Let your frame take the strain

Let your frame take the
strain
Living with your fixator
Information for patients
Orthopaedics - Limb Reconstruction
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Contents
A brief history
4
What is external fixation?
Bone healing
Post operative care
Inpatient physiotherapy
Outpatient physiotherapy
Life with a fixator
Travel information
Diet
Common emotional problems
Finance and benefits
Removal of the fixator
Frequently asked questions
Meet the team
Any questions?
5
7
8
10
11
13
16
19
21
18
23
24
25
26
Acknowledgements
With thanks to Nathan Babiker (Clinical Psychiatrist), Sarah Church and
Carolyn Taylor (Dieticians) for their professional input.
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A brief history
Ilizarov frames were devised by Professor Gavril Abramovich Ilizarov.
Born in the Soviet Union in 1921, Professor Ilizarov was not educated
until the age of eleven. In spite of this he went to medical school, going
on to practise medicine in the Kurgan region of Siberia.
In the 1950s, he developed his revolutionary method for treating
fractures, deformities and other bony defects, using a circular external
fixator. His research over the next ten years led to the development of
techniques in physeal distraction, corticotomy lengthening and bone
transport.
Professor Ilizarov was able to show that controlled mechanically applied
stress produced regeneration of bone and tissue. Unfortunately, due to
the iron curtain, his work was unknown elsewhere in the world until
1967. At this point he treated Olympic high jump champion Valery
Brumel for an infected non-union fracture.
After a visit to the Kurgan Institute in 1981, professor A.
Bianchi-Maiocchi introduced Ilizarov’s methods to the west. Professor
Ilizarov worked for 41 years in this field of orthopaedics.
In 1992 Ilizarov died at the age of 71.
Professor Ilizarov
The Kurgan Institute
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What is external fixation?
External fixation is a way of stabilising pieces of bone using an external
framework of rods, wires and rings, rather than internal metalwork.
Frames are built on an individual basis.
They can be used for a variety of problems:
•
•
•
•
•
•
Fixation of fractures
Lengthening of a limb
Non-union of a fracture
Correction of bony deformities
Correction of soft tissue deformities
Arthrodesis (fusing) of joint
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Variety of frames
The limb reconstruction team will discuss with you which frame will be
used during your treatment.
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Bone healing
Bone healing is a very individual process. There are some factors that can
affect this healing process both in a positive and negative way.
Factors that encourage bone healing:
• Weight bearing on your affected limb
• Eating a nutritionally balanced diet
• Regular exercise
Factors that limit bone healing:
• Smoking: Every tissue in the human body is affected by smoking.
Smoking often delays the healing of fractures and wounds which
results in the tissues not getting enough oxygen to fully repair
themselves in the event of an injury. You are strongly advised
to stop smoking during your treatment. For further advice and
help please contact the smokefree national helpline on 0300 123
1044 or visit www.nhs.uk/smokefree
• Non steroidal anti-inflamatory drugs: such as ibuprofen, naproxen,
diclofenac and many other anti inflamatory drugs should not be
used during your treatment. These drugs have been found to have
an effect on bone formation. Please inform your doctor if you are
prescribed any of them.
• Not weightbearing on your affected limb: bone is similar to
muscle; the harder you work it the stronger it gets.
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Post operative care
After your operation you will stay on your assigned ward until you are
medically and physically fit to return home.
The average length of stay in hospital after the application of an external
fixator is 3 to 5 days however, this can vary depending on your recovery.
It is usual to have a bulky bandage on your non-operated leg; this is to
protect your leg from the frame. This can be removed when you have
recovered from your anesthetic. You will also have a green elasticated
splint underneath your foot and attached to your frame. This is to hold
your foot up. You will also have air flow pumps on both legs during your
hospital stay. These are used to prevent circulation problems such as
blood clots. They must be worn at all times and should only be removed
for washing your feet, checking your skin is not getting sore and for
mobilising.
