Sign IM Nail and Interlocking Screw System Technique Manual

Insertion & extraction guide

Hide thumbs

Table Of Contents

Table of Contents

Quick Links

Technique Manual

SIGN IM Nail & Interlocking Screw System

Insertion & Extraction Guide

www.sign-post.org

Revision # TM-2011.07.01

Table of Contents

Need help?

Do you have a question about the IM Nail and Interlocking Screw System and is the answer not in the manual?

Questions and answers

Summary of Contents for Sign IM Nail and Interlocking Screw System

Page 1 Technique Manual SIGN IM Nail & Interlocking Screw System Insertion & Extraction Guide www.sign-post.org Revision # TM-2011.07.01...
Page 2 03signtech. Please read this manual several times before your first SIGN surgery. Refer to it for each step in the OR as you do your first surgeries. Sincerely, Lewis G. Zirkle, M.D.
Page 3: Table Of Contents
Index Page Subject Indication for SIGN Nails Operating room equipment SIGN instruments SIGN Nails Technique for all fractures in all locations Extractor/Compressor Tibia Retrograde approach to femur Antegrade approach to femur Fin nail Humerus Distractor instructions Removal of broken nail...
Page 4 The SIGN Fin nail is indicated for internal fixation of stable fractures in the femur and humerus. CONTRAINDICATIONS: Active or latent infection. Wounds should be closed and dry.
Page 5 Prior to and after each use, the instruments must be inspected where applicable for sharpness, wear, damage, proper cleaning, corrosion and integrity of the connecting mechanisms. Notify SIGN if they should be replaced. Instrument breakage or damage can occur when an instrument is subjected to excessive loads, speeds, or dense bone.
Page 6: Indication For Sign Nails
Patient must have no infected areas or injuries that preclude surgery. Patient should be told about risks, benefits of surgery and agree to insertion of SIGN nail. Please check the patient’s skin the night before surgery. If possible, washing the patient’s leg should be done the night before. The cast may be removed for washing.
Page 7: Operating Room Equipment
OPERATING ROOM EQUIPMENT These materials, which are not part of the SIGN set, should be present in the operating room: drill; chuck key; mallet; bone holding forceps; knife; forceps; clamps; cautery; suction; towel clips; needle holders; sutures; retractors, bone reamer, curved awl and periosteal elevator.
Page 8: Sign Instruments
SIGN Instruments...
Page 10: Sign Nails
SIGN NAILS Standard Length – Tibia/Femur Diameter = 8mm, 9mm, 10mm, 11mm and 12mm Length = 280mm, 300mm, 320mm, 340mm, 360mm, 380mm, 400mm and 420mm A solid nail decreases the risk of infection. The 9º proximal bend can be used in tibia, femur and humerus. The 1.5º...
Page 11 Technique for fractures in all locations Patient Preparation Check for open wounds Check the patient the night before the operation for open wound. Remove cast the night before to check skin condition. Cancel surgery if open wound is present. Wash the extremity the night before to decrease skin bacteria.
Page 12 Technique for use of SIGN Distractor (for full illustrated version see page 38) Free up both ends of the fracture fragments completely. The fracture fragments should be parallel Fig. 3 when the clamps are applied, figure 3. Once they are applied, place the clamps through the ends of the distractor and use the pins to stabilize them.
Page 13 Open fractures Adequate debridement is essential. The amount of tissue removed is dependent on vascular supply, muscle damage, and bacterial contamination. Bone fragments that are completely devascularized must be removed. Dead space must be closed. We must study proper timing of wound closure. If the wound is cleaned and can be closed, the nail can be inserted.
Page 14 Nail Preparation Assemble the Nail Insert the locking bolt through the hollow stem of the L-handle, figure 6. Fig. 6 Align the notches in the nail to the corresponding protrusions on the stem tube of the L-handle, figure 6. Be sure the L-handle rests on the side for proper interlock.
Page 15 Pearl: Insert caps screws downwards The shoulder and distal cap screws are inserted easier if they are inserted in a downward direction so the target arm is parallel to the floor and the cap screws are perpendicular to the floor. Removal is the reverse.
Page 16 Nail Insertion Use the tissue protector to prevent the nail from touching the skin. Push the nail into the canal as far as possible. Many surgeons do not use a mallet to insert the nail. If you decide to use a mallet, use small taps and rotate the Fig.
Page 17 Rotate the nail to orient the slot in the nail parallel to the hole in the near cortex. If the solid slot finder enters the slot and the “SIGN feel” is felt,...
