Original Article

Biomechanical comparison of monocortical and bicortical plate

fixation for rib fractures in a cadaveric model using a locking plate
system
Abby Choke1, Yoke Rung Wong2, Janna-Vale Joethy1
1
Department of Plastic, Reconstructive and Aesthetic Surgery, 2Biomechanics Laboratory, Singapore General Hospital, Singapore 169856, Singapore
Contributions: (I) Conception and design: JV Joethy, A Choke; (II) Administrative support: YR Wong; (III) Provision of study materials or patients:
JV Joethy; (IV) Collection and assembly of data: A Choke, YR Wong; (V) Data analysis and interpretation: A Choke, YR Wong; (VI) Manuscript
writing: All authors; (VII) Final approval of manuscript: All authors.
Correspondence to: Dr. Janna-Vale Joethy. Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, 20 College Road,
Singapore 169856, Singapore. Email: janajoethy@hotmail.com.

Background: Surgical stabilization of rib fractures is an established form of treatment for complex rib
fractures. Plate fixation with bicortical screws placement can cause injury to intra-thoracic organs and pleural
irritation from protruding screw tips. The aim of this study is to compare the biomechanical properties of
monocortical and bicortical plate fixation for rib fractures using a locking plate system.
Methods: Ten pairs of fresh-frozen cadaveric ribs were harvested. Native ribs were mounted onto a
biomechanical tester and statically loaded to failure to induce a rib fracture. The native stiffness of the rib was
measured. Next, the ribs were stabilized using the Synthes MatrixRIB (Johnson & Johnson, USA) locking
plate. Left-sided ribs were fixed in a bicortical manner and right-sided ribs were fixed in a monocortical
manner. The repaired ribs were subjected to cyclic loading of 50,000 cycles between 2 to 6 N to simulate
physiological respiration, followed by static loading at a rate of 10 N/min until failure. The pre and post-
repaired stiffness were measured. A high-speed camera was used to record the mechanism of failure.
Results: One left-sided rib was omitted from the study because the fracture occurred at the drill hole site.
Left-sided ribs demonstrated a mean native stiffness of 10.0 N/mm (SD 3.71) and right-sided 11.92 N/mm
(SD 3.57). After plate fixation, pre and post cyclic stiffness was 3.32 N/mm (SD 1.21) and 4.41 N/mm (SD
3.29) for the bicortical group; 3.14 N/mm (SD 1.24) and 3.91 N/mm (SD 1.98) for the monocortical group.
There is no statistical difference found between the two groups (P=0.872).
Conclusions: Our results show that there is no difference in stability between monocortical and bicortical
fixation for rib fractures using a locking plate system. Monocortical fixation is recommended to avoid
potential complications.

Keywords: Rib fracture; bicortical; monocortical; unicortical; locking plate

Submitted Aug 24, 2019. Accepted for publication Nov 15, 2019.
doi: 10.21037/jtd.2019.12.31
View this article at: http://dx.doi.org/10.21037/jtd.2019.12.31

Introduction and pain relief. While simple fractures can be managed

conservatively, it is well known that patients with multiple
Rib fractures are a common outcome of thoracic trauma.
The severity of fracture may range from a simple isolated rib fractures and the elderly are at a higher risk of adverse
rib fracture, to multiple level fractures and flail chest. outcomes which includes longer hospital stay, longer
Traditionally, management of rib fractures was largely dependence on mechanical ventilator, and higher risk of
conservatively and focused on symptomatic treatment developing pneumonia (1).

© Journal of Thoracic Disease. All rights reserved. J Thorac Dis 2019;11(12):4966-4971 | http://dx.doi.org/10.21037/jtd.2019.12.31
Journal of Thoracic Disease, Vol 11, No 12 December 2019 4967

drilling of both cortices poses a theoretical risk injuring

the intra-thoracic organs, and the prominence of the screw
tip can result in pleural irritation or pneumothorax. If
the screws were aim inferiorly, there is also the possibility
of injuring the intercostal neurovascular bundle at the
subcostal groove. While there were many comparison
studies on screw fixation in long bone fractures, there are
no similar studies for rib fractures to date (7,8). The aim
of this study is to compare the biomechanical properties of
monocortical and bicortical plate fixation for rib fractures
using an advanced plating system.

