Biomechanics of the Locomotor Apparatus: Contributions on the Functional Anatomy of the Locomotor Apparatus

526 Pages·1980·8.2 MB·English

by  Professor Friedrich Pauwels Dr. med.

F. Pauwels
Biomechanics of the
Locomotor Apparatus
Contributions on the Functional Anatomy
of the Locomotor Apparatus
Translated from the German, Completely Revised and
Enlarged, Including Seven New Chapters
Translated by P. Maquet and R. Furlong
With 733 Figures
Springer- Verlag
Berlin Heidelberg New York 1980
Professor FRIEDRICH PAUWELS
Dr. med., Dr. med. h. c., Dr. Ing. E. h., Orthopaedic surgeon
Zweiweiherweg 3, D-5100 Aachen
Translators:
PAUL MAQUET, M. D.
25, Thier Bosset, B-4070 Aywaille
RONALD FURLONG, MB, BS, FReS Eng.
149, Harley Street, GB-London, WIN 2DE
Translation of the German edition, 1965
Completely revised and enlarged. including seven new chapters
Gesammelte Abhandlungen zur funktionellen Anatomie
des Bewegungsapparates
ISBN-13: 978-3-642-67140-1 e-ISBN-13: 978-3-642-67138-8
DOl: 10.1007/978-3-642-67138-8
Library of Congress Cataloging in Publication Data. Pauwels, Friedrich. Biomechanics of the locomotor
apparatus. Rev. translation of the work published in 1965 under title: Gesammelte Abhandlungen zur
funktionellen Anatomie des Bewegungsapparates. Bibliography: p. Includes index. I. Human mechan
ics. 2. Human locomotion. 3. Extremities, Lower-Anatomy. I. Title. QP303.P313 599.01'88
80-21625 ISBN 0-387-09131-9 (U.S.)
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© by Springer-Verlag Berlin Heidelberg 1980
Softcover reprint of the hardcover 1s t edition 1980
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2124/3130-543210
Preface to the German Edition
The contents of this book are based almost exclusively on purely anatomical
researches. These were stimulated by questions posed in clinical practice. The
results are directed to practicing surgeons. Their chronological sequence leads to
a step by step development of theoretical bases and to a progressive rejection
of old conceptions.
Especially in the field of orthopaedic surgery, a responsible attitude is possible
neither without solid anatomical knowledge, nor without an idea of functional
relationships. W. Roux had already demonstrated this and he wanted his works
of functional anatomy to be considered from this point of view. He above all
preoccupied himself with a uniform theory of functional adaptation. Thus it is
understandable that the theories ofRoux formed the basis from which to start.
Our own researches seemed at first to corroborate the ideas of Roux, at least
in part. This is still evident in the monograph concerning fractures of the femoral
neck. Later it appeared that ST. KROMPECHER had made a step forwards in the
matter of chondrogenesis when he abandoned the shear theory postulated by
Roux and held that compression was the only effective stimulus for the forma
tion of cartilage. The research concerning the healing of fractures relies partly on
the theory of KROMPECHER which was new at that time. But ultimately more and
more discoveries could no longer be explained by this conception which was
only slightly different from the older theories (1. WOLF, W. Roux, W. GEB
HARDT, H. TRIEPEL, A. BENNINGHOFF). At the same time it appeared evident that
the whole classical construction had been built upon conceptions of the mechani
cal principles which were not very clear and often completely false. Meanwhile,
the application of improved research methods such as photoelasticity offered the
welcome possibility of veritying with experiments on models the theoretical ex
planations. Thus it seemed to me justified also to verity problems which ap
peared to be solved as is the case for the analysis of an ankylosis of the knee which
Roux carried out on a preparation of WOLFF.
The new conception considerably deviates from the existing classical picture in
several decisive points. This new conception is not only a matter of abstract theo
ries but its multiple and successful applications in clinical practice demonstrate
its practical significance. Numerous observations can show that, like any new
theory which rightly replaces an older, the ideas here permit the explanation of a
greater number offacts with fewer hypotheses.
I am most grateful to Mr. ing. NORBERT HERMES, a pupil of G. MESSMER, for
introducing me to the difficult method of photoelasticity, and also for carrying
out many calculations leading to the solution of complicated static problems.