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The limb reconstruction nurses will review you as soon as possible after
your operation and teach you/your next of kin/your care team how to
look after the frame and clean the pin sites, (plus any corrections if they
are necessary), once you feel you are able to tolerate this.
Once you are discharged to your usual residence you may shower the
frame once a week when your dressings are due for changing. The limb
reconstruction nurses will provide you with more information as
required.
It is expected that you will attend clinic regularly (usually around every 6
weeks) have x-rays of your affected limb/s and be reviewed by the
consultant.
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Inpatient physiotherapy
Whilst in hospital, the ward physiotherapists will carry out your
treatment. They will show you exercises to do to keep your joints
moving as freely as possible and give you strengthening exercises to
maintain your muscle power.
A green elastic splint (Theraband) will be provided to help control your
foot and ankle position and prevent tightness of your calf muscle. This
should be worn at rest but taken off for walking.
You must have your own footwear with you whilst in hospital.
The physiotherapists will help you to mobilise with a walking aid and
encourage you to take as much weight through your limb as possible.
This is important to start the healing process. Mobilising should start as
soon as possible after your surgery to prevent complications arising. This
can be with a zimmer frame or crutches.
You can expect some swelling and will be encouraged to elevate your
limb as high as is comfortable. But pillows must not be placed under
your knee as this will lead to tightness of your muscles at the back of
your knee and this can significantly affect your walking and function.
Once you can mobilise safely with a good walking pattern and can
manage stairs then you can be discharged home. At this point you will
be given exercises to continue at home.
During your treatment you will meet the Specialist Physiotherapist who
will discuss with you the aims and expectations of limb
reconstruction physiotherapy.
Every patient will then be referred for outpatient physiotherapy at their
local hospital.
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Outpatient physiotherapy
We strongly recommend you attend physiotherapy as often as
possible during your treatment in the frame. Most people can expect to
require physiotherapy after the frame is removed but that is decided on
an individual basis. The main aims of outpatient physiotherapy are:
Walking and weight bearing
The physiotherapists will teach you how to walk correctly with a good
walking pattern. They will aim to wean you off your walking aid as soon
as you are able (this is usually 6 - 8 weeks after the frame has been
applied but is longer if you are carrying out corrections). Weight bearing
is important as it stimulates the bone to heal.
Knee, ankle and hip range of motion
It is important that you maintain as much knee, ankle and hip
movement as possible. The two main aims are to keep your knee fully
straight and to keep the foot up as far as possible. You will be shown
exercises and stretches to help this. You will be advised when you can
wean off your theraband splint.
Exercises
You should begin gentle exercises in a gym environment where
possible. The exercises should be progressed as you are able and should
be carried out mostly in a weight bearing position.
Function
It is important that you try to continue to lead a normal life. The
physiotherapist can help you to rehabilitate to a stage where you may
be able to carry out your hobbies or household tasks.
Mobility
Every patient will be issued with a walking aid i.e. elbow crutches or a
walking frame. You are allowed to weight bear through the affected
limb as much as able, unless you are told otherwise. The use of
wheelchairs is not encouraged.
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Life with a fixator
Pain relief
Following surgery you will be prescribed pain relief medication. This will
be tailored to suit your needs and discussed with you by the prescribing
doctor. Painkillers are an important part of your treatment. Remember
to take them with you wherever you go. Always bring them with you
when attending outpatient appointments, as some procedures carried
out in outpatients can cause some discomfort; you are advised to take
your analgesia before the start of any procedure.
If you are doing any corrections then you may require extra pain relief.
Please speak to the limb reconstruction team about this.
Pin site infections
You may at times experience a pin site infection. If you do it may not be
your fault, unfortunately it happens. Signs of an infection are: extreme
pain around a wire (this can become acute within a few hours), feeling
unwell, not being able to walk on your leg due to the pain, redness and
an increase in discharge from the pin site. If you think you have an
infection you can discuss this with the limb reconstruction team or
speak to your GP.
