Sign IM Nail and Interlocking Screw System Technique Manual page 43

FRACTURE INFORMATION:
Patient Name:
Case Number:
1. Fracture Side:
2. Surgical Approach:
3. Location of Fracture:
(check all that apply)
4. Type of Fracture:
5. Stability of Fracture: (Hip Fracture Only)
(check all that apply)
6. Time from injury to Debridement: ____hours ____days
7. Time from injury to Skin Closure: ____days
8. Method of Wound Closure:
(check all that apply)
9. Nonunion:
10. Previous Implant Used:
If Yes, check all that apply:
If External Fixation:
11. Method of Reaming:
12. Fracture Reduction:
13. Comments:
_______________________________________________________________________________
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(Copy pages 44, 45, and 46 for each additional fracture.)
Left Right
Antegrade Femur
Antegrade Humerus
Retrograde Femur
Proximal Middle
Femoral Neck
Closed
Gustilo I
Gustilo II
Stable
Unstable Posterior Medial Fragment
Skin Graft
Primary
Secondary
Yes No
Yes No
External Fixation
IM Nail
1. How long was external fixation in place? ____days
2. Time between removal of ext. fixation and SIGN? ____days
None Hand
Open Closed
43
Tibia
Hip Fracture
Distal
Intertrochanteric
Gustilo IIIa
Gustilo IIIb
Gustilo IIIc
Unstable Lateral Femur Wall
Muscle Flap
Other: __________________________
Plate
Wire
Power
Segmental
Subtrochanteric