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Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Biomechanical effect of the conguration of screw hole style on locking

plate xation in proximal humerus fracture with a simulated gap:
A nite element analysis
Ya-Kui Zhang a, Hung-Wen Wei b,e, Kang-Ping Lin c,e, Wen-Chuan Chen e,
Cheng-Lun Tsai d,e, Kun-Jhih Lin c,e,*
a

Department of Orthopaedics Tongzhou Luhe Teaching Hospital, Capital Medical University, Beijing, China
Department of Physical Therapy and Assistive Technology, National Yang-Ming University, Taipei, Taiwan
c
Department of Electrical Engineering, Chung Yuan Christian University, Taoyuan, Taiwan
d
Department of Biomedical Engineering, Chung Yuan Christian University, Taoyuan, Taiwan
e
Translation Technology Center for Medical Device, Chung Yuan Christian University, Taoyuan, Taiwan
b

A R T I C L E I N F O

A B S T R A C T

Article history:
Accepted 29 February 2016

Background: Locking plate xation for proximal humeral fractures is a commonly used device. Recently,
plate breakages were continuously reported that the implants all have a mixture of holes allowing
placement of both locking and non-locking screws (so-called combi plates). In commercialized proximal
humeral plates, there still are two screw hole styles included locking and dynamic holes separated and
locking hole only congurations. It is important to understand the biomechanical effect of different
screw hole style on the stress distribution in bone plate.
Methods: Finite element method was employed to conduct a computational investigation. Three
proximal humeral plate models with different screw hole congurations were reconstructed depended
upon an identical commercialized implant. A three-dimensional model of a humerus was created using
process of thresholding based on the grayscale values of the CT scanning of an intact humerus. A virtual
subcapital osteotomy was performed. Simulations were performed under an increasing axial load. The
von Mises stresses around the screw holes of the plate shaft, the construct stiffness and the directional
displacement within the fracture gap were calculated for comparison.
Results: The mean value of the peak von Mises stresses around the screw holes in the plate shaft was the
highest for combi hole design while it was smallest for the locking and dynamic holes separated design.
The stiffness of the plate-bone construct was 15% higher in the locking screw only design (132.6 N/mm)
compared with the combi design (115.0 N/mm), and it was 4% higher than the combi design for the
locking and dynamic holes separated design (119.5 N/mm). The displacement within the fracture gap
was greatest in the combi hole design, whereas it was smallest for the locking hole only design.
Conclusions: The computed results provide a possible explanation for the breakages of combi plates
revealed in clinical reports. The locking and dynamic holes separated design may be a better
conguration to reduce the risk of plate fracture.
2016 Elsevier Ltd. All rights reserved.

Keywords:
Plate breakage
Combi-hole
Bone fracture
Stress concentration
Finite element method

Introduction
Fractures of the proximal humerus are among the most
common injuries. Due to cancellous bone depletes with age, it

* Corresponding author at: Department of Electrical Engineering, No. 200, ChungPei Rd., Chung Li District, Taoyuan 32023, Taiwan. Tel.: +886 3 265 4825;
fax: +886 3 265 4846.
E-mail address: kjlin2009@gmail.com (K.-J. Lin).

has become a typical injury of elderly individuals with osteoporosis [1]. Besides, a high energy impact or falling can also lead to
proximal humerus fractures. Various xation methods are
available, including percutaneous Kirschner wires, T-plates, angled
plates, cloverleaf plates, intramedullary nails, tension band wires,
and primary prosthesis [2]. Nowadays, locking plates are
increasingly used to surgically treat these injuries. Each of these
implants offers threaded screw holes, which allow screws to
thread to the plate and function as a xed-angle construct.
Although good clinical results were reported [35], the plate

http://dx.doi.org/10.1016/j.injury.2016.02.028
00201383/ 2016 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Zhang Y-K, et al. Biomechanical effect of the conguration of screw hole style on locking plate xation
in proximal humerus fracture with a simulated gap: A nite element analysis. Injury (2016), http://dx.doi.org/10.1016/
j.injury.2016.02.028