Page 18 The surgeon should both rotate the L-handle and manipulate the curved slot finder. Once the slot in the nail has been discovered by “SIGN feel,” insert the cannulated slot finder and drill the hole in the far cortex.
Page 19 Measure the proper length of the screw by placing the depth gauge through the cannulated slot finder. Do not bend the depth gauge. The depth gauge marks the hole. Remove the Fig. 20a cannulated slot finder and measure the depth of the screw using the cannula and depth gauge, figures 20a and 20b.
Page 20 Confirm location of the slot by using the solid slot finder and then the cannulated slot finder. Once the cannulated slot finder has been placed and confirmed by the “SIGN feel,” drill the hole in the far cortex. Measure and place the screw.
Page 21: Extractor/Compressor
EXTRACTION - EXTRACTOR/COMPRESSOR If the fracture needs compression, place the extractor-compressor on the locking bolt and attach the compressor rod with the slap hammer attached. Back slap the fracture. 1. First, make sure the locking bolt is connected tightly to the nail through the L-handle, figure 22.
Page 22 Placement of the second distal interlocking screw The second distal interlocking screw is used for additional stability. Place the alignment pin in the hex of the head of the Fig. 26 screw which has been inserted, figure 26. An assistant should be assigned to be sure this alignment pin remains in the hex.
Page 23: Tibia
Using SIGN nail in the TIBIA Position of patient for proximal Proximal tibia fractures can be reduced in the figure 4 position. Fig. 28 Push proximal fragment into flexion. Midshaft and distal tibia fractures can be treated with the knee flexed to 110º using gravity and sterile bump or triangle, figure 29.
Page 24 Skin incision Flex the knee to feel the patella tendon. Make the skin incision in the midportion of the tendon from the patella to the tibial tubercle. Figures 31 and 32. Fig. 31 Fig. 32 Bone entrance Do not enter the fat pad. A curved awl is used to make the bone entrance. The more proximal the fracture, the more proximal the entrance hole should be.
Page 25 Mid and distal tibia fractures Use gravity for other fractures. The awl is used to make the entrance hole. Use the reamers to extend the hole into the diaphysis, figure 35. Fig. 35 Ream until chatter and then select diameter 2mm smaller. If you are unsure that the nail is in the canal of the distal fragment, push the reamer until resistance is encountered.
Page 26: Retrograde Approach To Femur
Retrograde Approach to FEMUR SIGN technique that is used in all bones is recorded beginning on page 11. Indications distal Fractures in the distal femur should be treated with retrograde approach. This is surgeon preference. If manipulation of the knee is done after the nail insertion and interlocking and range of motion exercises follow postoperatively, full range of motion usually is achieved and maintained.
Page 27 Reaming Introduce the reamers after the bone entrance has been made using the awl. The reamers are rotated 360º in a clockwise manner. This is important to preserve the cutting edges which go only one way. Look at the distal femur fragment if the fracture site is exposed to direct the reamer. Save the bone from the flutes of the reamer in a bone cup for use as a bone graft.
Page 28 Fig. 5 insert the nail. SIGN nail is a straight nail. If it is inserted into the canal without a great deal of force, it will end up in the anterior portion of the femur, figure 5.
Page 29 NOTE: Distal and proximal refers to the nail rather than the bone, figure 9. Proximal Interlock Fig. 9 Distal Interlock NOTE: If you wish to compress the fracture site, place one interlocking screw in the nail hole nearest the knee. The locking bolt is struck to move the distal fracture fragment toward the proximal fragment, figure 10.
Page 30: Antegrade Approach To Femur
Antegrade Approach to FEMUR Position of patient Supine or lateral. Lateral is best for open reductions. Technique for lateral position will be described. Patient must be stabilized in the lateral position to prevent shifting during surgery. Reduction If open reduction is indicated, perform this prior to skin incision for nail insertion. Incision should be as short as possible.
Page 31 Preparation of the nail NOTE: See technique used in all approaches on page 11. Insertion of the nail Use tissue protector to keep the nail off the skin. Push the nail in as far as it will go. If the nail stops, tap the locking bolt with small taps.
Page 32 6. If nail ends in the wide part of the canal, the slots will be anterior, figure 7. The Fig. 7 SIGN nail does not have an arc of radius and the femur is curved. Recognizing this difference will determine where the pilot hole is made.
