 Orthopaedic Treatments with External Fixators By Jonathan Pagdin, Clinical Nurse Specialist for the Paediatric Limb Reconstruction Service, Sheffield Children's Hospital Over recent years the correction of bony limb deformities using external fixation devices in children by Orthopaedic Surgeons has become increasingly popular. External fixators are used to correct many different kinds of deformities in a large number of conditions including Hereditary Multiple Exostoses (HME). At Sheffield Children’s Hospital we predominantly use a type of external fixator called the Ilizarov frame, (named after its Russian inventor). This is just one type of many makes of external fixators and the choice of which fixator mainly depends on which make your Orthopaedic Consultant is happy with. External fixators are used for a number of reasons but in HME they will usually be used to correct limb deformities, whether they are in the arms or legs. Treatments with external fixators take long periods of time. Some children can have their fixators in place for many months. An average treatment can be six to eight months, but sometimes the fixator can be in place even longer. Unlike in Russia, the home of Ilizarov frame, we do not keep our children in hospital for the whole of their treatments. Most are admitted for a week or 10 days initially and then seen on an out-patient basis. An external fixator treatment is complex and we prefer to call it a programme. A successful programme depends on many things but perhaps the most important is total commitment from the patient and their carers. A number of issues should be considered before you begin an external fixator treatment programme and some are described below: What are the treatment options? Ask your Orthopaedic Consultant to explain why he wants to perform a correction. Also ask him what different methods are available to perform the correction. Obviously, he will prefer the method which deals with all aspects of correction of length and deformities, leading to the ultimate goal of improving function and reducing discomfort. There are different reasons for external fixator treatments in HME but they include straightening a bent bone, lengthening a shorter leg and sometimes a combination of both. Another reason for using an external fixator in the lower leg is to recreate or improve the ankle joint. External fixators are also used in HME in the forearm to correct problems at the elbow or wrist joints. What does the external fixator look he external fixator look like? At first sight most fixators look fairly horrendous but from my experience most children get used to them very quickly.
This picture (taken from the HME website)
shows one type of forearm fixator.
How does the correction take place? Most external fixators work in similar ways. The fixator is attached in such a way that by slowly altering the shape of the fixator you will gradually correct the bony limb deformity. Usually, to correct a bony deformity, that bone has to be broken and then corrected. Obviously, this break is done surgically under a general anaesthetic when the fixator is applied. The surgical technique and post operative management should be explained to you before you begin an external fixator programme. Corrections are done gradually as new bone forms at a certain rate and to prevent damage to the soft tissues and nerves. Why do external fixator treatments take so long? During an external fixation treatment you literally create new bone. On average, each new centimetre of bone takes 30 to 40 days to grow. Therefore a child requiring a five centimetre leg lengthening will need to ‘wear’ their fixator for roughly 150 to 200 days. (Wear is perhaps not the right term because once the fixator is in place you do not have the opportunity to take it off and put it back on again.) What do you have to do when your fixator is in place? There are a number of things that will become part of your daily routine once a fixator is in place, these will include: Daily ‘Pin Site’ Care The area around each site where the fixator wires or screws enter the skin has to be cleaned to prevent infection travelling into the bone. Your hospital will have a method of pin site care and this should be explained to you before you begin your programme. Low grade infections are fairly common and can be treated easily but steps should be taken quickly to prevent infections becoming deep rooted in the bone. Severe bony infections can prevent successful outcomes and are very difficult to treat. Adjusting the External Fixator You will be taught how to adjust your fixator and you should be instructed before you leave hospital. You should be told how many alterations (turns) to make and what date to do them on. In practice this is not as complicated as it sounds and you quickly become experts and never go anywhere without your spanners or Allen keys. Physiotherapy Exercises are essential if the programme is to be a success. We need to make sure your child maintains their joint movement throughout their treatment. It is not good to straighten a limb but reduce joint movement in the process. Mobility External fixators are usually designed to be walked with. Most hospitals encourage their patients to weight bear through their programmes. Weight bearing not only helps you lead as normal a life as possible but also helps the bone to form well. You should be taught how to use crutches or a rolator frame before you leave hospital. Some may provide a wheelchair. Some Things to Think About? Will it hurt? Yes, like any operation, it will hurt for a time but we will ensure this is relieved whenever necessary. Hopefully, as the days pass by the pain will ease. Most children say they cannot feel the actual lengthening and the only discomfort they may have is when cleaning their pin sites or when the muscles are being stretched. Can your child go to school? In the past we have found that the children who return to school cope better with the procedure. Remember like you, your school will need time to prepare and you should discuss you child’s possible treatment with them as soon as possible. Some of the problems you may have at home could also apply in school, e.g. toileting, mobility, eating and "what happens at break-times." Remember there is a legal entitlement for education and if this cannot be done in school then some other provision must be put in place, i.e. home tuition. This is the local education authority's responsibility and the school can request their resources. Your child may miss a number of days at school not only because of the admission for surgery but also because of repeated outpatient visits to check on progress. How long will the fixator be in place? This is a difficult question to answer and the best person to answer this is the consultant. Much depends on how much length or correction you are hoping to achieve. Effects on Family Life External fixator treatment programmes have many stresses and strains, and these will affect everyone in the whole family. Remember the treatment is hard work for all concerned and will disrupt many areas of family life. Siblings can often feel isolated when their parents' attention is mainly on the child undergoing the programme. You will be expected to make many journeys to the Outpatient Department at your hospital, which has implications for parent’s jobs. Supporting each other through what can be a long treatment is essential. Many thanks to Jonathan Pagdin for this excellent article. For more details on arm lengthening and HME, see the HMESG website at http://www.hmesg.co.uk/resources/pburge.htm
From Ian Warren
From Linda Ramsden
From Mandy Coombes
From Helen Jones
From Janet There is 50% chance of passing HME on to your children.
From Karen
From Kelly
Tax Returns You can nominate a charity to receive all of any tax repayment that may be due to you (tick box 19A.1) or share a repayment by entering an amount in box 19A.2. The charity code for our group that needs entering in 19A.3 is SAJ29JG. Put a tick in box 19A.4 this will enable the donation to be treated as a Gift Aid donation and give the group a further 22% and a tick in 19A.5 will ensure that you will get a personal thank you from the group for your effort (although we will be happy for you to remain anonymous!) The system only works for repayments of tax – if your Return shows that there is a net payment of tax due to the Revenue rather than an overall repayment then I’m afraid that the group cannot help and the payment will need to be made by you!!
Editor's Bit! Ok, hope you are all well and of those of you who went to Edinburgh had a thoroughly good time. I was reading through those seminar evaluations and I came across a point from a member who would like to know where to get pencil grips or foot pads, or various other bits like that from. I buy mine from our local Scootability shop. However, as I said I do have to buy them. But apparently, as I found out from our hospital, the hospital can provide them free of charge and if they cannot they will put you in touch with occupational therapists that can. Also my local social services have been very helpful. We have a local Red Cross near to us, whom are great at hiring out equipment, when I say hiring out you do not have to pay anything other than make a donation. I presume these Red Cross places are across the country – someone else to ring who would more than likely be able to put you in touch with people who can help. Have a good summer and please, please, please start sending in your articles for the next newsletter. I have no case histories left so hurry up and make my day. Take care, Debi
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© Hereditary Multiple Exostoses Support Group 2004
Last updated 7 August 2004
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