Swelling
The affected limb may swell up from time to time. This could be a sign
that you are doing too much. The swelling should reduce when the limb
is elevated (higher than your heart if possible).
If the swelling does not reduce with elevation of the limb then you need
to contact the limb reconstruction team as soon as possible.
Of note, immediate post-operative swelling can last for four weeks or
longer.
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Loose wires/pins
Loss of tension in wires and loosening of pins may cause pain,
inflammation, redness, discharge and infection. The wire tension can be
adjusted in clinic. Occasionally wires snap, this isn't an emergency
(unless your frame suddenly feel unstable). Please contact your limb
reconstruction team for further advice.
Cramp
You may experience cramp during your treatment, this may be eased in
various ways:
•
•
•
•
•
Weight bearing on the affected limb
Relaxing the area by gently massaging the muscle
Slowly and gently stretching the muscle
Drinking plenty of water, sports drinks or juice after exercise
Putting ice packs on the affected area for approximately 10
minutes*
• Applying heat – This improves circulation and causes muscles to be
more flexible*
• Some patients also find relief with magnesium supplements
*Please note: If full sensation is not present in the affected limb, please
seek advice before using ice or heat. You should also ensure you
massage the muscle after ice or heat treatments.
Skincare
You may experience a build-up of dry skin on your affected limb. This is
because the normal exfoliation process of clothing rubbing on skin is no
longer happening. Showering and drying with a towel will remove some
dead skin cells, but applying moisturiser will help keep the skin supple
(this helps the skin stretch better if you are doing any corrections). E45
and coconut oil have both been recommended by previous patients.
Keep the moisturiser away from pin/wire sites as it can cause infections.
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Chiropody
Foot care is also important. Please keep toenails cut correctly i.e. straight
across. An ingrowing toenail could become infected and pose an
unnecessary risk. It may be necessary for you to receive assistance with
this task.
Clothing
Frames can be quite bulky and you will find that a normal pair of
trousers will not fit over them. Baggy trousers will sometimes stretch to
accommodate but usually some form of alterations are required, for
example splitting the side seam and inserting a piece of material to
make the trouser leg wider, or using drawstring or tape to fasten.
When adapting clothing to accommodate an arm frame split the
underarm seam, not the shoulder seam.
Elasticated clothes tend to be more accomodating and stretch more
over the frame.
Frame covers
Frame covers can be useful to protect your leg from the cold and heat.
They can be easy to make from a simple pillow case with a draw string
at each end. Ensure that your leg gets plenty of air when wearing the
frame covers to prevent your limb from getting too warm. It is useful to
keep your frame covered as this can prevent your clothes, bed sheets,
apolstery etc from getting damaged by the frame.
Menstrual cycle
For women, an increase in stress levels can cause a release of hormones,
which can cause your periods to stop. This in turn creates problems with
the x-ray department. Pregnancy tests may be required before x-rays
can be performed. Alternatively women with this problem will be
treated as pregnant and lead shielded whilst x-rays are carried out.
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Travel information
Access and transport
Disabled access can be limited in certain places so it is advisable to
contact any unfamiliar venues you are planning to visit beforehand. If
you are concerned about the access into your property then please
speak to the occupational therapist on the ward.
As a passenger in a car you may travel in the front seat with the seat
pushed back, or in the back seat with your legs across the seat. You may
find that a pillow will help to make the journey more comfortable.
If you are wanting to drive during your treatment please discuss
this with the limb reconstruction team.
Public transport – trams, trains and a lot of buses have disabled access.
There are usually other local facilities such as the dial-a-ride scheme.
Ambulances are not automatically ordered for outpatient
appointments, please make your own arrangements. Individual needs
can be discussed with the nurses.
Escorts with ambulances are only allowed in special circumstances.