Methods

This study was conducted in the Biomechanics Laboratory

of Singapore General Hospital. Ethics approval from
the institution was not a requirement as this was a
Figure 1 Experimental setup using the Instron E-1000 Dynamic biomechanical study based on a cadaveric model.
Tester. The rib was statically loaded to failure to induce a clinically
realistic fracture pattern.
Specimen preparation

Ten pairs of fresh frozen ribs (Rib 5 to 9) were harvested

In 2002, Tanaka et al. randomized 37 patients with from two cadavers. Each rib was dissected free from
flail chest who required mechanical ventilation into two the surrounding soft tissues with careful preservation of
treatment groups: conservative versus surgical fixation. the periosteum. All the ribs were stored under −20 ℃
He reported that the group that was treated surgically and thawed on the day of experiment. To ensure that all
had a significantly shorter duration on ventilator, shorter specimens were tested under the same bending load, the
duration in intensive care, lower incidence of pneumonia, ribs were shortened to a consistent arc height of 5 cm. Two
and improved pulmonary function (2). Several smaller case 5 mm drill holes were made at both ends of the rib, one at
series also reported reduced mortality, better pain control, the rib tubercle and another 15 mm from the anterior edge
better clearance of secretions, and quicker back to work of the rib (Figure 1). One of the left-sided rib from the study
time (3-5). was omitted because the fracture occurred at the drill hole
Different methods of internal fixation have been tried end rendering it impossible to mount.
and tested over the years; these included conventional
compression plating, intramedullary wires, struts, or
Experimental setup
absorbable plates. Each of these have their benefits but
also had problems like hardware migration, screw pull out, The specimens were evaluated using the Instron E-1000
or injury to the neurovascular bundle. In 2010, Bottlang Dynamic tester (Instron Corp., USA). A customized jig was
developed a customized implant system based on the human fabricated for mounting of the specimens. A 5 mm diameter
ribs biomechanics and anatomy (6). This implant, known as metal rod was placed at each end of the ribs through the
the Synthes MatrixRIB system (Johnson and Johnson, USA) drill hole, and then mounted on the testing machine. The
is a customized titanium rib plating system that adopts the upper holder of the fixture was attached to the load cell of
contour of human ribs. These plates are low profile and pre- the tester while the lower holder remained stationary at the
contoured, and have a locking mechanism that allows the tester platform during testing (Figure 1).
fractured ribs to be immobilized at a stiffness level optimal
for bone healing.
Biomechanical test
Similar to conventional plating, the locking system
recommends screw placement in a bicortical manner. The The biomechanical tests were designed based on other

© Journal of Thoracic Disease. All rights reserved. J Thorac Dis 2019;11(12):4966-4971 | http://dx.doi.org/10.21037/jtd.2019.12.31
4968 Choke et al. Monocortical versus bicortical plating in rib fractures

A B

Figure 2 Bicortical and monocortical plate fixation of the rib using the Synthes MatrixRIB plating system. (A) In bicortical fixation, the
screw tip traverses both the inner and outer cortices of the rib; (B) the screw tip does not traverse the inner cortex of the rib in monocortical
fixation.

