This module allows medical officers and surgeons who are not orthopedic specialists to become confident and competent in performing irrigation and debridement, power and manual drilling, proper positioning and insertion of Schanz screws, construction of the rod-to-rod modular frame, and fracture reduction and stabilization as part of external fixation procedures for open humeral shaft fractures performed in regions without specialist coverage. To maximize patient safety, this module teaches learners to use a powered drill to insert self-drilling Schanz screws through the near cortex and then manually advance Schanz screws into the far cortex to avoid plunging.
It's highly recommended to: (i) print off this checklist and review it before simulation skills training, (ii) have an assistant read out and complete this checklist to verify that all the steps are properly performed during the simulation skills training, and (iii) file and save a back-up copy for your training records.
Training Logbook[edit | edit source]
Please print out the Training Logbook below and write your name, your assistant's name, and date of training at the bottom of the Training Logbook.
| # | Self-Assessment Checklist | Check the most appropriate response |
|---|---|---|
| 1A | Wore proper eye protection and gloves |
Done Correctly Done Incorrectly Not Done |
| 1B | Performed simulated irrigation using an average of 3L of irrigation solution for each successive Gustilo Type (i.e., 6L for Gustilo Type II open tibial fracture and 9L for Gustilo Type III open tibial fracture) |
Done Correctly Done Incorrectly Not Done |
| 1C | Debrided all foreign material and non-viable tissue | This Step Cannot Be Performed During Simulation Training But Must Be Performed During the Actual Clinical Procedure |
| 2A | Inserted the Schanz screws into the safe zones of the humerus by placing the pins anterolaterally in the proximal fragment and laterally in the distal fragment when the patient is supine. |
Done Correctly Done Incorrectly Not Done |
| 2B | Positioned the “far” Schanz screw (furthest from the fracture line) in the proximal fragment 7 cm below the acromion while avoiding traumatized soft tissues | This Step Cannot Be Performed During Simulation Training But Must Be Performed During the Actual Clinical Procedure |
| 2C | Placed the two “near” Schanz screws (closest to the fracture line) at least 2.0 cm (a finger breadth) from the fracture line while avoiding traumatized soft tissues |
Done Correctly Done Incorrectly Not Done |
| 2D | Placed the "far" Schanz screw in the distal fragment at least two fingers’ breadth proximal to the lateral epicondyle to avoid entry into the elbow joint |
Done Correctly Done Incorrectly Not Done |
| 2E | Used a 22 blade scalpel to make a stab incision in the skin overlying the anterolateral wall of the humerus for the near and far Schanz screws in the proximal fragment and used dissecting scissors to spread the soft tissue apart in each incision to expose the bone for drilling | This Step Cannot Be Performed During Simulation Training But Must Be Performed During the Actual Clinical Procedure |
| 2F | Used a 22 blade scalpel to make a lateral skin incision large enough to accommodate two pins and permit palpation and/or direct visualization of the radial nerve in the distal fragment and used dissecting scissors to spread the soft tissues apart in the incision to permit the practitioner to palpate and/or visualize the radial nerve, and to expose the bone for drilling | This Step Cannot Be Performed During Simulation Training But Must Be Performed During the Actual Clinical Procedure |
| 2G | Inserted pins in divergent directions in the distal fragment to minimize the size of the incision while permitting better control of displacing forces to optimize stabilization of the reduction |
Done Correctly Done Incorrectly Not Done |
| 3A | Prepared the powered surgical drill for use by inserting a Schanz screw into the powered surgical drill, inserting the chuck key into the opening in the drill, turning the chuck key clockwise to tighten the drill over the Schanz screw, and then engaging the switch for forward drilling direction |
Done Correctly Done Incorrectly Not Done |
| 3B | Confirmed that the drill is ready for use by pressing the on/off trigger and observing that the Schanz screw tip is rotating clockwise when the drill is pointing forward |
Done Correctly Done Incorrectly Not Done |
| 3C | Used the properly sized drill sleeve, placed the drill sleeve with the trocar directly on the near cortex, removed the trocar from the drill sleeve, inserted the Schanz screw into the drill sleeve, placed the Schanz screw tip directly on the near cortex of the humerus, and held the drill sleeve at least 3.0 mm above the near cortex during this simulation training |
Done Correctly Done Incorrectly Not Done |
| 3D | Used the properly sized drill sleeve, placed the drill sleeve with the trocar directly on the near cortex, removed the trocar from the drill sleeve, inserted the Schanz screw into the drill sleeve, placed the Schanz screw tip directly on the near cortex of the humerus, and held the drill sleeve directly on the cortex to protect the surrounding soft tissues when drilling in the real clinical procedure | This Step Cannot Be Performed During Simulation Training But Must Be Performed During the Actual Clinical Procedure |
| 4A | Directed an assistant to simulate irrigation with an empty syringe while drilling |
Done Correctly Done Incorrectly Not Done |
| 4B | Placed each Schanz screw tip on the near cortex of the humerus, started drilling with the screw tip rotating in a clockwise direction, and ensured that the tip did not slip on the near cortex |
Done Correctly Done Incorrectly Not Done |
| 4C | Power drilled all four Schanz screws through the near cortex and used tactile and acoustic feedback to stop drilling after passing through the near cortex and before or when the inner surface of the far cortex was reached |
