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

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

Fig. 2
Primary malreduction with the use of a locking plate for fixation of a distal femoral fracture (A)
and a tibial shaft fracture (B). A fundamental biomechanical difference between locking plates
and conventional plates is that locking head screws do not pull the bone to the plate but lock
into the plate in the identical position. These two examples of malreduced fractures empha-
size the notion that adequate reduction has to be achieved before a fracture is fixed with a
locking plate.
reduction. Particularly with specialty
plates, which have only locking holes,
fracture reduction must be achieved
primarily, before plate fixation. Once a
locking screw has been placed through
the plate into bone, this particular bone
segment can no longer be manipulated
by insertion of additional screws or by
using compression devices. This makes
the sequence of screw placement critical
in order to avoid fracture malreduction
(Fig. 2). Surgeons who use locking
plates need a variety of reduction tech-
niques such as “no-hands” traction,
femoral distractors, and percutaneous
clamps48. The surgeon must keep in
mind that, despite the “advanced tech-
nology” of expensive locking plates,
they do not improve the fracture re-
duction and cannot help a poorly re-
duced fracture to heal. For example, if
the final fracture construct is too stiff,
particularly when a bridging technique
is used, nonunion may occur. The com-
bination of a stiff plate, stiff screws, and
fracture distraction is a formula for
nonunion (Fig. 3).
Indications
Most fractures undergoing operative
treatment do not require a locking plate.
The majority heal with conventional
plates or intramedullary nails, provided
that the principles of safe surgery are
followed. There are specific fractures,
however, that are associated with a
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
plate for fracture fixation must be well
aware of the exact indication, accord-
ing to these four different principles, for
which the angular-stable implant will
be used (Table I). For simple, non-
comminuted diaphyseal fractures in
osteoporotic bone requiring an open
reduction and rigid internal fixation,
locking plates offer the advantage of
increased pullout resistance of the lock-
ing head screws compared with that of
conventional screws. Thus, for these
fractures, locking plates can be applied
according to the compression principle
through eccentric placement of screws
in the dynamic compression unit of the
“combi hole” or by the use of a com-
pression device after initial placement
of one locking head screw on the other
side of the fracture. On the basis of the
same rationale, locking plates can also
be used according to the neutralization
principle to protect a lag screw in os-
teoporotic bone, with increased pullout
resistance of the locking head screws.
However, it is crucial to understand that
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-
novative biomechanical and biological
properties of angular-stable devices,
surgeons expressed the desire to use a
combination of both concepts, locking
and compression plate fixation, with
only one implant. This option was
made available for the first time in the
early twenty-first century by the lock-
ing compression plate (LCP), which
was designed by Robert Frigg (Bettlach,
Switzerland) on the basis of an idea
from Prof. Michael Wagner (Vienna,
Austria)4,5,15,28.
The combination technique is in-
dicated for fixation of fractures with a
simple pattern (e.g., an intra-articular
split) at one level and comminution
(e.g., metaphyseal-diaphyseal commi-
nution) at a different level. Under these
circumstances, the plate can be used to
achieve interfragmentary compression
of the simple fracture pattern by means
of a dynamic compression technique or
placement of a lag screw through the
dynamic compression unit of the plate.
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
internal fixation technique are prone to
nonunion (Fig. 3). Similarly contrain-
dicated is percutaneous locking plate
fixation of simple fractures with use of
a minimally invasive technique. This
concept violates the principle of the
fracture gap width in relation to strain
and thus leads to nonunion, as de-
scribed in an excellent review article
by Stephan Perren12. Finally, indirect
reduction and locking-plate fixation
are contraindicated for displaced intra-
articular fractures, since these injuries
require anatomic open reduction and
rigid interfragmentary compression.
Because of their cost, locking
plates are relatively contraindicated
for fractures that can be stabilized
satisfactorily with conventional plates.
For example, diaphyseal forearm frac-
tures have healing rates in excess of 90%
with conventional plates. While there
are some claims that, theoretically, the
use of unicortical locking plates should
increase healing rates because of the
lack of soft-tissue stripping, this has not
been validated in any type of controlled
trial, to our knowledge. Overuse of
these plates in some health-care systems
may negatively impact overall patient
care by consuming resources that could
be better used elsewhere.
Fig. 5
Relationship of working length and strain at the level of the fracture for the locked internal fixator
principle. When a fracture is bridged with a locking plate, three or four plate holes should be
left empty at the level of the fracture in order to increase the working length and decrease the
strain and stress concentration on the plate (A). In contrast, if a locking construct is made too
stiff with too many screws at the level of the fracture (B), the short working length will lead to
increased strain and stress concentration with loading and torsional forces, causing the plate
to break42,47,49.
