Screw & Plates

Trauma’s Team

Dept. of Orthopaedic Surgery

Hasan Sadikin General Hospital
Medical School of Padjadjaran University
Bandung
Lag Screw
General Aspects
• Screw  very efficient tool for fixation of a
fracture by interfragmentary compression or for
fixing a splinting device (e.g : plate, nail or fixator
to bone)

• The axial force produced by a screw results from

rotating screw clockwise  the inclined surfaces
of its threads glide along a corresponding
surface of the bone.
General Aspects
A. The undersurface of the
screw head is spherical 
allowing a congruent fit to be
maintained while tilting the
screw, e.g., within a plate
hole. The thread is
asymmetrical.
The dimensions shown are
designed to offer a good
relation between axial force
& torque applied

B. These dimension result in an

inclination of the thread
which is self locking
General Aspects
• Two force components are active
 one along the circumference of the thread
 one along the axis of the screw
• The compression applied by a screw
affects a comparatively small area of the
bone by which it is surrounded  a single
intert=fragmentary lag screw does not
prevent rotation between two fragments
Types of Bone Screws
• Two basic types : cortical & cancellous
• Cancellous bone screw
- larger outer diameter
- deeper thread
- larger pitch
- metaphyseal or epiphyseal
• Cortical bone screw
- diaphysis
Raft Screws
• Compression of an epi-
metaphyseal fracture using a
raft screw
• The thread pulls the opposite
bone fragment towards the
head of the screw.
• The shaft of the screw does not
transmit any great axial force
between the shaft & the
surrounding bone.
• The length of the screw shaft
must be chosen  the
threaded part lies fully within
the opposite bone fragment.
• Washer is used to prevent the
screw head sinking into cortex
Mode of application of a Fully
Threaded lag Screw
• To act as a lag screw the
cortex screw requires a
gliding hole in the
near(cis) and a threaded
hole in the far (trans)
cortex
• In diaphyseal bone, shaft
screws or fully threaded
screws are used because
partially threaded
cancellous bone screws
are difficult to remove
after healing
Modes of failure
• Screws can fall because of axial pull out,
bending forces, or both.
• Screws usually resist axial pull out rather
well.
• Most screws are fairly weak in bending
due to their small core diameter
Special Considerations of
Screw Insertion
• A screw should not be tightened to the
limits of its strength, but only about 2/3 of
this  allow resistance to any additional
functional loading
Positioning of the Screw in
Respect to the fracture Plane
A. A lag screw oriented
perpendicular to the
fracture plane  ideal
inclination in the
absence of forces along
the bone axis
B. Inclination half way
between the
perpendiculars to the
fracture plane and to the
long axis of the bone 
better suited to resisting
compressive functional
load along the bone
long axis.
Lag screws in metaphyseal and
epiphyseal regions
• To obtain anatomical reduction and
absolute stability  interfragmentary lag
screws are mandatory in articular
fractures.
New Trends in Screw Application :
Internal Fixator with Locked Screws
• The new technology of
using the so-called
internal fixators for
biological internal fixation
takes advantage of short,
unicortical screws.
• The head of this screw is
locked within the body of
the fixator (plate) in a
position perpendicular to
the long axis of the
fixator.
New Trends in Screw Application :
Internal Fixator with Locked Screws

A. Shows the design & force components of a conventional screw as

used for the DCP and LC-DCP. The screw acts by producing
friction between the plate undersurface & the bone surface due to
compression of the interface.
B. Locked screws as used in newer implants. These are usually
unicortical & work more like bolts than screws; the axial force
produced by the screw is minimal. The screw provides fixation 
screw head is locked in a position perpendicular to the ‘plate’
body.
Cancellous screw

Cortical Screw
Plates
Introduction
• Rigid fixation Vs Biological fixation
• Rigid fixation with plates and screws has a
firm place in fracture treatment
• Articular fractures require anatomical
reduction and stable fixation as callus
formation is not desired
• The potential compromise of cortical blood
supply is a major draw back of
conventional plating
Dynamic compression plate
(DCP) 3.5 & 4.5
• Functions :
1. Compression
2. Neutralization
3. Tension band
• 3 sizes :
1. Broad DCP 4.5  femur & humerus
2. Narrow DCP 4.5  tbia & humerus
3. DCP 3.5  forearm,fibula,pelvis &
clavicle
Dynamic compression plate
(DCP) 3.5 & 4.5
Dynamic compression plate
(DCP) 3.5 & 4.5
When the screw is inserted & tightened

