Description of Event or Problem · 1
THE PATIENT WAS ON THE JACKSON FRACTURE TABLE WITH HIS RIGHT LEG SECURED TO THE TABLE WITH THE TRACTION PIN AND APPROPRIATE TABLE ATTACHMENT (KIRSCHNER BOW HOLDER). WHEN THE CIRCULATOR WAS ASKED BY THE MD TO INCREASE THE TRACTION ON THE AFFECTED LIMB, A COMPONENT OF THE VISE PORTION OF THE HOLDER CAME LOOSE DUE TO CRACKED WELDS THEREBY RELEASING THE AFFECTED LEG. THE MD CAUGHT THE LEG AND SUPPORTED IT BY PLACING IT ON A PADDED MAYO STAND. MD THEN ASKED THE CIRCULATOR TO HANG 90 POUNDS OF WEIGHT TO PUT THE AFFECTED LEG BACK IN TRACTION. SEVERAL INTRAOPERATIVE XRAYS WERE TAKEN TO CONFIRM NO FURTHER DAMAGE HAD RESULTED AND THAT REDUCTION OF THE FRACTURE WAS OPTIMAL. CASE RESUMED.====================== HEALTH PROFESSIONAL'S IMPRESSION======================THE VISE PORTION OF THE KIRSCHNER BOW HOLDER HAS TWO OPPOSING PLATES SEPARATED BY A FIXED DISTANCE, ABOUT 1CM. BOTH PLATES ARE WELDED TO A SOLID BASEPLATE THAT IS ITSELF ATTACHED TO A TUBULAR PART OF THE MAIN TABLE. THE HOLDER HAS A BLUE HANDLE FOR ADJUSTING THE POSITION OF THE VISE WITH RESPECT TO THE BASEPLATE AND A RED HANDLE FOR ADJUSTING THE ANGLE OF THE BASEPLATE WITH RESPECT TO THE TABLE. THE LEG PIN IS FASTENED TO THE VISE BY MEANS OF A THUMBSCREW. THE THREE WELDS HOLDING THE 3CM X 5CM X 0.8CM PLATE WERE CRACKED ALL THE WAY THROUGH. WHAT WAS SURPRISING IS THAT ONE OF THE WELDS IS POSITIONED SO THAT FORCE APPLIED BY THE THUMBSCREW CAN TILT THE PLATE BACKWARD AND FATIGUE THE WELD.====================== MANUFACTURER RESPONSE FOR ORTHOPAEDIC OR TABLE ACCESSORY, JACKSON FRACTURE TABLE======================NO RESPONSE AT THIS TIME OTHER THAN INTEREST IN ANALYZING THE PART THAT BROKE.