Tips, Tricks, and Pitfalls of technical success. The preoperative
Successful use of locking plates de- plan also ensures that the surgeon will
pends on adherence to established prin- have all necessary implants available at
ciples of operative fracture care and the time of surgery.
learning the tricks of the specific tech- Correct positioning of the pa-
nology. Gautier and Sommer recently tient is vital, particularly if the plan calls
presented prudent guidelines that may for minimally invasive or percutaneous
improve the individual learning curve insertion of the implant. The surgeon
of surgeons who are less familiar with should ensure that all necessary images
these new implants47. are obtainable prior to preparation and
In general, successful use begins draping of the patient. A radiolucent ta-
with a formal preoperative drawing. ble is very helpful. Tightly rolled bumps
The advent of digitized radiography at of different sizes fashioned prior to the
many centers requires that digital tem- operation can aid in fracture reduction
plates be available. If plain radiographs as well as visualization, particularly in
are used, utilization of tracing paper is the lateral plane. Fracture reduction can
still the most effective way to draw a be challenging with locking plates be-
preoperative plan. The sequence of cause the locking screws do not pull the
screw placement, the length and posi- plate to the bone in the manner of con-
tion of the plate, and the surgical ap- ventional screws. Therefore, it is essen-
proach are all critical to success. A tial that the surgeon have a preoperative
precise preoperative plan reduces the plan for fracture reduction. Combina-
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
and placement of bumps under the ex-
tremity to correct lateral plane deformi-
ties can successfully permit reductions
with minimal direct manipulation of
the fracture fragments. Specialized re-
duction clamps can be used judiciously
with percutaneous long-bone and peri-
articular reductions. Conventional
screws or “whirlybird” push-pull types
of devices can be used to pull the bone
to the plate initially to secure fracture
reduction. Once the fracture is re-
duced, then locking screws can be
added as needed to provide stability.
Effective use of locking plates re-
quires an understanding of the poten-
tial pitfalls of usage. Locking holes offer
minimal opportunity for screw angula-
tion. More than 5° of angulation be-
tween the screw and the locking hole
can cause the screw to eventually fail.
Careful technique is necessary to en-
sure that the screw is perfectly lined up
with the axis of the screw threads in the
plate. This may be quite difficult in a
minimally invasive procedure. Mala-
ligned screw threads can lead to loose
screws and loss of reduction (Fig. 4).
The weakest part of the combi locking
plate (e.g., the LCP) is the dynamic
compression unit. This is the part of the
plate that should be used for bending, if
required, and it is the part that breaks
when there is increased stress concen-
tration and strain on the plate17,42. For
this reason, when a bridge plate is used
to fix a comminuted fracture, at least
three or four plate holes should be left
empty at the level of the fracture, in or-
der to achieve a larger area of stress dis-
tribution on the plate (Fig. 5). In
contrast to conventional plates, which
fail at the interface between the screws
and the plate—often leading to break-
age of conventional screw heads—the
interface of the locking head screw with
the threaded locking hole is the stron-
gest part of the locking plate system.
Locking screw heads are less likely to
break since the difference between the
core diameters of the screw shaft and
head is much smaller than it is with
conventional screws. Nevertheless,
locking head screws can break in cases
of chronic instability and increased
strain as a result of rotational forces,
as is exemplified by proximal humeral
nonunion shown in Figure 4 (panel B).
Locking plates allow the use of
both bicortical and unicortical locking
head screws. The choice of screw type
(self-drilling/self-tapping or self-tapping
only) and screw length (unicortical or
bicortical) needs to be based on de-
fined principles in order to avoid
complications. As a general rule, self-
drilling/self-tapping screws, as are used
in minimally invasive locking plates
(such as the LISS), should be employed
exclusively in a unicortical fashion.
The main reason is that self-drilling
screws have sharp tips that may cause
neurovascular and/or soft-tissue dam-
age across the far cortex. Furthermore,
drilling of the far cortex with self-
drilling/self-tapping screws may lead
to simultaneous disruption of the
tapped thread in the near cortex and
thus reduce the overall purchase of the
locking head screws. Similarly, a pitfall
with unicortical placement of self-
tapping screws is the selection of an in-
adequate screw length. If the screw is
too short, the threads in the near cortex
will not have enough purchase and the
locking monoblock frame is prone to
failure by pullout with cyclic loading
(Fig. 6). In contrast, if the unicortical
screw is slightly too long, the nondrill-
ing screw tip will push off from the far
cortex, thus destroying the tapped
thread in the near cortex.
The pullout resistance of uni-
cortical locking head screws is almost
identical to that of similar-diameter
bicortical conventional screws and
about 70% of that of bicortical locking
head screws. Thus, how much pullout
strength is needed? There is no way to
objectively judge this, nor is it neces-
sarily important, because these con-
structs rarely fail through pullout per
se. Two factors are essential for deci-
sion-making with regard to the use of
unicortical or bicortical locking head
screws. These are, first, the quality of
the cortical bone and, second, the ex-
tent of rotational forces applied to the
fractured bone. Cortical thickness is of
great importance in determining the
adequacy of the working length of uni-
cortical screws47. The working length of
a unicortical screw in good-quality cor-
tical bone usually provides sufficient
pullout resistance equaling the pullout
strength of a bicortical conventional
screw, as mentioned above. In contrast,
in metaphyseal bone and osteoporotic
cortical bone, the cortex is usually very
thin, thus rendering the working length
of unicortical screws insufficient. This
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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THE JOURNAL OF BONE & JOINT SURGER Y · JBJS.ORG
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
the wires will prevent posterior or ante-
rior deviation of the plate. Another tac-
tic is to make 4 to 6-cm incisions at the
proximal and distal sites of the plate.