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breakages were continuously revealed [613]. Interestingly, these

failure series all were the recently introduced plate systems with
specially designed combination holes (so-called combi hole) in
which one side of the hole can be used with a traditional nonlocking screw and the other side can be used with a locking head
screw.
Locking plates were developed based on the biomechanical
principle of external xators which can provide good stability and
do not require compression of the plate to the bone that may
inhibit periosteal blood supply and compromise the vascularity of
the fracture site. With these benets, many manufacturers now
supply bone plates that have locking options. In contemporary
anatomical plates, the screw hole styles can typically be
categorized into combi hole design (like the PHILOS plate,
Synthes, Switzerland), locking hole only design (like the NCB
Proximal Humerus Plate, Zimmer, United States), and locking and
dynamic holes separated design (like the Proximal Lateral
Humerus Locking Plate, A Plus Biotechnology, Taiwan). A number
of clinical literatures had found breakage of the plate in the
dynamic compression part of the combi hole. From the
biomechanical viewpoint, this dynamic unite is the weakest part
of this screw hole design because it should be used for bending if
required. However, the biomechanical difference between these
three screw hole styles is still unknown. The objective of this
computational study was to investigate the effect of screw hole
style design on plate stress distribution with use of a nite element
analysis (FEA). We hypothesized that more stress concentration
would exist in the plate with combi holes. Also, the stiffness of the
plate-bone construct and the directional displacement within the
fracture gap were evaluated to compare the xation stability
between the implants with different screw hole styles.
Materials and methods
A three-dimensional (3D) geometry of an intact humerus was
generated from the CT scan of a 58-year-old Chinese male. The CT
scanning (Light Speed VCT, GE Medical System, General Electric
Company, USA) was collected with slice thickness of 1.25 mm and
512  512 pixels per image, which was approved by the
Institutional Review Board of Show Chwan Memorial Hospital
(No. 1021004). The CT scan data were then imported into a selfdevelopment image processing software to outline cortical and

cancellous contours via the grayscale difference of the CT images.

A CAD software, PTC Creo 2.0 (Parametric Technologies Corp.,
Needham, MA, USA) was utilized to reconstruct the 3D humerus
model via the cortical shell and cancellous core. A fracture gap at
the subcapital site was simulated by resecting a segment of 10 mm
length [14].
Three CAD models of proximal humeral plate with different
screw hole style were constructed using PTC Creo 2.0. Among the
three models, the Proximal Lateral Humerus Locking Plate (A Plus
Biotechnology Co., Ltd., New Taipei City, Taiwan) with locking and
dynamic holes separated design was designated as a baseline
model. Other two implants with combi holes and locking holes,
respectively, were modied from the Proximal Lateral Humerus
Locking Plate model, in order to directly compare different screw
hole styled implants of the same shape without the intervention of
other inuencing factors. Similarly, the locking screws were kept
identical in the three designs. All plate models were featured nine
holes anchored in the proximal humeral head and four holes in line
distally (Fig. 1).
The three plate-bone constructs were imported into a
commercial FEA solver of ANSYS Workbench 11.0 (ANSYS Inc.,
Canonsburg, PA, USA) for computational analysis. To evaluate the
accuracy of our nite element models, a convergence test of total
strain energy was performed. For the convergence test, a new FE
model with more element numbers was calculated and the results
of the presented FE model was compared with that of the new FE
model. After the completion of the convergence test, the mesh
generated for each designs contained 511,899 elements on
average. Due to the complex geometry of the bone plates and
the threaded screw holes the mesh consists tetrahedral elements
only.
Fig. 2 illustrates the loading and boundary conditions established on the model for each design. The base of the humerus was
xed in all degrees of freedom. A vertical compression point load
was applied to the humeral head until 200 N (loading increment:
50 N; four loading steps) based upon the experimental data
reported by Seide et al. [14] and Brianza et al. [15]. Isotropic and
linearly elastic behaviour is assumed for all components in the
current study. The material properties assigned in the FE models
are summarized in Table 1 [16]. For the interfacial surface between
the different components of the models, frictional contact was
dened between the boneplate interactions with a frictional

Fig. 1. CAD models of three humerus plates involved in the study. (a) Combi design; (b) locking and standard holes separated; and (c) locking hole only.