Movement of the bone fragment

relative to the plate

Compression of the fracture

Technique of DCP application
2 DCP drill guide :
• with an eccentric (load) hole
• with concentric (neutral) hole
Limited Contact Dinamic Compression
Plate (LC-DCP) 3.5 & 4.5
• The new LC-DCP
design reduces the
area of contact
between plate & bone
& thereby interferes
less with bone biology
Limited Contact Dinamic Compression
Plate (LC-DCP) 3.5 & 4.5
Technique of LC-DCP application
• 3 different modes :
1. Compression
2. Neutral
3. Butress
• 2 LC- DCP drill guides  plate 3.5 & 4.5
• LC-DCP universal drill guide  neutral or
eccentric position relative to the plate
hole.
Technique of LC-DCP application
Tubular plates (4.5/3.5/2.7)
• 1/3 tubular plate (3.5 version only)
 titanium / stainless steel
 1.0 mm thick
 useful in areas with minimal soft tissue
covering (e.g lat. malleolus, olecranon)
 Each hole is surrounded by a small collar
 Oval shape of each hole  eccentric screw
placement to produce fracture compression
• Semitubular plate (4.5 system)  less used
Tubular plates (4.5/3.5/2.7)
Reconstruction plate 3.5 & 4.5
• Deep notches between the
holes  allow accurate
contouring on the flat as well
as standard bending
• Oval holes  allow dynamic
compression
• Useful in fractures of bone
with complex 3-D geomtery
(e.g pelvis & acetabulum,
distal humersu, clavicle)
• Special instruments are
available for the contouring of
these plates.
Special plates
• Several special plates for
specific locations have
been developed

• They are shaped

anatomically 
corresponding to the site
where they are to be
applied
Classical Principles of Rigid
Internal Fixation with Plates
• Interfragmentary compression provides stability
through friction, but has no direct influence on
bone bridging or fracture healing
• 4 ways to obtain interfragmentary compression
with a plate :
1. Compression with a tension device
2. Compression with the dynamic
compression principle (DCP / LC-DCP)
3. Compression by contouring (overbending)
the plate
4. Additional lag screws through plate holes
Rigid Fixation by Lag Screw &
Neutralization (Protection) Plate
• The traditional & quite effective way to rigidly fix a
simple diaphyseal fracture is to use lag screws
combined with a neutralization (protection) plate.
• In metaepiphyseal split fractures  lag screw
fixation often needs to be combined with a buttress
plate to protect the screws from shearing forces.
Rigid Fixation by Lag Screw &
Neutralization (Protection) Plate
Compression with the
Tension Device
• In transverse or short oblique fractures of
the diaphysis, placement of a lag screw is
not always possible  best treated by
intramedullary fixation (except in the
forearm)
• Compression plate is used if nailing is
impossible.
Compression with the
Tension Device
Compression by Overbending
Contouring of Plates
• Straight plates often need to be contoured
prior to application  to fit the anatomy of
the bone.
• If this not done  reduction will be lost
esp. if no lag screws are placed across
fracture
• Repeated bending back & forth should be
avoided
Different functions of plates
• The function assigned to a plate does not
depend on its design
• Plate may also be used for other functions:
buttressing, bridging, or to act as a tension
band
Buttress Plate
• In a metaphyseal /
epiphyseal shear or split
fracture  fixation with
lag screws alone may not
be sufficient  combined
with a plate with buttress
or antiglide function
• In plates with DCP holes,
the screws should
inserted in the buttress
position
Tension Band Plate
• Criteria for a plate to act as a tension band:
1. The fractured bone must be
eccentrically loaded, e.g., femur
2. The plate must be placed on the tension
side
3. The plate must be able to withstand the
tensile forces
4. The bone must be able to withstand the
compressive force which results from the
conversion of distraction forces by the plate
There must be a bony buttress opposite to the
plate to prevent cyclic bending
Tension Band Plate

A plate under
tension
is much
stronger
than under
bending
forces
Bridge Plating
• Indicated in complex diaphyseal fracture
patterns.
• Fixed to the 2 main fragments only, leaving the
fracture zone untouched  acts as an
extramedullary splint.
• This concept combines adequate mechanical
stability offered by the plate with uncompromised
natural fracture biology to achieve rapid
interfragmentary callus formation & fracture
consolidation
Bridge Plating
Bridge Plating
Bridge Plating