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Observations On Evolving SIGN Fracture Treatment Techniques

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Drill Cover

Posted by on Jul 20, 2016 in Fracture Treatment | Comments Off on Drill Cover

We are writing to inform you that we have identified a vendor from whom you can obtain Surgical Drill Covers if you are in need of one. The vendor is a company located in Davao, Philippines and their contact information is listed below. Please be advised, this is not a SIGN product, nor does SIGN endorse the cover or make any claims regarding safety, effectiveness, or regulatory approvals related to it. Additionally, SIGN has no financial relationship with this company. It is up to you and your hospital, as the purchaser, to evaluate whether this product is suitable for your situation and environment. You must contact the company directly for questions and purchasing.

Dan Bray

Stitch of Truth Gear, Inc.

Davao, Philippines


Email: or

HV Plates and Standard FIN Nails

Posted by on Jul 13, 2016 in Fracture Treatment | Comments Off on HV Plates and Standard FIN Nails

HV Plate – HV plates are very effective for increasing stability of subtrochanteric fractures. These plates are used with standard or SHC hip nails whenever the fracture involves the greater trochanter below the interlocking screws. They can therefore be used for intertrochanteric and subtrochanteric fractures. 4.5 cortical screws can be used for the distal attachment. The plate spirals from its proximal screw attachment anteriorly to the distal screw attachment.

Fin Nail – The fin nail can be used to stabilize a fracture in the distal femur using retrograde approach. The fin replaces the distal interlocking screws. The screw holes used to place interlocking screws in the high stress area of the femur which is 6 cm below the lesser trochanter serve as stress concentrators. Additional trauma can cause a fracture in this area. Use of the fin nail does not require placing a hole in the high stress area of the femur.

Summary of Articles in Journal of Orthopedic Trauma July 2016

Posted by on Jul 11, 2016 in Fracture Treatment | Comments Off on Summary of Articles in Journal of Orthopedic Trauma July 2016

Early weight-bearing after surgery

Early weight-bearing provides better results after ankle fractures and tibia shaft fractures. There was reference to articles showing early weight-bearing after femur fractures provided good results also.


Nail – tibia Canal Ratio

The authors did a retrospective study and measured the canal of the tibia at the Isthmus and determined that the optimum size ratio was 0.8 – 0.99 indicating that the nail inserted should be as large as possible. You may note that I often comment on x-rays about the diameter of the nail. We have studied nonunions and nail breakage related to the size of the nail. There’s less chance of nonunion or nail breakage when the nail is large. We can feel chatter well during hand reaming and I ask that you ream until chatter for at least 6 cm and then choose the size nail for tibia and femur.


The six hour rule may not be absolute for debridement of open fractures. Many people have noted this, but I think it is difficult to study because biofilm begins forming four hours after injury. One problem is that they did not calculate how long after the injury and I know you see patients open fractures days or even weeks after injury. We are looking at ways to deal with these and I appreciate your thoughts and ideas.

Managing Infection

Posted by on May 16, 2016 in Fracture Treatment | Comments Off on Managing Infection

As surgeons we must take responsibility for all measures to prevent infection in our hospitals.

Infection depends on exposure of the fracture site and soft tissue damage at time of injury. The degree of both of these is variable and can only be calculated at the time of surgery. Predisposing causes of infection include:

  1. length of time to surgery after injury especially if the fracture is open. Biofilm begins to form within six hours of an open fracture
  2. time from injury in open fracture when antibiotic is given. Closed fractures only need one I dose of antibiotics one hour before surgery. This is often included an anesthesia protocol
  3. adequate debridement irrigation and soft tissue closure. Muscle flaps are very helpful.
  4. Ward conditions – noninfected patients should not be in beds close to infected patients.
  5. Double gloves during surgery
  6. esterile drill cover if you use a carpenter drill.

We all know these things but sometimes we must be reminded.

Backslapping the Fracture is Important 

Posted by on May 2, 2016 in Fracture Treatment | Comments Off on Backslapping the Fracture is Important 

One of the causes of nonunion is a gap in the fracture site. Please remember to back slap the fracture after the distal interlocking screws have been placed. This is also important in doing exchange nails for nonunion.

