Sign IM Nail and Interlocking Screw System Technique Manual 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.
Antibiotic prophylaxis
Start IV antibiotics 1 hour before surgery. Patients with open fractures should be given antibiotics as
soon after surgery as possible. Antibiotic should be given to patients with closed fractures one hour
prior to incision.
Pre-op scrub for surgeon and patient, Hexachlorophene is best, Betadine is less effective.
Soft tissue evaluation
If the fracture is open, the wound should be debrided, irrigated and evaluated as to whether wound
closure can be done. Factors that must be considered are contamination by virulent bacteria, high
energy vs. low energy trauma, foreign bodies. Virulent bacteria occur from "barnyard injuries" or
areas where bacteria are prevalent. The degree of injury is also determined by the forces that cause the
injury. These forces may destroy large amounts of muscle which leaves a dead space after
debridement. This dead space must be closed before the nail can be inserted. Therefore, the wound
classification is divided into wounds that can be closed without risk of infection, and those that can't.
Whenever a wound can be closed without risk of infection, a nail can be inserted.
Reduction of closed fracture
Closed reduction can often be accomplished if the fracture is less than
7-10 days old. If closed reduction is attempted, check stability in all
planes prior to the reduction so you can test and compare the stability
Fig. 1
after the reamer or nail is inserted. The reamers are passed into both
fragments followed by the nail.
Open reduction is necessary if the fracture is beginning to heal.
Transverse fractures can be reduced after both ends have been freed
from soft tissue. Figure 1 demonstrates one method. Allow the tissues
to slowly elongate during reduction. Figure 2 demonstrates
reduction of oblique fractures. Before reduction is
accomplished, ream both sides of the fracture site. Stop Fig. 2
reaming at the metaphysis.
The reamer should be turned 360º in clockwise direction
both during insertion and removal of the reamer from the
canal. The cutting edges of the reamer are damaged by
reaming counterclockwise or to-fro reaming. Save the bone
in a bone cup. Do not place on a sponge or in saline. Use
gradual distraction and allow time for the tissues to stretch.
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