biomechanical studies for rib fractures (6,9). The tests on both end of the fracture line;
comprised of 4 phases: (iv) the screw length was confirmed using a depth
(I) To determine the native stiffness of the rib; gauge and pre-drilled using a power hand drill
(i) each rib was statistically loaded at the rate of with 2.2 mm drill bit. Then, two screws were
10 N/second to induce a realistic fracture pattern placed adjacent to the fracture site to secure
(Figure 1). The native stiffness was measured the position of the plate. The remaining screws
based on the load displacement curve (N/mm) were then placed;
produced during the static loading; (III) Cyclic loading of plate construct;
(II) Rib fractures repaired using the Synthes MatrixRIB (i) the repaired specimen was mounted onto the
system; biomechanical tester and the pre-cyclic stiffness
(i) matching plates were chosen based on the side measured. Then, the specimen was subjected
(left or right) and level of the rib (4th to 8th). to cyclic loading for 50,000 cycles between
The plates were shortened to a 7-hole length 2 to 6 N load (Figure 3) to simulate 48 hours
and carefully bent to match the rib contour; of physiological breathing at 18 breaths per
(ii) the thickness of rib was measured using a minute (9). After cyclic loading, the stiffness of
caliper to determine the screw length. For the specimen was again measured to determine
left-sided ribs, 2 mm was added onto the the post-cyclic stiffness;
measured rib thickness to achieve a bi-cortical (IV) Load to failure;
fixation, e.g., a 12 mm screw for a 10 mm (i) the specimen was subjected to exaggerated
thickness rib. For right-sided ribs, 2 mm static loading until failure. This was used to
was deducted e.g., 8 mm screw for a 10 mm determine the post-repair construct stiffness;
thick rib to achieve a mono-cortical screw (ii) a high-resolution camera was used to analyze
placement (Figure 2A,B); the mechanism of failure (Figure 4A,B).
(iii) the fracture was reduced using a reduction Non-parametric Mann-Whitney U test was used
forceps. The plate was placed on the outer for statistical analysis. A P value of less than 0.05 was
cortex of the rib with 3 screw holes positioned considered to be statistically significant.

© Journal of Thoracic Disease. All rights reserved. J Thorac Dis 2019;11(12):4966-4971 | http://dx.doi.org/10.21037/jtd.2019.12.31
Journal of Thoracic Disease, Vol 11, No 12 December 2019 4969

Results sided and right-sided ribs were 10.03 N/mm (SD 3.71) and
11.92 N/mm (SD 3.57) respectively. The post repaired
Comparison of native and repaired stiffness within and stiffness was 3.32 N/mm (SD 1.21) for the bicortical
between the method of fixation group and 3.14 N/mm (SD 1.24) for the monocortical
group. There is significant difference when comparing the
As shown in Table 1, the mean native stiffness for left- before and after repair stiffness for both groups (P<0.001).
However, no significant difference was found when
compared between mono- and bi-cortically repaired ribs
(P=0.842).

Comparison of pre and post cyclic loading stiffness

As shown in Table 2, the mean pre- and post-cyclic stiffness

of bicortical repaired ribs was 3.32 N/mm (SD 1.21) and
4.41 N/mm (SD 3.29). For the monocortical group, it was
3.14 N/mm (SD 1.24) and 3.91 N/mm (SD 1.98) (Table 2).
No significant difference was found between both
groups after cyclic loading (P=0.872). This indicate that
monocortical repaired ribs were not inferior in stiffness
compared to the bicortical group.

Mechanism of failure

Figure 3 Following plate fixation, the specimen was subjected The mean load to failure was 76.2 N (SD 32.4) for the
to cyclical loading for 50,000 cycles at a load of between 2 to 3 bicortical group and 71.7 N (SD 32.48) for the monocortical
Newton. group. We observe that all the specimens in the bicortical

A B

Figure 4 The rib construct was statically loaded to failure at the end of the experiment. The mechanism of failure for this bicortical plating
was fracture at the previously fractured site associated with plate bending (A). The monocortical construct in (B) demonstrated screw pullout
of the distal portion of the plate.

