that directly averaging the Young’s modulus for each
element improved the prediction of strain within the model.
Assigning material properties Several integration strategies are used in the literature for this,
Assigning the material properties of individual elements when some taking the average of a number of points within each
assessing bone is difficult. Some have applied arbitrary values to tetrahedral element others taking the average of each node of the
each element, whereas other have based the values on CT element.11,13 The accuracy of this integration is dependent upon
attenuation values3e7 (Figure 7). the size of the matrix grid with respect to the element size.14
In order to base material properties on the attenuation level
Isotropic vs orthotropic
of the input data it is important that the attenuation values of
To complicate matters further, bone is orthotropic, meaning that
the CT scanner are calibrated. This can be done by calibrating
it has different material properties or strengths depending on the
against materials of know density, such as hydroxyapatite or
dipotassium hydrogen phosphate solutions (K2HPO4), or by
calibrating against muscle and fat.8,9 After calibration it is
possible to convert the degree of attenuation into the bone A sample of the relationships within the literature
mineral density (BMD) of each voxel. Several equations are between Young’s modulus and material density
quoted in the literature for the conversion of BMD (r ¼ Publication Young modulus (E ) to density (r)
density) into material properties (E ¼ Young’s modulus), see relationship
Table 1.
As the relationship between BMD and Young’s modulus is Taddei et al.10 E ¼ 10 500 r 2.29
a power relationship and not a linear relationship it is important Bessho et al.11 r ¼ 0 E ¼ 0.001
in which order the conversion is made. 0 <r  0.27 E ¼ 33 900r2.20
Within the literature, integrating the material properties into 0.27 < r  0.6 E ¼ 5307r þ 469
the mesh has been done in two ways: 0.6 < r E ¼ 10 200 r 2.01

HU integration e firstly the attenuation of each element is Dragomir-Daescu et al.12 E ¼ 14 664 r 1.49
calculated and then the element’s Young modulus is
calculated Table 1

ORTHOPAEDICS AND TRAUMA 26:6 413 Ó 2012 Elsevier Ltd. All rights reserved.
 BASIC SCIENCE
direction of the applied force. At present the majority of FEA
studies have considered bone to have isotropic behaviour, i.e. its
material properties are uniform in all directions. Some authors
have produce FEA models which allow orthotropic behaviour,
but that then raises problems in identifying the orientation of the
orthotropic behaviour.15,16 Yang et al. has shown that this can
have important effects, particularly in specific regions, such as
the proximal femur with its complex trabecular pattern.15 The
resolution of standard clinical CT scanners is currently not small
enough to allow this to be defined.
Loading forces
Another limitation of FEA models in orthopaedics is the lack of
physiological loading conditions. This is also true of the majority
of biomechanical laboratory testing, in that muscle forces
themselves are largely ignored. When FEA nodes are applied to
the lower limbs, for example, several publications describing the
proximal femur consider a static one-legged stance with only
joint reaction forces modelled. The vast majority of FEA models
are static in nature, or at best quasi dynamic, with none showing
a completely dynamic simulation.
Some recent papers, such as that by Taylor et al. have gone
further and analyzed muscle forces and the effect they have on
internally fixed clavicle fractures.17 However this kind of analysis
also has its limitations.
Defining muscle forces
Defining muscle forces is in itself a challenge. Measuring the
physiological loading conditions of bone accurately is extremely
difficult, if not impossible, due to both ethical and technical
constraints. Attempts have been made to obtain details of femoral
loading by implanting instrumented devices.18,19 Bergmann et al.
implanted a series of four instrumented total hip replacements
from which they were able to get accurate joint loading informa-
tion.18 Similarly Schneider et al. implanted an instrumented intra-
medullary nail into a comminuted femoral fracture and from this
was able to collect loading information.19 The fact that Schneider
et al. obtained a bending moment of only 8.7 Nm at the fracture site
when expecting a bending moment of 20 Nm whilst in a sitting
position illustrates the importance of muscle in the loading of the
femur.19 Various methods have been described in the literature to
measure muscle forces. Not all are relevant or applicable to every
situation. A brief description of the various methods follows.
Direct methods: these often involve the measurement of super-
ficial tendons such as the Achilles tendon, or intra-operative
measurements, such as measurements from the flexor tendons
during carpal tunnel release. This method is not possible for the
majority of bones.
Non-invasive measurement: these all rely upon Newton’s third
law of motion in that,
“To every action there is always an equal and opposite reac-
tion: or the forces of two bodies on each other are always equal
and are directed in opposite directions.”
Therefore, each muscle pull that results in a skeletal move-
ment will cause a change in the ground reaction force. This
ORTHOPAEDICS AND TRAUMA 26:6
allows movement and joint torques to be modelled in a mathe-
matical model (inverse dynamic analysis). This mathematical
model is able to produce estimates of joint torques, each of which
represents the resultant action of those muscles that cross the
joint. However, due to the complexity of the human body, with
complex interactions between different muscle groups, it is not
possible to calculate individual muscle forces through this
method. Neither is it capable of providing information regarding
muscle load sharing, agonistseantagonist activity, energy trans-
fer between joints via biarticular muscle and dynamic coupling.20
The relationship between movement and muscle forces in
a musculoskeletal model is represented by the equation below.
