Biomechanics of Fractures

and Fixation
 Basic Biomechanics
• Material Properties • Structural Properties
– Elastic-Plastic – Bending Stiffness
– Yield point – Torsional Stiffness
– Axial Stiffness
– Brittle-Ductile
– Toughness • Depends on Shape
and Material!
• Independent of
Shape!
 Basic Biomechanics
Force
Area L

Stress = Force/Area Strain Change Height (L) /

Original Height(L0)
 What is the elastic modulus of
bone?
• The Young's Modulus (or Elastic Modulus)
is in essence the stiffness of a material. In
other words, it is how easy it is bent or
stretched. when graphed, the resulting plot
will look something similar to this:
• The Young's
modulus is
the slope of
the initial
section of the
curve (i.e. m
in y = mx +
b).
 Basic Biomechanics
Stress-Strain & Elastic Modulus

Stress =
Slope =
Force/Area
Elastic Modulus =

Stress/Strain

Strain =
Change in Length/Original Length
 Basic Biomechanics
Common Materials in Orthopaedics

• Elastic Modulus (GPa) • Stainless Steel 200

• Titanium 100
• Cortical Bone 7-21
• Bone Cement 2.5-3.5
Stress • Cancellous Bone 0.7-4.9
• UHMW-PE (Ultra-high-
molecular-weight
Strain
polyethylene) 1.4-4.2
 Basic Biomechanics
• Elastic Deformation Elastic Plastic
• Plastic Deformation
• Energy
Force
Energy
Absorbed

Displacement
 Basic Biomechanics
Elastic Plastic
• Stiffness-Flexibility Failure
Yield
• Yield Point
• Failure Point Force
• Brittle-Ductile
• Toughness-Weakness Stiffness

Displacement
 Stiff
Ductile
Tough
Stiff Strong
Brittle
Strong

Ductile
Stress Weak
Brittle
Weak

Strain
 Flexible
Brittle Flexible
Strong Ductile
Tough
Strong

Flexible
Flexible
Stress Brittle
Ductile
Weak
Weak

Strain
 Basic Biomechanics
• Load to Failure • Fatigue Failure
– Continuous application – Cyclical sub-threshold
of force until the loading may result in
material breaks (failure failure due to fatigue.
point at the ultimate – Common mode of
load). failure of orthopaedic
– Common mode of implants and fracture
failure of bone and fixation constructs.
reported in the implant
literature.
 Basic Biomechanics
• Anisotropic • Viscoelastic
– Mechanical properties – Stress-Strain character
dependent upon dependent upon rate of
direction of loading applied strain (time
dependent).
 Bone Biomechanics
• Bone is anisotropic - its modulus is
dependent upon the direction of loading.
• Bone is weakest in shear, then tension, then
compression.
• Ultimate Stress at Failure Cortical Bone
Compression < 212 N/m2
Tension < 146 N/m2
Shear < 82 N/m2
 Bone Biomechanics
• Bone is viscoelastic: its force-deformation
characteristics are dependent upon the rate
of loading.
• Trabecular bone becomes stiffer in
compression the faster it is loaded.
 Basic Biomechanics
• Bending
• Axial Loading
– Tension
– Compression
• Torsion

Bending Compression Torsion

 Fracture Mechanics

Figure from: Browner et al: Skeletal Trauma 2nd Ed, Saunders, 1998.
 Fracture Mechanics
• Bending load:
– Compression strength
greater than
tensile strength
– Fails in tension

Figure from: Tencer. Biomechanics in Orthopaedic

Trauma, Lippincott, 1994.
 Fracture Mechanics
• Torsion
– The diagonal in the direction of the applied force is in
tension – cracks perpendicular to this tension diagonal
– Spiral fracture 45º to the long axis

Figures from: Tencer. Biomechanics in Orthopaedic

Trauma, Lippincott, 1994.
 Fracture Mechanics
• Combined bending &
axial load
– Oblique fracture
– Butterfly fragment

Figure from: Tencer. Biomechanics in Orthopaedic

Trauma, Lippincott, 1994.
 Moments of Inertia
• Resistance to bending,
twisting, compression or
tension of an object is a
function of its shape
• Relationship of applied
force to distribution of
mass (shape) with
respect to an axis.