Tips For Placing The Distal Interlocking Screw

Posted by on Apr 26, 2016 in Fracture Treatment | Comments Off on Tips For Placing The Distal Interlocking Screw

When the nail is inserted into the femoral canal, the nail may bend as it passes through the isthmus or narrow part of the canal. The distal end of the nail is now curved because it is more posteriorly than if it had not bent. The target arm was set up with a straight nail and therefore will appear to be anterior or even off the bone.

The solution for this is to loosen the distal end of the target arm and move the target arm over the bone. Drill the hole in the bone as per usual technique. The nail may have rotated as it bent. If this happens, the curved slot finder must be used to find the slot in the nail after removing the distal target arm. This is described in the technique video and especially in the virtual animated video at the end of the technique video. Please do not use the cannulated slot finder to find the slot in the nail and do not rotate the nail when the cannulated slide finder is in the slot. I see many bent curved slot finders due to this deviation of technique.

(To access this video go to the publications tab, and click on “IM Nail Videos.”)

I would appreciate you sending evaluation of the technique video and the animated video to SIGN.

Subtrochanteric Fractures

Posted by on Apr 15, 2016 in Fracture Treatment | Comments Off on Subtrochanteric Fractures

Subtrochanteric fractures have a 40% complication rate according to reports in the US literature. Reduction can be maintained if the reaming and nail insertion is done while the fracture is held in reduction. Additional stability can be supplied by connecting the HV plate to an interlocking screw. The plate is then placed distal to the fracture and held by cortical screws. There are three lengths of HV plates the initial supply will have 2 plates of each size.

Post op


Review of the SIGN Technique

Posted by on Aug 19, 2015 in Fracture Treatment | Comments Off on Review of the SIGN Technique

Antegrade Versus Retrograde Approach

The retrograde approach should be used to stabilize fractures in the distal femur. This provides much better fixation. If using the standard nail, the nail should end up below or above the high stress area of the femur which spans the 4 cm below the lesser trochanter. We prefer to use the fin nail because stress concentrators from the interlocking screw holes may cause fractures in high stress areas.

Open Reduction

In detecting the fracture site, consider the location of the non-movable fragment when deciding where to make the incision. The fracture site will be at the end of the non-movable fragment. A small incision is made which extends through the tensor fascia lata and the muscle fascia. Sometimes there is a hole in the muscle where the bone protruded temporarily and this will lead to the fracture site. To go through muscle such as the vastness laterality, do not use a knife or cutting cautery. Use a periosteal elevator to spread the fibers, look for perforators, clamp and cauterize them.

Free up one fragment at a time. Ream the fragments especially in older fractures because bone often grows into the canal. Reduce using the SIGN or other distractor. Other methods include pressure from periosteal elevator between the fragments or hooking the fragments together in flexion and gradually extending the fracture site. Check for the irregularities of the fracture fragments to be sure the fragments are in the proper rotation. Align the linear aspera on both sides of the fracture to assure proper rotation.


The starting hole is made with the curved awl in the tip of the greater trochanter at the junction of the posterior and middle third. The tip of the greater trochanter can only be identified after the fascia has been incised. Make a small incision through the gluteus attachments where the hole will be made. Shape the hole so it is oriented anteriorly in the femur and the tibia. As you ream think of yourself at the end of the reamer. The cutting edge of the reamer is in one direction only so use only clockwise rotation during insertion and removal. You should feel the reamer throughout 360°. When you feel chatter for 4 cm, the diameter of the nail chosen should be 2 mm smaller.

Nail Insertion

The nail is set up on the target arm and the interlock holes in the target arm of the nail are lined up. Use progressive tightening of the cap screws with checking the alignment pin in the slot of the nail after each screw is tightened. The target arm is then removed and the nail inserted by rotation while the surgeon pushes the nail down the canal. If the nail stops progressing, use light taps with intermittent rotation. If the nail stops progressing, remove this nail and ream higher or choose a smaller diameter nail.

When the nail insertion reaches the proximal 9° bend, allow the nail to rotate without surgeon pressure. The bend is proceeding down the helix of the proximal femur. Interlocking can be done anterior – posterior or lateral – medial.

Distal Interlocking

If using one screw, place the screw in the slot nearest the fracture. Two screws should be placed in the metaphysis (slots proximal to the lesser trochanter and the distal femur). The cortex is weaker in the metaphysis compared with the diaphysis.

