Data Collection Sheets

For Data Entry Into The SIGN Online Surgical Database, 2016 Version
www.signsurgery.org

PATIENT CASE INFORMATION: (All fields are required unless otherwise noted.)
Hospital Name: Case Number: (optional)
Patient Name:
Age: Gender: Cause of Injury:
Date of Injury: Date of Admission: Date of Discharge:
Prior Admission For Fracture Treatment: (If Previous Implant is present, please complete this section).
Hospital Name: Date of Admission:
Optional Patient Contact Information: (This information will be available only to the applicable hospital).
Address:
Phone Number: Email Address:

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 SURGERY INFORMATION: Copy this page for each additional surgery for this patient.
Surgery Date (month/day/year):
Surgeon Name(s):

1. Antibiotics After Injury? Yes No Unknown

If yes:
How long from time of injury? _____ hours _____ days

Name of Antibiotic: ________________________________

Duration of Antibiotic Coverage: _____ hours _____ days

2. Antibiotics Before Surgery? Yes No Unknown

If yes:
How long before surgery? _____ hours

Name of Antibiotic: ________________________________

Duration of Antibiotic Coverage: _____ hours _____ days

3. Duration of Surgery: Start Time: _____________ End Time: _____________

(time of skin incision) (time of skin closure)
OR

Total Time: _____ minutes (time from skin incision to time of skin closure)

4. Duration of Reduction: _____ minutes (time from skin incision to time of main bone fragments being aligned)

5. Barriers to Immediate Surgery:

Lack of Blood Lack of Funds Medical Condition
(check all that apply)
Lack of Operating Time Other: __________________________

6. Associated Injuries? ____________________________________________________________________

7. Surgery Comments:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

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FRACTURE INFORMATION: (Copy for each additional fracture.)
Patient Name:
Case Number:

1. Fracture Side: Left Right

2. Surgical Approach: Antegrade Femur Tibia

Antegrade Humerus Hip Fracture
Retrograde Femur Retrocalcaneal Fusion

3. Location of Fracture: Proximal Middle Distal Segmental

(check all that apply) Femoral Neck Intertrochanteric Subtrochanteric

4. Type of Fracture: Closed Gustilo IIIa

Gustilo I Gustilo IIIb
Gustilo II Gustilo IIIc

5. Time from injury to Debridement: ____hours ____days Unknown

6. Time from injury to Skin Closure: ____days Unknown

7. Method of Wound Closure:

Primary Skin Graft Perforator Flap
(check all that apply)
Secondary Muscle Flap Other: _________

8. Nonunion: Yes No

9. Lengthening On Nail: Yes No

10. Previous Implant Used: Yes No

External Fixation Plate
If Yes, check all that apply:
IM Nail Wire
1. How long was external fixation in place? ____days
If External Fixation: 2. Time between removal of external fixation and SIGN
surgery? ____days

11. Method of Reaming: None Hand Power

12. Fracture Reduction: Open Closed

13. Comments:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

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FRACTURE INFORMATION (continued from previous page.)
Patient Name:
Case Number:

14. Nail Type Used: (Please mark the type of nail used to treat this fracture.)
200 220 240 260 280 300 320 340 360 380 400 420
Standard Nails mm mm mm mm mm mm mm mm mm mm mm mm
8 mm
9 mm
10 mm
11 mm
12 mm

Standard 160 190 240 280 320 340 360 Pediatric 140 170 200 240
Fin Nails mm mm mm mm mm mm mm Fin Nails mm mm mm mm
7 mm 6 mm
8 mm 7 mm
9 mm 8 mm
10 mm (You will be prompted for patient weight)
11 mm
12 mm

Standard 280 320 240

Hip Nails mm mm Fin Hip Nail mm
10 mm 10 mm

15. Screw Quantities Used: (Please enter the quantity of each type of screw used with this nail.)
Standard Interlocking Screws
Length in mm 25 30 35 40 45 50 55 60 65 70 75
Quantity

Note: These additional screw types are for treatment of hip fractures only.
Compression Screws
Length in mm 60 65 70 75 80 85 90 95 100 105 110 115
Quantity
SHC Proximal Interlocking Screws
Length in mm 60 65 70 75 80 85 90 95
Quantity
Cortical Screws
Length in mm 30 35 40 45
Quantity

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16. Plate Quantities Used: (Please enter the quantity of each type of Plate used for this treatment.)
Hip Hip Hip Large Large Large
2 Hole HV 3 Hole HV 4 Hole HV 4 Hole HV 6 Hole HV 8 Hole HV

Quantity

Hip 2 Hole HV Hip 3 Hole HV Large 4 Hole HV

Hip 4 Hole HV Large 6 Hole HV – Not Yet Available

Large 8 Hole HV – Not Yet Available

17. X-Rays Taken: (Please list the names of the digital image files for all x-rays of this fracture.)
Digital Image X-Ray File Name(s) Pre-Op Post-Op Date Taken

Notes on uploading digital image x-ray files:

1. This table is provided for you to keep track of digital x-ray images so that the process of
uploading these images to the online database goes smoothly.
2. The time required to upload image files is determined by the size of your digital image files and
your internet connection speed.
3. VERY IMPORTANT: You can reduce the size of your digital image files by converting them to
grayscale (remove all color) and by reducing the dimensions of your pictures to approximately
640 x 480 pixels. Many digital cameras come with software programs capable of these tasks.

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FOLLOW-UP INFORMATION: (Copy this sheet for each additional follow-up.)
Patient Name:
Case Number: Date (month/day/year):
If multiple fractures, which fracture is this a follow-up for?

1. Infection: Yes No
If yes:
Incision of the wound: Yes No
Infection depth: Superficial Deep (patient returns to surgery)
Duration of infection: _____ weeks
Osteomyelitis Amputation

2. Squat & Smile Picture Taken: Yes No

3. Painless full weight bearing: Yes No
4. Healing by x-ray: Yes No
5. Knee flexion greater than 90 degrees: Yes No
(Not applicable for Hip Fracture)
6. Screw loosening: Yes No
If yes, what screw type: Standard Interlocking Compression
SHC Proximal Interlocking Cortical
7. Implant Breakage: Yes No
If yes, what implant type: Nail Plate Screw

8. Deformity: Yes No (under 20 degrees)

If yes:
Alignment: Over 20 degrees varus Over 20 degrees valgus

Rotation: Over 30 degrees

9. Comments:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

10. Follow-up Images: (Please list the names of all the digital image files for this follow-up.)
Digital Image File Name(s) Follow-up X-Ray Squat &Smile Shoulder AER Date Taken