Aachen FRIEDRICH PAUWELS
Table of Contents
1. The Fracture of the Femoral Neck. A Mechanical Problem
2. Biomechanics of Fracture Healing . . . . . . . . . . 106
3. Stressing of the Pelvis and Especially of the Pelvic Joints. Contribution
to Its Explanation . . . . . . . . . . . . . . . . . . . 138
4. The Principles of Construction of the Locomotor System. Their
Significance for the Stressing of the Tubular Bones .. . . . 149
5. The Mechanical Significance of the Gross Structure of the Cortex
in Normal and Pathologically Bent Tubular Bones ...... 183
6. Principles of Construction of the Lower Extremity. Their Significance
for the Stressing of the Skeleton of the Leg . . . . . . . . 193
7. Significance of the Muscular Forces for the Regulation of the
Stressing of the Tubular Bone During Movement of the Limb 205
8. The Static Significance of the Linea Aspera. . . . . . . . 223
9. Critical Examination of the Work ofRoux: "Description and
Explanation ofa Bony Ankylosis of the Knee". . . . . . . 229
10. The Significance of the Mechanical Factors Acting on the Elbow
Joint for the Carrying Capacity of the Flexed Upper Limb . . . 249
II. On the Distribution of the Density of Cancellous Bone in the
Upper End of the Femur and Its Significance for the Theory of the
Functional Structure of Bone ............... 299
12. The Functional Adaptation of Bone Through Growth in Length.. 310
13. The Structure of the Superficial Fibre Layer of the Articular Cartilage
of the Glenoid Cavity as an Example of an Embodied Stress Field . 329
14. A New Theory Concerning the Influence of Mechanical Stimuli on
the Differentiation of the Supporting Tissues . . . . . . . . 375
15. The Distribution of Pressure in the Elbow Joint Together with
Fundamental Remarks on Joint Pressure. . . . . . . . . . 408
16. The Significance of a Tension Band for the Stressing of the Tubular
Bone with Application to Compression Osteosynthesis . . . . . 430
17. Contribution to the Study of Functional Adaptation of the Cortex
ofa Tubular Bone. An Examination of Three Femora Deformed
by Rickets. . . . . . . . . . . . . . . . . . . . . . . . 450
VIII Table of Contents
18. Biomechanics of Bone Grafting. 463
19. Short Survey of the Mechanical Stressing of Bone and Its Significance
for Functional Adaptation . . . . . . . . . . . . . . . . . .. 478
20. The Significance of the Medullary Cavity for the Mechanical Stressing
of the Tubular Bone . . . . . . . . . . . . . . . . . 504
21. A Clinical Observation as Example and Proof of Functional
Adaptation of the Bone Through Longitudinal Growth. . . 508
22. On the Modelling Effect of the Functional Adaptation of the Bone 514
1. The Fracture of the Femoral Neck.
A Mechanical Problem
The Bases of the Healing Process. Prognosis and
Fundamental Treatment *
With 186 Figures
Part One
This study will contribute to clarifying the generation is sufficient to resist the mechani
problem of the fractured neck of the femur. cal stressing. It is on a similar theory that the
The leading idea is the recognition of the definition of the essential nature of a pseud
fact that mechanical forces can gain a deci arthrosis given by WALTER MULLER is
1
sive influence on the biology of bony tissue. based: "The state of the pseudarthrosis is the
The healing of a fracture is only possible if, result of a disproportion between the capac
at each stage of the evolution, the capacity ity of the bone to form callus and the me
for mechanical resistance of the tissue of re- chanical changes."
The Exceptional Position of the Femoral Neck Fracture
Amongst fractures, the femoral neck fracture percentage of pseudarthrosis than any other
occupies an exceptional position character fracture.
ized firstly by its strikingly poor and variable The justly pessimistic estimate concerning
tendency to heal. Until a short time ago, it the femoral neck fracture is not based solely
was not clear whether the sub capital fracture on the poor tendency to heal. It is also sup
could heal by bony union at all. A question ported by experience that the results present
naire on this subject which SENN sent to an enigmatic and apparently arbitrary dis
English, French, G~rman and Swiss sur parity which seems to contradict our accu
geons (1904) attracted only 27 affirmative mulated experience concerning fracture treat
and 18 negative answers. The results were so ment. As HENSCHEN has aptly said, the
3
unsatisfactory that in 1924, in the surgical fatefulness and peculiarity of the fracture of
clinics of Tiibingen, Rostock and Frankfurt, the femoral neck consist, above all, in that
primary excision of the femoral head for side by side with a series of magnificent heal
subcapital fracture was considered to be the ings, both anatomical and functional even in
method of choice, "to avoid, from the begin patients in their seventies and eighties, cases
ning, a long wait for extremely questionable are repeatedly observed where, although X
healing." A desperate point of view for a rays show ideal repositioning of the frag-
fracture that represents 7% of all fractures!
