Ilizarov (external) Frame for tibial fractures

What is an Ilizarov frame and why is it used?

Illzarov is a circular frame used to hold bones in place; this is a type of external fixation. The frame holds broken bones in place to allow healing through the use of rings and wires. The metal rings will go fully or partly round your leg with the metal wires going through your bone and attaching to the rings. The tension between the rings and wires hold the bones to allow healing, this can take some time and your frame can be on for 6 months to 2 years.

Frames are used for:

Bone breaks
Correcting deformities
Leg lengthening
Infection of metalwork
Non-union of bone internal fixation

Rehabilitation

Rehabilitation is a large part of your recovery once your frame is applied. The physiotherapists and occupational therapists will work with you on the ward from the first day after your surgery until you are fit for discharge home; this will include mobility and other daily tasks such as washing and dressing. It is very important that you work with the physiotherapist and occupational therapists; this is your recovery and your progression relies upon your willingness and co-operation to work with the team looking after you.

If your frame is on the lower half of your leg you will be provided with footwear to fit below the frame and a band will be fitted around the shoe and to your frame to help maintain your ankle movement. See picture below.

Exercises

Once your frame has been applied, you will be expected to learn and perform exercises that will be explained to you by your physiotherapist. It is important to exercise the joints and muscles around the frame to prevent any other problems that would slow your recovery and to promote new bone formation. The main aim of these exercises is to maintain muscle length and strength. Try to repeat these exercises 3 times per day.

Toe exercises

Bend and straighten your toes. Repeat 10 times.
If you find this is difficult and your toes remain in a bent position try to gently straighten them out with your hands – hold this stretch for 30 seconds and repeat 3-5 times.

Ankle exercises

Lying on your back or sitting. Bend and straighten your ankles briskly. If you keep your knees straight during the exercise you will stretch your calf muscles.
You can do this against the elastic band that is attached to your frame to make this exercise more difficult.

A towel looped around the bottom of your foot can help pull your foot into a stretch – you should feel this up the back of your calf. Hold for 30 seconds and repeat 3-5 times.

Knee exercises

1. Knee bend

Either sitting or lying on your back. Bend and straighten your hip and knee by sliding your foot up and down.
Repeat this 10 times.
If you are struggling with this then you can use a towel to assist with this as shown.

2. Knee Strength:

Lying on your back with legs straight. Bend your ankles up and push your knees down firmly against the bed. Hold 5 seconds then relax. Repeat 10 times.

Inner range Quads: Place a roll underneath your knee. Point your toes to the ceiling, rest the back of the knee against the roll and lift your heel off the bed while straightening your knee. Hold for 3-5 seconds then relax. Repeat 10 times.

Straight leg raise: Lying on your back with one leg straight and the other leg bent. Exercise your straight leg by pulling the toes up, straightening the knee and lifting the leg 20 cm off the bed. Hold approx 5 secs. – slowly relax. Repeat 10 times.

Knee Stretch:

In sitting or lying. Rest your ankle on a stool or a rolled up towel. Stay in this position for 5-10 minutes to stretch the back of your knee.

Hip strength:

Lying on your front. Squeeze buttocks firmly together. Hold approx. 5 secs. Relax. Repeat 10 times

Sidelying on your non frame side. Keep the leg on the bed bent and the upper leg straight. Lift the upper leg straight up with ankle flexed and the heel leading the movement. Repeat 10 times.

Sidelying on your non frame side. Keep the leg on the bed bent and the upper leg straight. Lift the upper leg up 10cm then keeping the ankle flexed and the heel leading the movement take the leg behind you and back. Repeat 10 times.

Hip Strength in Standing

Hip Extension: While standing, hold onto a steady object (e.g. the back of a chair). Keep your trunk still in an upright position and bring your leg backwards. Hold for 3-5 seconds then relax (you can hold for longer as the exercise gets easier). Repeat 10 times.
Hip Abduction: While standing, hold onto a steady object (e.g. the back of a chair). Keep your trunk still in an upright position and lift your leg out to the side. Hold for 3-5 seconds then relax (you can hold for longer as the exercise gets easier) Repeat 10 times.

Mobility

After frame application you can fully weight bear on your leg, you will receive pain killers from nursing staff at regular intervals in the day to allow you to participate in your rehabilitation.

Your physiotherapist will provide walking aids to allow you to mobilise from the first day after your operation, the aid used will vary depending how much support you require. It is advisable that you have pain relief prior to therapy input as this will allow you to get the most out of your time with the therapist.

Walking with a frame

Place walking frame out in front.
Step your frame leg first then weight bear down through your arms and step your non-operated leg in to meet it then repeat.
With therapy input you should move to walking one foot past the other, this encourages heel contact and weight bearing on your frame leg which is important.

Walking with elbow crutches

You will be progressed to elbow crutches if able
Place both elbow crutches out in front
Step your frame leg first followed by your non operated leg.
When able start to walk one foot past the other again to encourage heel contact and weight bearing on frame leg.

Stairs

If a handrail is available then always use it as well as one crutch. Your physiotherapist will teach you how to carry your other crutch up and down the stairs as you will need it when you get to the top/bottom.