Done Correctly Done Incorrectly Not Done |
| 5A | Inserted the chuck key into the opening in the drill, turned the chuck key anticlockwise, detached the drill from the Schanz screw, and removed the drill sleeve from the Schanz screw |
Done Correctly Done Incorrectly Not Done |
| 5B | Slid the universal chuck with T-handle over each Schanz screw, and tightened the chuck over the Schanz screw by manually rotating the proximal part of the chuck clockwise or by inserting the chuck key into the opening in the chuck and turning the chuck key clockwise |
Done Correctly Done Incorrectly Not Done |
| 5C | Used the universal chuck with the T-handle to turn each Schanz screw clockwise for one to two 360 degree rotations to anchor the screw tip into the far cortex without exiting the far cortex |
Done Correctly Done Incorrectly Not Done |
| 5D | Detached the universal chuck with T-handle from each Schanz screw by manually rotating the proximal part of the chuck anticlockwise, or by inserting the chuck key into the small, circular opening in the chuck and turning the chuck key anticlockwise |
Done Correctly Done Incorrectly Not Done |
| 6A | Applied the pin-to-rod clamps to connect the two Schanz screws in each fragment to a 150 mm rod |
Done Correctly Done Incorrectly Not Done |
| 6B | Tightened the pin-to-rod clamps initially by hand and then applied and turned the 11 mm spanner with T-handle wrench clockwise for final tightening |
Done Correctly Done Incorrectly Not Done |
| 7A | Applied the rod-to-rod clamps to loosely fix the 100 mm connecting rod to interconnect the two 150 mm rods for the proximal and distal fragments |
Done Correctly Done Incorrectly Not Done |
| 8A | Loosened one nail or the right vise clamp securing the distal fragment to simulate a displaced fracture and used the two 150 mm rods as handles to manually reduce the fracture and adequately restore alignment
|
Done Correctly Done Incorrectly Not Done |
| 8B | Manipulated the two near Schanz screws to compress the fragments together
|
Done Correctly Done Incorrectly Not Done |
| 9A | Used an assistant to stabilize the reduced and compressed fracture while using the spanner with T handle wrench for final tightening of the rod-to-rod clamps around the 100 mm connecting rod |
Done Correctly Done Incorrectly Not Done |
| 9B | Verified the reduction visually, to confirm whether alignment has been adequately restored
|
Done Correctly Done Incorrectly Not Done |
| 9C | If required, adjusted the fragments to achieve an adequate reduction
|
Done Correctly Done Incorrectly Not Done |
| 10A | Checked for skin tenting around Schanz screws and if present, widened the stab incision to release soft tissue tension around the pin site | This Step Cannot Be Performed During Simulation Training But Must Be Performed During the Actual Clinical Procedure |
| 10B | Cleaned the extremity and applied sterile gauze dressings to all four pin sites | This Step Cannot Be Performed During Simulation Training But Must Be Performed During the Actual Clinical Procedure |
| 10C | Re-evaluated the Gustilo open-fracture classification in the operating room, and updated the antibiotic regimen and surgical treatment plan accordingly | This Step Cannot Be Performed During Simulation Training But Must Be Performed During the Actual Clinical Procedure |
| 11A | Took an anterior view photo with a ruler in the image to provide scale |
Done Correctly Done Incorrectly Not Done |
| 11B | Visually inspected the humeral shaft in the anterior view photo and confirm that the reduction is within acceptable parameters:
|
Done Correctly Done Incorrectly Not Done |
| 11C | Used a ruler to measure the distance of the two near Schanz screws from the fracture line in the anterior view photo |
Done Correctly Done Incorrectly Not Done |
| 11D | Confirmed two near Schanz screws were placed at least 2.0 cm (a finger breadth) from the fracture line in the anterior view photo |
Done Correctly Done Incorrectly Not Done |
| 11E | Used a ruler to verify that the far Schanz screw in the distal fragment is at least two fingers’ breadth proximal to the lateral epicondyle in the anterior view photo |
Done Correctly Done Incorrectly Not Done |
| 12A | Took a lateral view photo |
Done Correctly Done Incorrectly Not Done |
| 12B | Confirmed both near and far Schanz screws were inserted anterolaterally into the proximal fragment in the lateral view photo |
Done Correctly Done Incorrectly Not Done |
| 12C | Confirmed both near and far Schanz screws were inserted laterally into the distal fragment in the lateral view photo |
Done Correctly Done Incorrectly Not Done |
| 13A | Took a medial view photo |
Done Correctly Done Incorrectly Not Done |
| 13B | All four Schanz screws did not perforate the far cortex in the medial view photo |
Done Correctly Done Incorrectly Not Done |
| 13C | Visually inspected the humeral shaft in the medial view and confirmed that the alignment is within acceptable parameters:
|
Done Correctly Done Incorrectly Not Done |
| 14A | Provided specific, clear, and concise directions to the assistant during the simulated procedure |
Done Correctly Done Incorrectly Not Done |
| 15A | Photographed this completed training logbook on a cellphone as a backup and filed this original completed training logbook in your training records. |
Done Correctly Done Incorrectly Not Done |
The learner must perform all the checklist items correctly (except for the steps that cannot be performed during simulation training) in order to pass this module.
Learner's Nameː
Learner's Signature:
Assistant's Nameː
Assistant's Signature:
Procedure Start Time:
Procedure End Time:
Date of Trainingː
Acknowledgements[edit | edit source]
This work is funded by a grant from the Intuitive Foundation. Any research, findings, conclusions, or recommendations expressed in this work are those of the author(s), and not of the Intuitive Foundation.