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Observations On Evolving SIGN Fracture Treatment Techniques

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Lengthening/Nailing of 4 Month Old Tibia/Fibula Fracture in 35 Year-Old Female

Posted by on Nov 20, 2017 in Fracture Treatment | Comments Off on Lengthening/Nailing of 4 Month Old Tibia/Fibula Fracture in 35 Year-Old Female

1) Proximal pin placed from lateral immediately anterior to the fibular head, free hand, but pretty much perpendicular to the axis of the tibia. Drill all the way across, exiting medially, balancing pin lengths medially and laterally, since this is going to be a “full frame” distraction.

2) Apply PAHS Distractor to the proximal pin on the lateral side of the leg.

3) Insert distal pin using the distal PAHS pin clamp as a drill guide, since this distractor does not have a multi-planar adjustment. We chose a calcaneal attachment distally, since this is a fairly distal tibial fracture, going 2 cm distal and 2 cm posterior to the tip of the lateral malleolus, again exiting medially.

4) Applied a medial half frame and manually pulled the medial side out to length as much as we could by hand, with the lateral side undistracted, just following passively.

5) Activated the screw jack mechanism of the PAHS distractor laterally until it started to create varus of the subtalar joint.

6) Loosened the bar nut of the bar/pin clamp of the distal, medial half frame, while a simple bone clamp was applied to the end of the bar and one side of the bar/pin clamp. Applied as much distraction force as possible, then tightened the bar nut of the bar/pin clamp. The subtalar joint should be back in slight valgus and the medial side a bit longer.

7) Activated the PAHS distractor again laterally, and repeated going from lateral screw jack to medial, bone clamp distraction as needed to achieve the tibial length/alignment  required. This approach worked like a charm, and really didn’t take much time.




Thoughts and Innovations for Southern Philippines Medical Center

Posted by on Aug 16, 2017 in Fracture Treatment | Comments Off on Thoughts and Innovations for Southern Philippines Medical Center

Last week I went into 2 SIGN cases.

The first was a proximal femur fracture involving the basicervial and intertrochanteric area.  I indicated this for fixation with the SIGN hip construct nail.  Unfortunately the residents of the service involved had lapses in their preparation and were not able to autoclave the SIGN hip nails– for this lapses they were given sanctions .  We modified and fixed the fracture with a standard nail and was only able to place a single screw going to the neck and 2 proximal locking screws and a side plate.

What we learned here was that exposure and insertion of the nail was easier done with the patient on lateral decubitus position, which what was done to the patient.  BUT it is ver important to put a bolster in between the thighs so as to prevent fixation in varus, which happened in this patient when we forgot to do just that, we had to revise the fixation and was able to correct the varus.

The second case was a rotationplasty procedure in an 8 year old boy for an osteosarcoma of the distal femur.  We innovated and fixed the femur and tibia with a fin nail and got a stable fixation, procedure was shortened. Because we did not need to lock distally, and I think this fixation provided less trauma to the rotated limb by avoiding the need of distal locking screws.

Image below are those of the proximal femur and the other image is the first SIGN fin nail in a rotationplasty.

Physical Therapy Website

Posted by on Dec 23, 2016 in Fracture Treatment | Comments Off on Physical Therapy Website

Free website that has a ton of info for building PT exercises for patients.  These customized exercises can also be posted to the site for sharing and the exercises can be printed out and given to the patient.

Femur Fracture Indications

Posted by on Dec 13, 2016 in Fracture Treatment | Comments Off on Femur Fracture Indications

No.1 – Antegrade femur with Four Interlocking Screws: Antegrade nail is used for fractures in the superior half of the femoral shaft.

No.2 – Retrograde Standard Nail: Retrograde standard nail is used for fractures of the distal femur, BUT fin nail is a better choice.


No.3 – Retrograde Fin Nail: The retrograde approach is used to treat fractures of the distal half of the femoral shaft.  The fin nail is preferable because no interlocking screw holes are placed in the high stress area of the femur as in standard nail.

Hip Fracture Indications

Posted by on Dec 13, 2016 in Fracture Treatment | Comments Off on Hip Fracture Indications

No. 1 – SIGN Hip Construct No Compression Screws with Standard Nail

No.2 – Full SIGN Hip Construct: HV Plate is used when the fracture exits the greater trochanter below the interlocking screw.

No.3 – SIGN Hip Construct with No Plate: The compression screws are inserted parallel to the fracture line.  An HV plate is not necessary.

No.4 – Compression Screws Only: Compression screws should be placed parallel with each other next to the wall of the femoral neck.

Posted by on Nov 1, 2016 in Fracture Treatment | Comments Off on


Distal Tibia Fractures – At the OTA meeting and in the recent journal of orthopedic trauma, the attention has been focusing on treatment of distal tibia fractures. There are no clear recommendations regarding IM Nail versus plate fixation of these fractures.

There are no clear recommendations about when to stabilize the fibula. My empiric thinking is that when the fibula is overlapped, the fracture site is in valgus and it should be stabilized. We must continue to observe our results. Certainly fibular fixation is indicated when there is a syndesmosis.