Toileting
Most people undergoing treatment with a fixator are able to use a toilet
in the normal way. Whilst in hospital you will be taught how to transfer
on and off the toilet by the occupational therapists. Raised toilet
seats/rails can be provided if needed. Commodes and urinal bottles can
be provided if felt appropriate.
You may wish to consider obtaining a key for access to disabled toilets
in public places by calling 0800 849 8032 or visit
www.ageukincontinence.co.uk for more information.
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Going on holiday
Always check with your limb reconstruction team that they are happy
for you to go away on holiday at your stage in treatment.
If travelling outside of the UK we recommend that you ensure you have
adequate medical supplies that you normally use, such as dressings,
pain relief etc. Make sure your insurance is adequate as medical
treatment can be expensive.
Remember to keep your leg covered and protected from the sun as the
frame will be susceptible to heat, and there will be an increased risk of
sunburn. (This applies in this country as well).
Swimming is allowed but please ensure this is in chlorine treated water.
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Finance and benefits
The benefits you are entitled to may differ between local authorities.
Disabled parking permits are available on a ‘discretionary criteria’ only,
for non-permanent disability.
For more information please contact 0800 055 6688 or visit
www.gov.uk/jobcentreplus
Travel to hospital
If you are on income support or certain benefits then fares for travelling
to the hospital can be reclaimed. You will need to provide proof of
attendance (available from clinic reception), proof of receipt of benefits
and the bus or train tickets used to travel to hospital. These need to be
presented to the cashiers office for a refund.
Prescription costs
Prescriptions are free for those receiving income support. Please bring
your benefit book as proof.
Buying a prepaid prescription certificate may reduce costs.
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Diet
Where bone growth is required, the body’s requirements for nutrients
increases. The diagram shows what a balanced diet is and what each
meal should be based on.
Eat all types and
choose high fibre
kinds if possible
Choose a wide
variety - fresh,
frozen or tinned
Fruit and
vegetables
Bread, other
cereals and
potatoes
Meat, fish and
alternatives
These can include
sausages, fishfingers,
meat paste, tinned
fish, kidney and liver
Milk and dairy
products
Fatty and
sugary
foods
Try not to
eat these
too often
Try to have a
minimum of half a
pint of milk per day
in drinks and on
cereal
During this time you will become less mobile and it will affect you in one
of two ways.
1. You may loose your appetite. Milk and milky drinks will help
increase your nutrient intake. Small meals with snacks such as
yoghurt, cheese and biscuits or sandwiches can help. Remember
to include a variety of foods.
2. As you are less active and eat the same amount of food, you may
gain weight. This should resolve once you start mobilising so
don’t worry too much about this. You could reduce sugary/fatty
foods but continue to have a balanced diet to continue to
promote bone growth.
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Constipation
You may experience some constipation after your surgery which can be
caused by the anaesthetic, reduced mobility, pain relief and many other
factors. In order to relieve this constipation it is advised to eat plenty of
fibre enriched foods and drink plenty of water.
If you are concerned about your diet or need further advice please ask
to be referred to the dietician.
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Emotional reactions to fixators
Your fixator may be in place for several months, therefore, it is
important for your wellbeing to try and return to your normal activities
as soon as you are able to. This may include returning to work, college,
or school which can be discussed with you on an individual basis.
Throughout treatment some people experience a few common
emotional reactions. If you think about these things in advance and plan
how you might cope with them, you are increasing your chances of
coping.
Please do not read this and think that all these things will happen
to you.
An important thing to remember is that for many people, having a
fixator is the result of having an accident or a lengthy period of time
with your limb(s) not functioning in the way that you want them to.
Leading up to the time of having a fixator you may have already
experienced traumatic circumstances, including surgery and treatment
which may not have been successful. You may also be involved in court
action or compensation relating to your injury.