Please cite this article in press as: Zhang Y-K, et al. Biomechanical effect of the conguration of screw hole style on locking plate xation
in proximal humerus fracture with a simulated gap: A nite element analysis. Injury (2016), http://dx.doi.org/10.1016/
j.injury.2016.02.028

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Table 1
Material properties of the components involved in the FE model [15].

Cortical bone
Cancellous bone
Titanium alloy (plate and screw)

Elastic modulus (GPa)

Poissons ratio

12
0.1
110

0.3
0.3
0.3

combi hole plate, especially around the dynamic compression part

of the combi hole.
The load displacement curves were illustrated in Fig. 4 for the
three screw hole styled plates. The linear stiffness of the plate-bone
construct was derived from the load divided by axial displacement
of the model. Although no signicant difference between three
screw hole designs was observed, the linear stiffness of the
construct was lowest in the combi hole design. The value of the
construct stiffness was 15% higher in the locking screw only design
(132.6 N/mm) when compared with the combi design (115.0 N/
mm), and it was 4% higher than the combi design for the locking
and dynamic holes separated design (119.5 N/mm).
Table 2 showed the directional displacement data after static
load for the three screw hole styled plates. The movement within
the fracture gap was greatest in the combi hole design, whereas it
was smallest for the locking hole only design.
Discussion

Fig. 2. Boundary conditions applied to all models.

coefcient of 0.42 [17] whereas full constraints were applied

between the screws and surrounding bone, and between the
threaded areas of the plat and the screw head to simulate the
tightened locking. Each analysis was examined and compared in
terms of peak von Mises stress in the plate, the stiffness of the
plate-bone construct and directional displacement within the
fracture gap. To calculate the construct stiffness, the load and
displacement data were recorded during simulation.

Results
Fig. 3 exhibited the von Mises stress distribution of the three
humeral plates with different screw hole styles. The maximal von
Mises stress was located around the screw hole of the plate shaft
for the three designs. The von Mises stress was more evenly
distributed in the plate with locking and dynamic holes separated
design, while an apparent stress concentration was appeared in the

Fixed-angle locking plates are a relatively new method of

xation for complicated fractures, especially in patients with
pathological fractures and osteoporosis [18,19]. The use of such
plates to treat comminuted fractures of the proximal humerus has
theoretical biological and mechanical advantages over conventional techniques, thereby allowing early joint mobility and return
of function. Recently, many plate failure cases around the combi
screw hole had been reported [613]. Understanding the effect of
screw hole style on the stress distribution surrounding the screw
hole is critical. The current study attempted to recognize the
biomechanical performance of three contemporary screw hole
styles of the proximal humeral locking plate.
In the three screw hole designs, an obvious stress concentration
surrounding the screw holes was demonstrated. It is known that a
smooth round hole in a plate causes a stress concentration factor of
3 [20]. Among three screw hole designs in this study, the geometry
of the combi hole is more complicated. Consequently, it might
explain why the combi hole style resulted in highest peak von
Mises stress over the plate shaft. On the other hand, the result
displayed that the peak von Mises stress in locking and dynamic
holes separated design was lower than the locking hole only
design. The possible reason may be the oval-shaped screw hole in
the locking and dynamic holes separated design while it is a
rounded hole in the locking hole only plate. From the mechanics
point of view, the oval-shaped hole style could reduce the stiffness
of the bone plate more, thus decreasing the stress in the implant.
According to the fatigue strength of Ti-6Al-4V (approximately
600 MPa) [21], the peak von Mises stresses on the combi hole plate
(493 MPa) is close to the endurance limit of the material. One can
expect that this screw hole style is endangered in high risk of
breakage. A majority of fractures of the proximal humeral plate
found in clinical literatures are the PHILOS plate (Synthes,
Oberdorf, Switzerland) which has combi screw hole design
[613]. The material used for the Philos plate is pure titanium
(CPTi) [22], however, the fatigue strength of CPTi is 230280 MPa
only [23]. Furthermore, the combi design was manifested the
higher peak von Mises stresses surrounding four screw holes on
the plate shaft. Accordingly, it absolutely interprets the plate
fracture cases found in clinical reports.