Going up stairs

Instructions for climbing upstairs are:

Place your un-operated leg up onto the step
Bring your frame leg up to the same step
Bring the crutch up onto the same step

Going down stairs

Instructions for climbing downstairs are:

Place your crutch down onto the step below
Step down with your frame leg
Bring your un-operated leg down to the same step

Transfers

Your Occupational Therapist and Physiotherapist will likely ask you to demonstrate your ‘transfers’, i.e. how you move from one surface to another. This includes getting in/out of your bed, and on/off your toilet and chair. You will need to demonstrate that you can safely do these transfers before going home. Your rehab team will offer you advice on techniques, and may recommend specialist equipment to help. Some general tips for transfers are as follows:

Bed

Sit-down high up the bed to minimise the need to adjust your position later.
Shifting your weight over each hip in turn can help you shuffle further on/off the bed.
Lift your leg high to avoid catching your frame or ripping your sheets/mattress. You may have to change which side you sleep on depending on which leg you find easiest to lead with.
The frame can be very heavy, so your Occupational Therapist may provide equipment to make getting in and out of bed easier.

Toilet

Your Occupational Therapist will assess your ability to sit down and stand up from the toilet based on information provided about your home
Do not sit down until the backs of both knees are touching the toilet.
To sit/stand, stick your affected leg out in front, and bending forward at the hips to put your weight through your unaffected leg.
To control your movement, your Occupational Therapist may provide you with equipment which gives a sturdy hand-hold, or you can place your hands on the toilet bowl itself for support.

Chair/sofa

It is important to choose a chair that is high enough for you to get off easily. Your occupational therapist may provide equipment to raise your chair heights if required.
A chair with armrests on both sides can be useful to push up from.
You may wish to elevate your leg for comfort on a stool. Be careful with recliner footrests as your pins may get caught.

Washing and Dressing

Dressing

You will find wearing loose fit trousers, shorts, dresses, skirts or t-shirts ideal for getting on/off over your frame. You may find wearing a bigger size of clothing helps when dressing. When taking clothes on / off over your Ilizarov frame you will be required to be careful of the wires and pin sites You may even wish to cut trousers/ leggings / t-shirt arms above the external fixator. During your hospital stay, your Occupational Therapist will look at you getting dressed to provide further information and equipment to make getting dressed easier if required.

Personal care

You will be advised to try keeping your frame and pin sites dry. It is recommended in between pin site cleans to have a strip wash while sitting on a chair being careful to avoid your pin sites. On the day you are completing pin site clean you can shower beforehand.

Sleeping

When sleeping, you may find it more comfortable sleeping on your back. The metalwork around the frame may cause ripping to your bed sheets, to limit this wrap a pillow case around the External Fixation to protect your bed sheets. Do not place pillows under your frame, this can cause your knee to bend and over time this can limit your ability to fully straighten your knee.

Going home and activity levels

You will be involved in your own discharge planning throughout your rehabilitation including any ongoing needs you may have such as rehabilitation and care package.

Depending on your level of mobility and mobility aid, there are lots of things you will still be able to do for yourself. However, for the more robust activities, it is important to plan, and consider what support you have available to assist you.

Housework

You may still be able to complete basic tasks, for example washing & drying the dishes. In order to make this task easier, consider storing your frequently used dishes and utensils in an easily accessible place at waist height, for example, on the work top, or, an easily reachable cupboard at eye level.

For more robust tasks such as hoovering or changing the bedding, you may want to arrange help. Speak to friends and family about this, or if you are able, privately arrange a cleaner.

Shopping

Your ability to go to the shops will depend on your level of mobility. Being able to attend the shop for groceries should be a goal of yours if you were able to do this before. Initially for convenience, you may wish to speak to friends or family about arranging assistance.

If you have access to the internet, you can also arrange a delivery with a local grocer or supermarket.

Kitchen activity and meal prep

There are many ways you can retain your independence in the kitchen. Your Occupational Therapist will discuss these with you during your assessment.

If there is an able bodied person at home with you, they may be asked to assist you with your meal preparation, and carrying items.

If you live alone, your Occupational Therapist will discuss your kitchen environment, how you will safely transfer items, and may assess you with appropriate equipment depending on your level of mobility at discharge.

Exercises and Mobility

Try not to sit for long periods when at home, go for short walks regularly and keep using your walking aid(s) as instructed by your physiotherapist. Build up your walking distance gradually from short distances around the house to getting out and about.

Continue with your exercises at home 3 times a day.

You will be referred to your local physiotherapy department for ongoing progression of exercises and mobility; they will contact you with appointment once you are at home.

Returning to work

If you are of a working age, and currently in employment, either the Doctor on your ward, or your own GP, can provide you with a sick line as required.

When returning to work, you should speak to your employer’s Occupational Health department. If your employer does not have an Occupational Health department, speak to your GP.

Either your GP or your Occupational Health department can provide advice and guidance with regard to a phased return to work.

Driving

You cannot drive with an ilizarov frame. If you drive you must wait until your frame is removed before returning to driving.

Mental Wellbeing

Having an External frame fitted can require a big adjustment to you (and your families) life. Following the application of your External Fixation you may find you have emotional ‘ups and downs’. Some frame users have described feelings of:

Fearfulness
Loss of identity
Feeling useless
Feeling like a burden
Fear for the future
Concern regarding pain/infection/your own ability

Prior to surgery you may find it beneficial to think of ways of coping and identifying people whom you could speak to when you feel frustrated and low. Your GP, consultant, nurse and AHP staff are also there to support you, providing advice and/or referring you onto other relevant services in your local area. Very often challenges can be overcome by finding ways to adapt to, or overcome, the situation.

You may also benefit from speaking with other frame wearers at the weekly clinic to share experiences and advice. It is important to remember that every frame-wearer will have a different experience, and it is impossible to predict how you will feel, or what challenges you may come across.