Sign IM Nail and Interlocking Screw System Technique Manual page 46

FOLLOW-UP INFORMATION:
Patient Name:
Case Number:
If multiple fractures, which fracture is this a follow-up for?
1. Infection: Yes
If yes:
Incision of the wound:
Infection depth:
Duration of infection:
Osteomyelitis
2. Partial weight bearing:
3. Painless full weight bearing:
4. Healing by x-ray:
5. Knee flexion greater than 90
degrees:
(Not applicable for Hip Fracture)
6. Screw breakage:
7. Screw loosening:
8. Nail breakage:
9. Nail loosening:
10. Deformity:
If yes:
Alignment:
Rotation:
11. Repeat Surgery:
If Yes, check all that apply:
If For Non-Union, check all that apply:
12. Comments:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
13. X-Rays Taken:
Digital Image X-Ray File Name(s)
(Copy this sheet for each additional follow-up.)
No
Yes No
(under 10 degrees)
Over 10 degrees varus
Over 20 degrees varus
Over 30 degrees
Yes No
For Infection
(Please list the names of the digital image files for all x-rays during this follow-up.)
Date (month/day/year):
Yes No
Superficial
_____ weeks
Amputation
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
For Deformity
Dynamize
Iliac Crest Bone Graft
Other:____________________________________
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Deep
(patient returns to surgery)
Over 10 degrees valgus
Over 20 degrees valgus
For Non-union
Exchange Nail
Date Taken