Fractures and the SIGN cure

Prof Dr RK Shah


A surgery was performed at the Nepal Medical College on a 50-year old driver who was injured in a road traffic accident. The patient had a grade-IIIa open segmental fracture of tibia in the right leg for which SIGN Intramedullary nailing was done free of cost as he could not afford the cost of implants. He recovered after 13 months and he now has well united leg bones with no wounds. The best part of his treatment was that he has returned to his job of commercial driving.

What is SIGN?

SIGN — Surgical Implant Generation Network — mission began in 1968 while founder and president of SIGN, Lewis G Zirkle, Jr, MD, from the United States served as an army orthopaedic surgeon in Vietnam. During his tour of duty, he spent much of his spare time treating Vietnamese civilians. His concern for medical care in Southeast Asia continued after his tour of duty. In May of 1999, Dr Zirkle initiated four SIGN ‘pilot projects’ in public hospitals

— one each in Thailand and Indonesia, and two in Vietnam. Its goal is to create equality of fracture care throughout the world.

SIGN’s guiding principles

To provide an all-encompassing system of training, hardware, follow up and repeat visits to orthopaedic surgeons in developing countries.

SIGN in Nepal

Ram Kewal Shah, MCh-Orth established the first project in Kathmandu. The other doctors in the team are Dr Anil Mishra and Dr ramesh Singh. In a February 2005 email update, Dr Shah reported the total number of SIGN surgeries performed is 125 (tibia and femur). “We are primarily doing SIGN nailing in tibial shaft fractures and SIGN retrograde nailing in distal femoral shaft fractures.” ( This project ensures the participating hospital/surgeon a continued supply if required implants

and instruments free (at no cost) to the host. But the host needs to enter all the details of the surgery into the database at and the implants will be supplied free to patients. It is open to any ody to participate by visiting this site and fulfilling the requirements of the project by sending an application form.

Why SIGN is applicable here

Recent data show the mortality and morbidity due to accidents (road traffic or others) to be in epidemic proportions. Nepal is the one of the four countries in the world with the highest mortality rate of more than 20 per cent due to road traffic accidents (RTAs). Trauma care facilities available at existing health institutions here are improper and inadequate. The prevalence of physical disability in Nepal has been estimated as 10 per cent on an average. It has also been felt that over half of these physical disabilities could be prevented by proper primary trauma care of most common injuries. The vast majority of injuries, particularly those which are non-fatal, occur at home, work or in the street. In our country such type if injuries commonly occur due to fall from trees or hills. The orthopaedic care in Nepal ranges from traditional healers and bone-setters in villages to scarcely equipped hospitals in towns. However, the average cost of proper orthopaedic treatment remains too high to be affordable by the average person mainly because of poverty, because the cost of quality materials used in fracture care remains very high and most of the time not available locally. On the one hand we have an extremely large number of patients needing fracture treatments while on the other hand, we are short of skilled manpower, basic operation facilities and other ancillaries (like proper implants). The need for supply of proper quality implants from some philanthropic

organisation for the poor countries on a regular basis had been felt since long time, and began SIGN.

How SIGN sets fractures

Pictured above (first X-ray) is a fracture of the tibia (lower leg bone). Many times, a trauma fractures the bone into several pieces. Without surgical intervention, the broken ends of the bone cannot knit together properly, which can leave the patient disabled for life. In adults, a cast or a splint is insufficient to treat a fracture like this, where the bone has been completely broken in two. This fracture is typical of what SIGN surgeons normally treat. These fractures are common in developing nations where bicycles and motorbikes are the primary mode of transportation, and overcrowded streets make accidents frequent. The second X-ray shows the same fracture as in the first following treatment with a SIGN Intramedullary (IM) Nail.

The IM nail is a long rod made of surgical-grade stainless steel which passes through the canal of the bone to secure pieces together and allow for proper healing. The nail is secured to the bone on either end by cortical screws which pass thro-ugh the bone and through holes in the nail. The screws can be seen in the x-ray as short, white lines running perpendicular to the IM nail.

SIGN goal

This technique is state-of-the-art fracture treatment. It is the standard method of treating serious fractures in developed nations, making such fractures little more than painful (and temporary) inconveniences. Until recently, this kind of treatment has only been available in wealthy western nations.  SIGN’s goal is to make this the world-wide standard for fracture treatment.

(Prof Dr RK Shah is the President of Orthopaedic & Trauma Foundation, Nepal)