MðqÞq_ þ Cðq; qÞ
_ þ GðqÞ þ RðqÞFMT þ E ¼ 0 ð1Þ
where M(q) is the system mass matrix (n  n)
_ is the centrifugal and coriolis loading (n  1)
Cðq; qÞ
G(q) is the gravitational loading (n  1)
E represents external forces.
R(q)FMT represents muscular joint torques (n  1), where
R(q) is the matrix of muscular moment arms (n  m) and
FMT are the muscle forces (m  1, m: number of muscles).
The number of unknown muscle forces often exceeds the
number of equations (m > n). In order to estimate muscle
forces, either muscles must be combined or a method relying on
the optimization principle must be used.20 In its simplest form
the generalized system equations reduce to a one-to-one corre-
spondence between the degree of freedoms and the muscle
loading:
MðqÞq_ þ Cðq$qÞ
_ þ GðqÞ þ TMT þ E ¼ 0 ð2Þ
Where TMT are the muscular joint torques (n  1) which are
equal to R(q)FMT
This obviously would not contain enough detail for the
loading applied to the femur.
Muscleeskeleton coupling: muscle produces torque or moment
(of force) at a joint. This is defined in simple terms by:
Torque ¼ distance to centre of rotation  force ð3Þ
Where the force is perpendicular to the displacement vector.
Within the human body the moment arm (the distance
between a muscle’s line of action and the joint’s axis of rotation)
is dependent upon the origin and the insertion of the muscle in
question. This distance is often joint angle dependent. Any model
that is used to estimate muscle forces must therefore incorporate
accurate and anatomical descriptions of muscle insertions and
the three-dimensional path of muscles relative to the moving
skeleton.
Muscle modelling
The magnitude of force that a muscle is capable of generating is
dependent upon its activation level and its forceegeneration
properties which are defined by the force-fibre length and force-
fibre velocity relationship.
Inverse solution: as has previously been discussed, in some
situations it is not possible to know muscle excitation or joint
414 Ó 2012 Elsevier Ltd. All rights reserved.
 BASIC SCIENCE
torques therefore we are unable to solve Equation (1) as
a forward solution. However standard gait analysis, in the form
of motion capture and pressure plates gives joint kinematic data
and ground reaction forces. With the time history of these vari-
ables it is possible to calculate muscular joint torques at each
instant of the movement by re-arranging Equation (1).
TMT ¼ MðqÞq_ þ Cðq; qÞ
_ þ GðqÞ þ E ð4Þ
In practice, muscular joint torques are often derived from
single segments, working from distal to proximal. Therefore
the more proximal the segment, the less accurate are the
assumptions.
Muscle force estimation
Firstly the joint torques for each instant in time are calculated
using Equation (4). The muscular load-sharing problem is then
solved for each instant in time by minimizing an objective
function J (e.g. total muscle force) subject to constraints repre-
senting the equality of the sum of individual muscular moments
to the joint torques calculated. The individual muscular moment
is calculated from the muscle force (the unknown of the opti-
mization problem) and muscle moment arms, which may or may
not depend on joint angles. Usually, the maximum possible
muscle forces are limited by physiological values as an additional
boundary constraint.
Figure 8 A screen capture of the OpenSim interface.
ORTHOPAEDICS AND TRAUMA 26:6
Software
Software packages such as OpenSim (www.simtk.org) and
Anybody (www.anybodytech.com) are available which are able
to convert gait laboratory data into muscle force calculations.
These have models of various complexities and validations, such
as the London Lower Limb Model which is available in OpenSim
based on an anatomical study by Klein Horsman et al. and
validated against the Hip98 data of Bergmann et al.18,21,22
(Figure 8).
Validation
Muscle force predictions are usually validated against Electro-
myography (EMG) data. However the temporal characteristics of
muscle firing during movement and muscle force generation
aren’t necessarily the same. Another method of validation is to
calculate joint reaction forces and compare these with the results
of instrumented implants.
A major weakness of these muscle models is that they are
based often upon cadaveric studies and offer little in the form of
customization for individual subjects. Further developments
such as that by Scheys et al. have based their muscle properties
upon MRI data, which may be the future.23
The future
Advances in computer technology over the past decades have
allowed FEA to develop at a rapid pace. It currently allows very
accurate analysis to be performed in all kinds of situations.
Currently in orthopaedics its accuracy is hindered by assump-
tions which are made necessary by the limitations of raw data,
such as CT scan data, and loading estimations. In the future
integrated solutions may be developed which will allow accurate
simulation of individual persons, allowing the tailoring of
implants and procedures to individuals. Mimics, Anybody and
ANSYS in collaboration are currently developing an integrated
system capable of combining the whole process.
Conclusion
FEA is an important step in any engineering problem. It
certainly has a role to play in the development and refinement
of orthopaedic implants and procedures. However it must be
remembered that FEA is based upon a number of assumptions
and simplifications. The results obtained therefore need to be
assessed in context and require further work to validate
them. A
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