© Journal of Thoracic Disease. All rights reserved. J Thorac Dis 2019;11(12):4966-4971 | http://dx.doi.org/10.21037/jtd.2019.12.31
4970 Choke et al. Monocortical versus bicortical plating in rib fractures

Table 1 Comparison between mean native rib stiffness and mean bicortical screws placement is a traditional technique well
repaired stiffness described in literature (4,5). These conventional plates are
Method of Mean native Mean repaired
P value
high profile and exceed the stiffness of human ribs, making
fixation stiffness (N/mm) stiffness (N/mm) it prone for failure by screw pullout. Moreover, in the
Bicortical (n=9) 10.03 (SD 3.71) 3.32 (SD 1.21) <0.001 setting of an emerging elderly population who suffers from
Monocortical (n=10) 11.92 (SD 3.57) 3.14 (SD 1.24) <0.001 osteoporosis, these highly rigid implants can cause chronic
pain and peri-prosthetic fracture (11). The introduction
P (Mann 0.842, not significant
of a low-profile titanium locking plate system addressed
Whitney test) between both groups
many problems of a conventional plate. The locking design
distributes the stress along the length of the plate without
the need for compression of the bone, allowing it to
Table 2 Comparison between pre- and post-cyclic stiffness of the
preserve the periosteal blood supply (12). The thinner pre-
two groups
contoured plates also allow better conformation onto the
Method of Pre-cyclic Post-cyclic
P value curvature of the rib and reduce the need for intra-operative
fixation stiffness (N/mm) stiffness (N/mm)
bending of plates.
Bicortical (n=9) 3.32 (SD 1.21) 4.41 (SD 3.29) 0.878 With an increasing number of operative fixations,
Monocortical (n=10) 3.14 (SD 1.24) 3.91 (SD 1.98) 0.579 hardware related problems are also anticipated. The
P (Mann 0.872, not significant intimate anatomy of the underlying thoracic organs and
Whitney test) between both groups great vessels are at risk. The drilling of both cortices
risks injury to the intra-thoracic organs, ranging from
lung parenchymal injury to fatal cardiac injury (13). The
Table 3 Comparison of load to failure (N) and mechanism of prominence of the screw tip may result in pleural irritation
failure or pneumothorax. Technical caution is imperative during
Failure mode Bicortical Monocortical P placement of screws. If plating can be performed in a mono-
cortical fixation, we can minimize the complications related
Mean load to 76.2 (SD 32.4) 71.7 (SD 32.48) P=0.549, not
failure (N) significant
to bicortical fixation.
Not surprisingly, our data suggested that bicortical
Mechanism
fixation demonstrated a higher stiffness than monocortical
Plate bending 9 (100%) 8 (80%) fixation. This can be attributed to the greater number
Screw pull out 0 (0%) 2 (20%) of cortices the screw engages in a bicortical fixation (12
cortices for 6 screws). However, this property is less
relevant in human ribs as stress loading in human ribs is not
axially directed and does not involve weight bearing. This
group (n=9) failed by plate bending and re-fracture at the
is in contrast to other long bones where a rigid construct
previously fractured site. The same mechanism was seen in
is required to withstand axial loading. The greater number
8 out of 10 specimens in the monocortical group, with the
of cortices the screw engages can also weaken the bone,
other 2 specimens demonstrating screw pull out (Table 3).
making it a potential site for periprosthetic fracture.
This study has several limitations. Firstly, this study
Discussion focused on the testing of individual rib, whereas in reality
the chest wall moves in tandem with the diaphragm,
There are several indications for surgical fixation of rib sternum and chest wall musculature. This study is also
fractures including multiple rib fractures, chronic painful limited to the single method of axial compressive loading
rib fractures, non-union deformity, and flail chest (10). An and did not account for the torsional force that occurs in
ideal fracture fixation should have satisfactory reduction physiological breathing. The induced fracture also may not
of fracture, provide sufficient stability for bone healing, accurately represent the in-vivo behavior of rib fractures
sufficient blood supply and soft tissue, as well as allow early which in reality could be more complex and compounded
mobilization. This task is challenging because of the unique by other injuries.
anatomy of the human ribs. Compression plating with In summary, our results demonstrated no significant