Today, thanks to the histological researches MOLLER, W.: Die normale und pathologische
1
of SCHMORL, LINDEMANN and others 2, Physiologie des Knochens. Leipzig 1924.
we know that the subcapital fracture of the SCHMORL: Die pathologische Anatomie der
2
femoral neck is capable of healing by bone Schenkelhalsfraktur. Miinch. med. Wochenschr.
and that bony union can reliably be expec 1924, Nr. 40. - LINDEMANN: Beitrlige zur Frage der
ted in a great percentage of cases. But even periostalen Callusbildung bei Schenkelhalsfraktu
ren unter Mitteilung eines anatomisch geheilten
today, in spite of improved methods of treat
Falles von medialer Schenkelhalsfraktur. Deutsch.
ment, the fractured femoral neck has a higher
Zeitschr. f. Chir. Vol. 214,1929.
HENSCHEN: Behandlung der medialen Schenkel
3
" To the memory of Alfred SCHANZ. Z. Orthop. halsbriiche durch femoropelvine AufHidelungsver
63, supplem. (1935). schraubung. Die med. Welt. 1933, Nr. 14.
2 The Fracture of the Femoral Neck. A Mechanical Problem
ments and despite prolonged immobilization, neck are attributed, according to our actual
consolidation fails to occur. Bony absorption knowledge, above all to a retarded and in
angulations, deformations of the upper ex sufficient formation of callus, that is to say,
tremity of the femur, mobile pseudarthroses to a feebleness of the bony tissue of regener
or nearthroses make the months of struggle ation which finds its ultimate cause in the
for a good result delusive. Besides, as clinical particular biological behaviour of the fracture
experience shows, the evolution towards of the femoral neck. This is apparently true
healing of a fracture of the femoral neck since, as the researches of FRANGENHEIM,
presents variations, as yet incomprehensible SCHMORL, BONN, HESSE and others4 have
in relation to that of other fractures. The demonstrated, the formation of callus in
considerable resorption of the fracture ends fractures of the femoral neck deviates in es
so often observed is peculiar and even typi sential points from the formation of callus in
cal of it, that is to say, the partial or complete other fractures. At first, in fractures of the
disappearance of the femoral neck that is femoral neck there is no periosteal callus
observed in a large number of cases even which in other fractures constitutes the bulk
when the fracture has been ideally reduced of the callus. Even the portions of the fem
and carefully treated. It is a striking fact that oral neck covered with periosteum show
impaction of the fragments does not neces practically no tendency to form callus (HES
sarily permit a favourable prognosis, con SE). SCHMORL insists that having examined
trary to other fractures. On the other hand, many histological specimens, in no case could
weight bearing in a walking plaster spica he observe any appreciable periosteal callus
which has been practically experienced as an formation, irrespective as to whether he was
efficient way to favour the formation of de dealing with intracapsular or extracapsular
layed callus not only usually fails in the frac fractures. Bony healing can consequently
ture of the femoral neck but actually it ac occur essentially only through endosteal cal
celerates the formation of a pseudarthrosis. lus formation. Compared with periosteal cal
Perhaps even it provokes it. It is also not lus, medullary callus only forms slowly. It
understandable why the so-called abduction has no tendency to proliferate and conse
fracture always heals by bone, in many cases quently only a limited possibility of develop
even in very aged patients and without any ing in the medullary space because of the
treatment, whilst, on the other hand, the ad limitation of the latter. Often its develop
duction fracture can only exceptionally be ment is even more hindered by the conse
brought to bony union, even by the best quences of the violence to which the marrow
known methods of treatment. The different has been subjected. In addition, at least in
final states of old fractures of the femoral some cases, the formation of medullary cal
neck do not allow any uniform conclusion. It lus can be further prevented in a purely me
cannot be explained why, when bony heal chanical way, for example by the interposi
ing has not been obtained, the end result is tion of fragments of capsule (FRANGENHEIM)
in one case a more or less firm fibrous union or by displacement of the fragments one in
and in another case a true nearthrosis. Just relation to the other. Finally, according to
as puzzling is the appearance that a fracture the conception of BIER and ZIEGLER, there
at first "healed" later becomes a pseudar also exists the possibility that synovial fluid
throsis or a nearthrosis, often only after prevents healing.
many months. Inversely, a pseudarthrosis
can heal by bone after months or even years
without treatment and for no recognized 4 FRANGENHEIM: Studien iiber Schenkelhalsfraktu
reason. ren und die Vorgange bei ihrer Heilung. Deutsch.