Factors such as a traumatic accident, a lengthy period of treatment,
failed treatment, a lot of problems and other stresses prior to the
accident/start of treatment, or any combination of these could make it
more likely for you to experience a difficult emotional reaction. Having
an external fixator can, on its own, cause people to experience a wide
range of emotions. It can, however, be a positive experience as well as
a negative one – it depends on how emotionally stable you feel at the
start and if you have been able to prepare for having a fixator.
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If you do have specific problems such as:
•
•
•
•
•
Disturbed sleep
Feeling irritable or extremely angry
Feeling panicky, anxious or extremely worried
Feeling withdrawn or isolated
Feeling tearful or depressed
Please let a professional know and they can help you to think about any
additional support, reading materials or activities that might be useful
for you.
For example, some psychologists specialise in working with people who
have experienced traumatic events related to physical injuries. Most
people who speak to a psychologist have had a normal reaction to an
abnormal event and want some detailed advice about how to cope with
specific emotional issues
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Removal of the fixator
Usually, the bone will be tested before the frame is removed. Firstly, the
frame will be loosened at the site of injury and tested, then the loosened
rods will be removed and tested and then the frame will be removed if
the x-rays remain unchanged and the consultant is convinced the bone
is strong enough.
The fixator is usually removed in the Outpatients Department. The
tension is taken out of the frame by undoing it. The wires are cut close
to the skin at one side, the wires are cleaned with a clenser and pulled
out at the other side. The feelings described by patients having gone
through this procedure ranges from ‘feels strange’ to ‘very painful’.
Everyone is different, pain is a very individual experience and there is no
right or wrong way to feel. Bring your painkillers to clinic; these can then
be taken prior to frame removal. If necessary gas and air can be used
throughout the procedure to provide additional pain relief.
Wire/pin sites heal in approximately 48 hours, they are covered by light
dressings.
You may require some form of splint once the fixator has been removed
but this is on an individual basis depending on your treatment plan.
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Frequently asked questions
What footwear is recommended?
We strongly advise that you wear footwear that is non-slip, comfortable
and secure. You may need to wear old trainers, pumps or sandles to
allow for the increase in swelling or buy a size bigger then usual. If you
have the frame going onto the foot it is harder to get footwear to fit.
You may have to modify your footwear to fit your foot, therefore old
sandles are ideal as you may need to cut bits off them to fit around the
frame.
Can I get the frame wet?
Once a week on the day you change your pinsite dressings you can get
your frame wet. We recommend that you shower and not bathe as it is
more hygenic. If you wish to go swimming ensure that it is in chlorine
enriched water and on the day of your dressing change only.
What if I fall over onto the frame?
Accidents can happen, it is unlikely that you will have done any serious
damage however, if things suddenly feel unstable then you need to
attend your nearest hospital or medical centre and contact the limb
reconstruction team. When you fall onto the frame or bang the
frame the wires cut through the flesh and bruise you which is what
causes the pain. You may need to rest the leg for a few days but still try
to continue as you normally would.
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Meet the Limb Reconstruction team
Consultants
Mr M G Dennison
Mr S L Royston
Mr J C McGreggor-riley
Mr E J Mills
Limb Reconstruction Nurses
Maria Vincent (CNS)
Katy Cooke (RN)
• 0114 226 6368
• 0114 243 4343 (bleep 2570)
Clinical Specialist Physiotherapist in Limb Reconstruction
Nicola Glossop
• 0114 226 6368
• 0114 243 4343 (2519)
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Any questions for the Limb Reconstruction
team?
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Produced with support from Sheffield Hospitals Charity
Working hard to fund improvements that make life better
for patients and their families
Please donate to help us do more
www.sheffieldhospitalscharity.org.uk
Registered Charity No 1059043
organdonation.nhs.uk
Alternative formats may be available on request.
Please email: [email protected]
© Sheffield Teaching Hospitals NHS Foundation Trust 2015
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Issue Date: November 2015. Review Date: November 2017