Page 33 Compression of fracture After the first distal interlocking screw is placed, the fracture site may be impacted, figure 8. Fig. 8 Proximal interlock This may be directed from lateral to medial or anterior to posterior, figure 9. We are studying the stability of these interlocks. Mechanism of interlock is the same as tibia.
Page 34: Fin Nail
SIGN Technique for FIN NAIL Description The SIGN intramedullary fin nail is designed so the fin Fig. 1 takes the place of the distal interlocking screw, figure 1. Cross section of fins Proper technique including location of the fin will optimize seated in bony canal the fixation.
Page 35 Ream using the next 2 larger sizes to accommodate for the bend of the nail. This reamer only penetrates 4cm. Proximal interlocking This procedure is similar to proximal interlocking of the standard SIGN nail. The proximal portion of the standard target arm, short target arm, or hip and pediatric target arm may be used.
Page 36: Humerus
HUMERUS Position The patient is placed in beach chair position on the OR table, figure 1. All prominences must be padded especially the radial nerve. The patient should be placed so the arm can hang off the table as gravity may be used in the reduction. Fig.
Page 37 Reaming Be sure the fracture site is not distracted during Fig. 4 reaming, figure 4. Nail insertion The diameter of the nail is 1mm less than the largest reamer that achieved chatter. Be sure the fracture site is not distracted during Apply counter pressure to the olecranon during placement of the nail.
Page 38: Distractor Instructions
Distractor Instructions Figure 1 Initial Clamp Placement Figure 2 Placing Distractor Over Clamps NOTE: One fragment is mobile and one fragment is stationary. For example the proximal fragment in a femur fracture is stationary. The ratchet should go on the moveable fragment. Figure 3 Placing Retaining Pin Figure 4 Turn Handle to Distract the Bone Fragments...
Page 39: Removal Of Broken Nail
Try to use the same distal holes for interlocking in the replacement nail if the broken nail is SIGN. Use the same length of nail, but a wider width. Four holes in the femur provide a stress concentrator which may result in a fracture at the distal interlocking area. If the broken nail is not SIGN try to line up at least one hole to SIGN slot.
Page 40 No matter how we improve them they become dull. SIGN surgeons began to use a commercial drill which allowed them to drill faster and more accurately. We were not satisfied with the sterility of the drill. A drill cover placed over the drill with a chuck extension has allowed us to use commercial drills in a sterile manner.
Page 41: Data Collection Sheets
Data Collection Sheets For Data Entry Into The SIGN Online Surgical Database www.signsurgery.org PATIENT CASE INFORMATION: (All fields are required unless otherwise noted.) Hospital Name: Case Number: (optional) Patient Name: Age: Gender: Weight: Injury Date: Optional Patient Contact Information: (This information will be available only to the applicable hospital).
Page 42 SURGERY INFORMATION: Copy this page for each additional surgery for this patient. Surgery Date (month/day/year): Surgeon Name(s): 1. Antibiotics Used? If yes: How long from time of injury? _____ hours _____ days Name of Antibiotic: ________________________________ Duration of Antibiotic Coverage: _____ hours _____ days 2.
Page 43 If Yes, check all that apply: IM Nail Wire 1. How long was external fixation in place? ____days If External Fixation: 2. Time between removal of ext. fixation and SIGN? ____days 11. Method of Reaming: None Hand Power 12. Fracture Reduction:...
Page 44 FRACTURE INFORMATION (continued from previous page.) Patient Name: Case Number: 14. Nail Type Used: (Please mark the type of nail used to treat this fracture.) Standard Nails 8 mm 9 mm 10 mm 11 mm 12 mm Standard Pediatric Fin Nails Fin Nails 7 mm 6 mm...
Page 45 FRACTURE INFORMATION (continued from previous page.) Patient Name: Case Number: 17. X-Rays Taken: (Please list the names of the digital image files for all x-rays of this fracture.) Digital Image X-Ray File Name(s) Pre-Op Post-Op Date Taken Notes on uploading digital image x-ray files: 1.
Page 46 FOLLOW-UP INFORMATION: (Copy this sheet for each additional follow-up.) Patient Name: Case Number: Date (month/day/year): If multiple fractures, which fracture is this a follow-up for? 1. Infection: If yes: Incision of the wound: Infection depth: Superficial Deep (patient returns to surgery) Duration of infection: _____ weeks Osteomyelitis...
Page 47 On the web: www.sign-post.org © Copyright 2001 by Surgical Implant Generation Network. All Rights Reserved. For more information on the Surgical Implant Generation Network (SIGN) or any of the techniques described in this manual, please use the contact information listed above.