Zeitschr. f. Chir. VoL 83, 1906. - BONN: Zur Frage
The Inadequacy of the Existing der knochernen Heilungsrahigkeit subkapitaler
Schenkelhalsfrakturen. Arch. f. klin. Chir. VoL
Knowledge Concerning the Particular
128, 1924 and VoL 134, 1925. - HESSE: Zur patholo
Evolution to Healing gischen Anatomie der Schenkelhalsfraktur. Arch.
f. klin. Chir. VoL 134, 1925 - HESSE: Beitrag zur
The bad results and lack of uniformity in the Anatomie und Therapie der Schenkelhalsbriiche,
healing process of fractures of the femoral Deutsch. Zeitschr. f. Chir. VoL 199, 1926.
The Fracture of the Femoral Neck. A Mechanical Problem 3
It is, then, a valid notion that the repair to heal must be sought in the inadequate
tissue of a fracture of the femoral neck en treatment of the fracture of the femoral neck.
joys a capacity to resist which is consider This hypothesis is not plausible. This issues
ably less than that of other fractures, as much solely from the fact that some fractures of
owing to its volume as by reason of its vital the femoral neck, even in patients of very
ity. Its weakness is not, however, by itself advanced age, heal without any treatment,
sufficient to explain the poor and variable whereas, on the other hand, the formation of
tendency to heal, as is also shown by clinical a pseudarthrosis cannot be avoided in cases
experience. Sometimes, the repair tissue is apparently similar occurring in the young
sufficient to lead to bony healing even in un and in spite of careful and prolonged treat
favourable circumstances, for example in ment.
patients who are very old, whereas at other The pathophysiology of the fracture of the
times it does not attain bony healing in spite femoral neck thus, in itself, hides a problem.
of favourable conditions for its development, The ultimate cause of the obviously unfa
as for example in the young, and in spite of vourable results, and especially of the arbi
the most careful treatment. This inconsis trary and enigmatic evolution of healing,
tency cannot be explained. In the same way remains unexplained up to now, although
it is not understandable why, in fractures this problem has been studied for 30 years.
which biologically guarantee the healing tis But the reproach of a certain one-sided
sue the most favourable basis for develop ness in the research conducted until now can
ment, the results are often completely oppo not be avoided, since again and again only
site. In this regard the arbitrary behaviour of the biological factor, the quality of the tissue
the impacted fracture is especially character of regeneration, has been pushed into the
istic. Although the conditions most favour foreground. It has been overlooked that, in
able for the development of healing tissue general, for the healing of a fracture, besides
are created, even in the impacted fracture the quality of the healing tissue, the action of
we often see the formation of a pseudarthro mechanical forces, i.e. the mechanical stress
sis, the cause of which cannot be explained ing of the healing tissue, assumes decisive im
from a biological point of view. portance. Precisely, the mechanical factor
Clinical observations also contradict the must be elucidated if the problem of the frac
conception advanced notably by ANSCHUrZ ture of the femoral neck is to be given a con
5,
that the ultimate cause of the poor and vari sistent basis and if the enigma of the evolution
able tendency of the femoral neck fracture of healing is to be solved.
Mechanical Factors Present During the Healing of Fractures
It has been shown that the healing of a frac LICH have demonstrated that an exagger
6
ture can be influenced decisively by mechani ated mechanical stressing can provoke a typ
cal forces. The functional stressing does not ical fatigue syndrome in sound and intact
in all cases constitute a trophic stimulus for bone, the so-called acute remodelling of
the tissues, in the sense of LAMARK. On the bone (MULLER). It can finally lead to local
contrary, in certain circumstances, a perma
MARTIN: Ober experimentelle Pseudarthrosen
nent mechanical stressing, such as is pro 6
bildung und die Bedeutung von Periost und Mark.
voked by muscular tension at rest and by
Arch. f. klin. Chir. Vol. 114, 1920. - MOLLER, W.:
body weight when standing or during walk Experimentelle Untersuchungen tiber mechanisch
ing, can exert an extremely damaging effect bedingte Umbildungsprozesse am wachsenden
on the biology of the bony tissue. It can de und fertigen Knochen und ihre Bedeutung fiir die
stroy both mature tissue and regenerative tis Pathologie des Knochens, insbesondere der Epi
sue. physenstOrungen bei rachitisiihnlichen Erkran
Firstly, the experimental researches of kungen. Beitr. z. klin. Chir. Vol. 127, 1922. - WAL
TER: Die klinische Bedeutung der Umbauzonen
MARTIN, MULLER, WALTER and WIL-
des Knochens. Arch. f. klin. Chir. Vol. 178, 1933.