Use the alignment pin to indent the skin to mark the incision. Considerations for length of incision include number of screws to be placed and the incision should be long enough so will fit. The finger is used to stabilize the cannula as the hole is drilled. So the cannula will rest on the bone. Do not hammer the cannula or you will deform it.

If the target arm lines up so the alignment pin is directed anteriorly, loosen the cap screws or the adjustment screw (depending on your target arm) and swing the target arm so the cannula will rest on the bone. This will not affect the longitudinal alignment between the cannula and the slots.

Be sure the locking bolt, shoulder bolt and alignment screws are tightened.

Drill pilot hole through the near cortex. Be sure the hole is perpendicular to the cortex. Enlarge this hole using the step drill. When the step drill engages in the slot of the nail or hits the nail, stop immediately. Do not use the step drill to find the slot in the nail because when metal hits a cutting-edge of the step drill, the cutting-edge will become dull very quickly.

Use the solid slot finder to find the slot in the nail. If the solid slot finder will not rotate, it may be caught in the in the cortex. Enlarge the hole with the screw hole broach and place the solid slot finder through the hole and hopefully into the slot of the nail.

Another method to find the slot in the nail: Place the solid slot finder into the cortex hole oriented in the plane of the nail. Use the L-Handle to rotate the nail. If the solid slot finder does not enter the slot, use the curved slot finder. If the curved slot finder does not enter the slot, turn the slot finder 180° so the slot faces the other way. The target arm must often be moved aside by loosening the cap screws or alignment pin to allow more motion. If the curve slot finder does not enter the slot, consider longitudinal movement of the bone through shifting of the fracture site or longitudinal shifting of the nail after the initial insertion and making the pilot hole. The technique of placing the slot finder over the nail and rotating the nail works very well.

If the solid slot finder enters the hole and goes into the slot as seen by 10° of rotation and the cannulated slot finder will not rotate when it is placed in the hole, enlarge the hole with the screw hole broach.

After the cannulated slot finder is placed in the slot of the nail, place the depth gauge through the slot finder past the hole in the far cortex. Replace the cannulated slot finder with the cannula leaving the depth gauge in the hole. Measurement for the screw length is done by reading the depth gauge at the level of the cannula. Do not bend the depth gauge. Add 8 mm to the measurement for the length of the screw.

Place the screw and leave two threads prominent for removal if necessary.

The animated video section at the end of the standard SIGN Technique video gives another view of placing the distal interlocking screw. Please send us your evaluation of this video and your ideas about technique.

Humility is important during surgery. This simply means being receptive to the reality of each individual surgery. We all learn from each other during surgery. Each person involved with the surgery should take credit or blame depending on the circumstances. This allows us to learn.

I’m always happy to discuss technique, indications or other questions about SIGN. Please place these questions on the comment section of your surgeries as I always answer comments you make if I am in the country.

Nail Insertion

Posted by on Aug 19, 2015 in Fracture Treatment | Comments Off on Nail Insertion

Allow passive nail rotation as the proximal bend is inserted into the greater trochanter. The bend of the nail follows the helical anatomy of the proximal femur canal. This occurs because the SIGN nail is not enlarged in the proximal end as other nails are. We feel this provides better stability.

Nail Insertion 01












The final rotation of the nail allows anterior – posterior direction of proximal interlocking screws.

Nail Insertion 02














The final rotation of the nail allows lateral – medial direction of the proximal interlocking screws.

If the surgeon resists this final rotation, hoop stresses are produced which may cause a fracture of the femoral neck.

Masquelet Technique

Posted by on Aug 19, 2015 in Fracture Treatment | Comments Off on Masquelet Technique

Once you have measured the size of the bone defect, apply methyl methacrylate around a nail of similar size to the one you will use. Cut the cement longitudinally before it hardens. Place the nail in the defect and then place the cement around the nail. Hold the cement in place with a suture.

Masquelet 01













Final placement of the cement. Some surgeons leave the cement in for four weeks and then remove and bone graft the defect. Others leave the cement in for much longer. There are articles in the literature advising both methods.

SIGN surgeons are using Masquelet technique more frequently. Some use the technique around the SIGN nail and walk the patient.

Masquelet 02