© Journal of Thoracic Disease. All rights reserved. J Thorac Dis 2019;11(12):4966-4971 | http://dx.doi.org/10.21037/jtd.2019.12.31
Journal of Thoracic Disease, Vol 11, No 12 December 2019 4971

difference in the construct stiffness between monocortical Prospective Randomized Study of Management of
and bicortical screw fixation. This suggested that Severe Flail Chest Patients. J Trauma 2002;52:727-32;
monocortical plate fixation can provide similar stability discussion 732.
as a bicortical fixation, and represents a reasonable option 3. Ahmed Z, Mohyuddin Z. Management of flail chest
to avoid complication associated with bicortical screw. injury: internal fixation versus endotracheal intubation and
However, it remains unclear whether these differences ventilation. J Thorac Cardiovasc Surg 1995;110:1676-80.
will be clinically significant. We hope to expand future 4. Engel C, Krieg JC, Madey SM, et al. Operative chest wall
study to include rotational forces. We believe that with this fixation with osteosynthesis plates. J Trauma 2005;58:181-6.
understanding, modification can be made intra-operatively 5. Lardinois D, Krueger T, Dusmet M, et al. Pulmonary
to reduce the risk of injury caused by the screws, or function testing after operative stabilisation of the
combine the use of both monocortical and bicortical screw chest wall for flail chest. Eur J Cardiothorac Surg
for a locking plate. 2001;20:496-501.
6. Bottlang M, Walleser S, Noll M, et al. Biomechanical
rationale and evaluation of an implant system for rib fracture
Acknowledgments
fixation. Eur J Trauma Emerg Surg 2010;36:417-26.
Funding: This work was supported by the SingHealth 7. Pater TJ, Grindel SI, Schmeling GJ, et al. Stability of
Surgery Academic Clinical Program (ACP) Seed Grant unicortical locked fixation versus bicortical non-locked
[GRDUKS002301]. fixation for forearm fractures. Bone Res 2014;2:14014.
8. Doht S, Meffert RH, Raschke MJ, et al. Biomechanical
analysis of the efficacy of locking plates during cyclic
Footnote
loading in metacarpal fractures. ScientificWorldJournal
Conflicts of Interest: The authors have no conflicts of interest 2014;2014:648787.
to declare. 9. Sales JR, Ellis T, Mayberry JC, et al. Biomechanical testing
of a novel, minimally invasive rib fracture plating system. J
Ethical Statement: The authors are accountable for all Trauma 2008;64:1270-4.
aspects of the work in ensuring that questions related 10. Cacchione RN, Richardson JD, Seligson D. Painful
to the accuracy or integrity of any part of the work are nonunion of multiple rib fractures managed by operative
appropriately investigated and resolved. Ethics approval stabilization. J Trauma 2000;48:319-21.
from the institution was not a requirement as this was a 11. Hellberg K, de Vivie ER, Fuchs K, et al. Stabilization of
biomechanical study based on a cadaveric model. flail chest by compression osteosynthesis – experimental
and clinical results. Thorac Cardiovasc Surg
1981;29:275-81.
References
12. Cronier P, Pietu G, Dujardin C, Bigorre N, Ducellier
1. Holcomb JB, McMullin NR, Kozar RA, et al. Morbidity F, Gerard R. The concept of locking plates. Orthop
from rib fractures increases after age 45. J Am Coll Surg Traumatol Surg Res 2010. [Epub ahead of print].
2003;196:549-55. 13. Pieracci FM, Johnson JL, Stovall RT, et al. Completely
2. Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical thoracoscopic, intra-pleural reduction and fixation of
Stabilization of Internal Pneumatic Stabilization. A severe rib fractures. Trauma Case Rep 2015;1:39-43.

Cite this article as: Choke A, Wong YR, Joethy JV.

Biomechanical comparison of monocortical and bicortical
plate fixation for rib fractures in a cadaveric model using a
locking plate system. J Thorac Dis 2019;11(12):4966-4971. doi:
10.21037/jtd.2019.12.31

© Journal of Thoracic Disease. All rights reserved. J Thorac Dis 2019;11(12):4966-4971 | http://dx.doi.org/10.21037/jtd.2019.12.31