Please cite this article in press as: Zhang Y-K, et al. Biomechanical effect of the conguration of screw hole style on locking plate xation
in proximal humerus fracture with a simulated gap: A nite element analysis. Injury (2016), http://dx.doi.org/10.1016/
j.injury.2016.02.028

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Y.-K. Zhang et al. / Injury, Int. J. Care Injured xxx (2016) xxxxxx

Fig. 3. von Mises stress distribution in the three screw hole styled plates, with peak values around the screw holes in the plate shaft labelled. (a) Combi design; (b) locking and
standard holes separated; and (c) locking hole only.

Fig. 4. Load displacement chart sketched after FE analysis under static load of 200 N
for all three plates. The locking hole only design shows the highest construct
stiffness.

Table 2
Maximum displacement within the osteotomy site after static load.

Combi hole
Locking and standard holes separated
Locking hole only

Axial (mm)

Shear (mm)

1.09
1.05
0.97

0.53
0.45
0.32

growth of blood vessels across the gap [24,25]. Therefore, delayed

or non-union and subsequent fatigue failure in the combi plate
would easily occur during cyclic loading. We thought that the
locking and dynamic holes separated design is superior to the other
two.
The present study contains a number of limitations. Tied
constraints are applied to contact surfaces between the screws and
surrounding bone and between the threaded areas of the plat and
the screw head. The assumption that complete adhesion exists
between these components may not be fully representative of the
true condition, but it is believed that this assumption would not
affect the ndings in this computational analysis. Linear elastic
material behaviour is assumed in the current study. However,
simulations did not display high stresses in the regions around the
screw hole that will lead to component plasticity. Additionally, the
plate-bone constructs were examined under one loading and
boundary condition based on previous publication [14] without
muscle forces that is not representative of any physiological
environment. Further development of a model that simulates
physiological conditions is necessary for future researches such as
the evaluation of the risk of implant failure and the mechanics
between implantbone interfaces.
Conclusion

For the stiffness of the plate-bone construct, the value from high
to low is in the order of locking hole only design (132.6 N/mm),
locking and dynamic holes separated design (119.5 N/mm) and
combi hole design (115.0 N/mm). From the mechanics of material,
this is reasonable because the screw hole is smallest in the locking
hole only design. Nevertheless, the von Mises stress in the locking
hole only design is higher than that of locking and dynamic holes
separated design due to more stiff of the plate-bone construct. As
for the model movement, the displacement within the fracture gap
for the combi hole design was greater either in axial or in shear. It is
recognized that limited axial motion improves fracture consolidation, and excessive shear motion at the fracture site hampers bone
formation in the osteotomy gap and reduces the longitudinal

This study is the rst computational analysis to compare the

stress distribution between different screw hole congurations in
commercialized bone plates. The computed results demonstrated
our hypothesis that more stress concentration exists in the combi
styled screw hole. Furthermore, the shear movement within the
fracture gap for the combi hole design was greater, thus impairing
the fracture healing process. Such screw hole style could put the
plate at higher risk of fracture. Relatively, the peak von Mises stress
for locking and dynamic holes separated design is lowest within
three contemporary screw hole styles for proximal humeral plate.
Additionally, the displacement within the fracture gap in locking
and dynamic holes separated design was moderate although the
load displacement data indicated that the stability of the platebone construct might not be sensitive to screw hole style. We

Please cite this article in press as: Zhang Y-K, et al. Biomechanical effect of the conguration of screw hole style on locking plate xation
in proximal humerus fracture with a simulated gap: A nite element analysis. Injury (2016), http://dx.doi.org/10.1016/
j.injury.2016.02.028

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concluded that locking and dynamic holes separated conguration

may be a better design in terms of prevention of plate fracture.

[9]

Conict of interest statement

All authors declare that they do not have any conicts of
interest.

[10]
[11]
[12]

Acknowledgements
[13]

We acknowledged the nancial support of the Ministry of

Science and Technology of Taiwan (MOST 103-2623-E-033-001)
and the computational support from A Plus Biotechnology Co. Ltd.
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Please cite this article in press as: Zhang Y-K, et al. Biomechanical effect of the conguration of screw hole style on locking plate xation
in proximal humerus fracture with a simulated gap: A nite element analysis. Injury (2016), http://dx.doi.org/10.1016/
j.injury.2016.02.028