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It was reported that, during an internal fixation surgery while trying to lock the distal radius volar plate with a 2.4 mm screw, the tip of one (1) t7 linear driver shaft w/ ao qc broke.Fragments fell into the wound and were removed with forceps.The procedure was performed, after a non-significant delay, using an equivalent sn back-up.No additional anesthetic was required.No further complications were reported.
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The associated device was returned and evaluated.The visual inspection revealed that the device returned worn from use, with the distal tip twisted and the end fractured off with no material returned.The clinical/medical investigation concluded that, he fluoroscopy/x-ray was reviewed, and correspondence confirmed that no fragments were retained in the patient.The photo shows the driver and fragments, but it does not provide clear insight into the clinical root cause of the event.The surgical instruments notes that excessive force may lead to instrument failure.While a definitive clinical root cause cannot be determined, a variation in user technique or procedure cannot be ruled out as a likely contributing factor.A review of the production order did not reveal a manufacturing abnormality that could have caused or contributed to the reported incident.A review of complaint history based on the historical data revealed a similar event for the listed batch, this failure mode will be monitored for future complaints for any necessary corrective actions.A review of the risk management file revealed this failure mode was previously identified.The anticipated risk level is still adequate.A historical review concluded that there are no prior actions related to this product and event.At this time, we have no evidence to conclude that the product failed to meet any specifications at the time of manufacture.This device is a reusable instrument that can be exposed to numerous surgeries.Damage from prolonged use, misuse or rough handling are likely potential factors that could contribute to the reported event.We recommend that all reusable instruments be routinely inspected for wear and damage and replaced as necessary.Based on this investigation, the need for corrective action is not indicated.Should additional information be received, the complaint will be reopened.No further investigation is warranted for this complaint; however, we will continue to monitor for future complaints and investigate as necessary.We consider this investigation closed.
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