Synopsis from October 2016 OTA Conference

Posted by on Oct 25, 2016 in Fracture Treatment | Comments Off on Synopsis from October 2016 OTA Conference

Infection Control – Nasal povidone decreases infection of the hip fracture stabilization in the elderly.

Vancomycin power or fluid placed in open fractures is most effective if used within six hours from injury. Vancomycin only works for 48 hours when placed in the wound.

Stability is necessary to treat infection. If a nail has been used for stabilization and infection occurs, leave the nail in. Studied extensively by Mike McKee at University of Toronto – 92A: 823

Tibia Plateau Fractures – Over reduce the tibia plateau fracture because many subside. Malalignment is the most important.

The posterior approach to treating tibia plateau fractures is becoming used more often because most of the articular malalignment is due to the posterior fractures. Start with a prone position – and then go to supine position.

Tibia Fractures – Immediate weight-bearing does not cause displacement.

Fixation of the fibula is now being questioned in tibia fractures. Some studies show it does not affect the long-term stability but I think this needs to be studied. I wonder if distal tibia fractures that are comminuted need further stability. If the fibula is overlapped, reduction is in valgus.

One study showed that close reduction and mini open reduction do not have differences in infection rate.

Humerus Fractures – Non-operative treatment failed 37% of the time.

Many distal femur fractures are reduced at 5 – 8° of valgus, but this has no clinical significance.

Femoral Neck Fractures – If a valgus hip osteotomy is performed, a 20 – 30° increase in valgus is enough.

Most common displacement of femoral neck fractures is shortening of the femoral neck.

Close reduction of femoral neck fractures results in less avascular necrosis than open reduction. Close reduction resulted in less re-operations than open reduction.

Subtrochanteric Fractures – Immediate weight-bearing as tolerated works best. There is less hospital stay and less re-operations. The HV plate is recommended for SIGN Surgeons.

Fracture Healing – Fractures treated earlier show more callous and faster healing. Fractures treated more than two weeks after injury show less callous and delayed healing. I have always questioned whether the late reduction causes the healing process to start over again.

Vitamin D – We know it plays a role, but the vitamin D level of the average person is not known. Wide difference of opinion regarding optimal doses given after fracture.

Open Fracture – We are developing algorithms for treatment of open fractures. Questions such as when to place immobilization. Which immobilization – plate, external fixator, or early nail fixation.

Role of Traction – Continuous traction to keep the fracture out to length from time of admission until surgery, will decrease operating time – Duane Anderson.

We are studying the time it takes to do surgery on patients who arrive late, compared with those who arrive within two weeks of surgery.

Reaming – We should study if there are lung symptoms after hand reaming. We know that there is lung compromise after power reaming. We also know that power reaming affects increase coagulant ability and therefore possibility of blood clots.

Cerclage – The dangers of nonunion when cerclage wires are placed around a fracture site was emphasized.

The Detrimental Screw Hole

Posted by on Aug 25, 2016 in Fracture Treatment | Comments Off on The Detrimental Screw Hole

A screw hole in the bone concentrates the stress in torsion. There is a 70% decrease in energy storage capacity. In other words, a much smaller amount of torsion can cause a fracture through this stress concentrator. If the screw is removed it takes 11 months for the hole to fill in. If the screw is left in place, the stress riser will be present for four years.

Application the fractures that occur when the retrograde standard nail ends at the high stress area of the femur. This is 6 cm below the lesser trochanter. The screw holes that are used to place the interlocking screws may result in fracture through these holes. SIGN accordingly suggest using the fin nail for retrograde stabilization of the femur.

xray-243949 High Stress Area from Technique manual

Transverse Fractures

Posted by on Aug 17, 2016 in Fracture Treatment | Comments Off on Transverse Fractures

The most common fracture resulting in nonunion is a transverse fracture, midshaft femur. Why?

  1. Transverse fractures are created by tension and therefore the cortical stem cells are not mechanically stimulated to form bone.
  2. Strain or magnitude of deformity is concentrated in a small area of the fracture as opposed to a comminuted fracture.

We must therefore place the largest diameter and length nail possible to stabilize the fracture. In fractures of the distal femur, we must place the nail retrograde. If a nonunion develops and the nail appears to be large enough, adding a plate to decrease shear often results in healing. Bone grafting using bone from the flutes of the reamer must be placed at this fracture site.


Posted by on Aug 9, 2016 in Fracture Treatment | Comments Off on Education

From AAOS volume 24, page 505

Retention of Skills after Simulation-Based Training in Orthopedic Surgery

Education involves transferability which means using the knowledge in performance such as surgery and retention which is retaining the knowledge in your head. SIGN has been working on simulators to simulate the placement of distal interlocking screws. We are developing this new technique which we feel will be more reliable.

The SIGN Model which has evolved over the years fits the concept very well. The SIGN Technique is learned through reading through reading the technique manual, watching the technique videos and now using simulators with a SIGN Nail, L-Handle, and Slot Finders. The next step is imprinting this knowledge by doing SIGN Surgery.

We are interested in your feedback regarding implementation of this model.

These skills will decline after six months so we must constantly evaluate our technique.