With use of blunt dissection down to
bone, the plate can be directly visual-
ized as it passes into the wound. Lock-
ing drill sleeves should be attached to
the most proximal and distal holes of
the plate to form a frame for easier po-
sitioning of the plate on the bone as de-
picted in Figure 1. This way, the plate
can be centered on the bone at each end
and anchoring screws can be placed un-
der direct visualization. If the fracture
is well reduced with regard to length,
alignment, and rotation, then the plate
will be appropriately positioned along
the entire length of bone when it is cen-
tered at each end. The plate must be
held to the bone by first placing a con-
ventional screw or a “whirlybird” tool,
since the placement of a self-drilling/
self-tapping screw will push the plate
away from the bone and may cold-weld
the screw head to the plate. Since the
incisions are distant to the fracture site,
the principle of minimally invasive fixa-
tion is preserved, as the fracture frag-
ments and soft-tissue attachments are
undisturbed.
Locking plates, particularly the
specialized so-called all-locking plates,
require an approach to fracture reduc-
tion that is completely different from
what most of us have practiced. When
one begins to use locking plates, a good
approach is to “start easy.” One should
consider initially using combination
plates that permit the use of traditional
reduction techniques. Lost in the cur-
rent enthusiasm for this new technol-
ogy is the recollection that ten years ago
almost no surgeons in the world were
using locking plates routinely. Most of
the current high-volume experts in this
field started by practicing on Sawbones
and attending workshops. This is a
good approach for anyone starting to
use these techniques.
1. Greiwe RM, Archdeacon MT. Locking plate
technology: current concepts. J Knee Surg. 2007;
20:50-5.
2306
LO CK I N G P L A TE S : TIP S
Malreduction can result in failure
regardless of whether the plate is con-
ventional or locking. Common prob-
lems include varus in the proximal part
of the humerus and distal part of the fe-
mur and distraction in diaphyseal frac-
tures (Figs. 2, 3, and 4). In many cases,
locking plates are used as bridge plates
in the presence of substantial commi-
nution. Plates that are very stiff or stiff
fracture constructs with too many
screws can lead to nonunion and even-
tually plate failure (Fig. 5). Bridge plates
must be longer, and fewer screws are
needed. For the treatment of periarticu-
lar fractures, few screws are needed in
the diaphysis but more screws may be
required near the articular surface. The
precise length of the bridge plate and
the number of screws needed for a spe-
cific fracture remain controversial. In
general, the length of the plate should
be more than two times the length of
the fracture zone. Screws should be
spread evenly, and ideally there should
be at least one empty hole between each
pair of holes filled with screws. As
mentioned above, when the bridging
principle is used, three or four screw
holes should be left empty at the level
of the fracture to avoid a local stress
concentration, which may lead to
breakage of the plate42. The even dis-
tribution of force over a long working
plate length with relatively few screws
appears to provide a stable stimulus
for indirect bone-healing and callus
formation.
Overview
Locking plate technology offers im-
proved fixation stability in osteopenic
bone and for comminuted and periar-
ticular fractures. The additional stabil-
ity per screw compared with that of
conventional nonlocking fixation en-
hances the application of minimally in-
vasive fracture techniques such as use
of bridge plates and percutaneous frac-
ture stabilization. The application of
locking plates is somewhat more dif-
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AND TR I C K S
ficult than the placement of conven-
tional plates. Fracture reductions are
often done indirectly, the locking screw
must be carefully aligned along the axis
of the receiving hole to ensure proper
tightness, and the length of the plate
must be selected carefully. Despite the
necessity of mastering these nuances,
the use of locking plates will likely in-
crease, particularly with the increasing
prevalence of fragility fractures in our
aging population and the increase in
high-energy fractures in younger pa-
tients surviving severe trauma. While a
substantial amount of biomechanical
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carefully in both the literature and one’s
own practice in order to learn from
mistakes and refine our techniques.
Wade R. Smith, MD
Philip F. Stahel, MD
Department of Orthopedic Surgery, Denver
Health Medical Center, University of Colorado
School of Medicine, 777 Bannock Street, Den-
ver, CO 80204. E-mail address for W.R. Smith:
wade.smith@dhha.org
Bruce H. Ziran, MD
Department of Orthopaedic Surgery, St. Eliza-
beth Health Center, Youngstown, OH 44501
Jeff O. Anglen, MD
Department of Orthopaedics, Indiana Uni-
versity School of Medicine, Indianapolis, IN
46202
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Academy of Orthopaedic Surgeons. This arti-
cle, as well as other lectures presented at the
Academy’s Annual Meeting, will be available in
March 2008 in Instructional Course Lectures,
Volume 57. The complete volume can be or-
dered online at www.aaos.org, or by calling
800-626-6726 (8 A.M.-5 P.M., Central time).
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