Figure from: Browner et al, Skeletal Trauma 2nd Ed,

Saunders, 1998.
 Fracture Mechanics
1.6 x stronger
• Fracture Callus
– Moment of inertia
proportional to r4
– Increase in radius by
callus greatly increases
moment of inertia and
stiffness

Figure from: Browner et al, Skeletal Trauma 0.5 x weaker

2nd Ed, Saunders, 1998. Figure from: Tencer et al: Biomechanics in
Orthopaedic Trauma, Lippincott, 1994.
 Fracture Stability and Healing

• The clinical goal of effective fracture treatment is rapid healing,

without significant deformity or limb shortening
• In the elderly, rapid mobilization is essential.
• Some simple fractures are inherently stable with low loading
and thus require minimal treatment
• Some fractures need surgical intervention and insertion of an
internal fixation device for adequate fixation.
• Traditional methods for the treatment of
fractures are externally applied and include
– Cast
– Brace
– Traction
 FRACTURE HEALING
• Micromotion aid healing.
• Rigid fixation may lead to delayed healing,
bone atrophy, and a lack of external stimuli necessary for
the healing process.
• Recent studies have examined the use of biologic agents
such as growth factors to promote fracture healing
 SURGICAL FACTORS
• A principle factor is the mechanical loading, specifically
the types.
• Another important factor is the bone quality, which
determines the strength available to support the fixation
device.
• Clinical trials are the other major method used to
evaluate the efficacy of a particular fixation method.
 Fixation Devices and Methods
• Common implant devices used to achieve fracture fixation.
– Wires
– Nails
– Staples,
– Pins,
– Plates,
– and Screws

• These are usually made of stainless steel (316L),

sometimes of titanium alloy(Ti-6A1–4V), or occasionally
of cobalt chromium alloy.
• Clinical application of biodegradable polymers such as polylactic acid..
• Polymers are more flexible than metals and would lead to greater load
bearing by the healing fracture; biodegradable materials do not have to be
removed in a secondary operation and their mechanical properties
gradually decrease with time, thus avoiding stress shielding.
• Multiple wires are required to provide stable, three-dimensional fixation.
• For cerclage applications, there is concern about
compromise of the periosteal blood supply and the resulting increased
healing time required for revascularization.
Cerclage wire technique
• Cerclage requires achieving equal tension during
tightening because loosening at one or more sites
can provide a locus for motion and possible
nonunion or cause mal positioning.
• There is concern about compromise of the
periosteal blood supply and the resulting increased
healing time required for revascularization.
• Sutures can be used with suture anchor systems to
attach soft tissue and eliminate the difficulty of
looping a suture through bone and suture abrasion
against the bone.
• Staples alone usually do not provide sufficient
mechanical stability for permanent fixation, and
their use often requires predrilling holes for the
staple legs.
• Kirschner wires (K-wires) are normally used to
hold fragments of bone prior to rigid fixation and
for percutaneous pinning of small bone fractures,
but, in general, they
lack sufficient mechanical stability for their use as
a primary fixation in weight-bearing bones.
• Types of screws are cortical and cancellous
and are distinguished by their thread design.

a. Cortical b. Cancellous
• Intrinsic factors that influence screw-holding
power are
– outer thread diameter
– thread configuration, and
– thread length
• Extrinsic factors are
– bone quality
– type, and
– screw insertion orientation and
– driving torque
• Insertion torque determines the force with
which bone fragments are held together,
which, in turn, creates friction that prevents
their motion.
• Plate designs vary with applications and
intended location such as an expanded end
for condylar fixation. Owing to anatomic
constraints such as soft tissue thickness,
occasionally, thinner plates are used.
• The major surgical considerations for the
use of plates are the requirements of a large
exposure for their insertion and the
possibility of compromising periosteal
blood supply by the exposure or plate
insertion
• Gross motion, instability, and inadequate blood
supply may lead to fracture nonunion.
• Factors determining optimal fixation for specific
fracture applications are the following:
– Mechanical considerations, such as the types and
magnitude of forces to which the fixation will be
subjected and their duration
– Bone quality (strength)
– Surgical, anatomic, and clinical considerations
– The type and extent of the bone fracture and the
amount of soft tissue damage
Biomechanics of External Fixation
 Biomechanics of External Fixation
A
C
Third pin (C)
out of plane of
two other pins
(A & B)
stabilizes that B
segment.