5 ANSCHUTZ and PORTWICH: Prognose und Therapie WILLICH: Experimentelles tiber Knochenregene
der veralteten Schenkelhalsfraktur. Ergeb. d. Chir. ration und Pseudarthrosenbildung. Arch. f. klin.
u. Orthop. Vol. 20,1927. Chir. Vol. 123, 1923.
4 The Fracture of the Femoral Neck. A Mechanical Problem
weakening of the bone and to a true pseud can inhibit the formation of bony callus. This
arthrosis. In a similar way, the bony healing statement has far-reaching significance for the
tissue in formation can also evolve defini understanding of the healing process in the
tively from its still undifferentiated state to femoral neck fracture.
wards the same types of inadequate tissue, The logical question then arises: why do
fibrous tissue and cartilage tissue, under the damaging mechanical stimuli acting, without
effect of a damaging permanent mechanical doubt, in each fracture in a more or less im
stressing. Finally, if it is assumed that forma portant manner exert a decisive influence
tive tissue of bone is a polyvalent tissue, one precisely on the healing process of femoral
understands that it is able to develop in dif neck fractures, whereas a definitive distur
ferent directions and definitively arrives at bance of the healing of other fractures by
maturity as easily as connective tissue, as mechanical forces is only rarely observed?
cartilage or as bony tissue. The final product This apparent contradiction is based on the
of development is bony tissue only if the fact that, in the fracture of the neck of the
vitality of the formative tissue is adequate femur, the state of equilibrium necessary for
and if the possibility of development is not the healing, between the capacity of the heal
disturbed. Permanent mechanical stimuli ing tissue to resist stress and the stressing it
can orientate the development of the forma undergoes can be disturbed much more easily
tive tissue. According to the quality of the me than in other fractures, and this for two re
chanical stimulus, the final product of devel asons. First, the mechanical stressing of the
opment is one of the three possible types of fracture of the femoral neck is very much
tissue. Bone can be formed as well as con greater than the stressing of most other frac
nective tissue or cartilage. The formation of tures. We shall return to this in detail later.
the different types of tissue should be con But above all, the medullary healing tissue of
sidered as an adaptation of the formative the femoral neck fracture does not offer the
tissue to the function demanded of it, in the necessary capacity for resistance and the bio
sense of Roux's law concerning the action logical protection against damaging mecha
of functional adaptation. According to the nical forces that is guaranteed in other frac
theory of Roux, the following must be at tures principally by the periosteal callus.
tributed to the different mechanical stimuli.
Functional compression, that is to say, The Mechanical Effect of the
compression periodically alternating with
Periosteal Callus
relief of compression (LANGE, DUBOIS,
JONES 7) provokes bone formation and fa Periosteal callus generally forms the main
vours that of bony callus in a remarkable mass of callus. Even in unfavourable me
way. Tensile and shearing forces provoke chanical circumstances, it is able by itself to
the formation of connective tissue. Friction ensure sufficient stability and bony consoli
or shearing movement leads to the appear dation of the fracture (Fig. I). Its volume is
ance of a space between the fragments and in general proportional to the degree of dis
provokes the formation of cartilage on the location and to the mechanical irritation.
surfaces sliding one upon the other. Accord This shows that periosteal callus represents
ing to Roux's law, functional stressing in not only a mass of cement, insensitive to me
compression favours the formation of bony chanical irritation, but also that its growth is
callus whereas shearing and tensile stressing promoted precisely by mechanical irritation.
The effect of the periosteal callus on the
7 LANGE, W. G.: Ober funktionelle Anpassung, healing of a fracture is decisive above all be
ihre Grenzen, ihre Gesetze in ihrer Bedeutung fUr cause this callus protects the sensitive, essen
die Heilkunde. Berlin 1917, Springer. - DUBOIS: tial medullary healing tissue, which hesitant
Beitrage zur Biologie des Knochens und zur ortho
ly follows, against damaging stimuli. Often it
padisch-chirurgischen Therapie der Spondylitis tu
is only thanks to this protection that the
berculosa. Beilageh. d. Zeitschr. f. orthop. Chir.
healing tissue is able to develop without
Vol. 48, 1927. - JORES: Experimentelle Untersu
chungen liber die Einwirkung mechanischen being disturbed. Mechanical analysis of the
Druckes auf den Knochen. Beitr. z. pathol. Anat. effect of periosteal callus in different frac
u. aUg. Pathol. Vol. 66. tures shows this without doubt. Thus, for ex-