Week 3, Day15. The Last Working Day

Today we attended the Orthopaedic Breakfast meeting (in the canteen), were I had polite chat about the mornings events. It seemed a bit of a treat, with it being the last day of the week(unless you are on call) for the all the Orthopods.

Today was to review some patients that had Dynamised over the last few days, and review new imaging on arrival. This was to decide whether they would have their frame removed today or another week or so.

Dynamising, is the term used for the removal/loosening of the support rods and to weight bear for a time. they would then come back and talk honestly about how they felt i.e. pain, un-steadiness etc. The patients always seemed keen or very nervous, and i felt that this was due to the amount of time they had had their frame.

The afternoon consisted of a very large ward round prior to the weekend this would make sure every thing was squared away regarding discharges, drugs, physio reviews, rehabilitation, anything that needed doing was done. I met patients who I was able to scrub in with during their operation, this was encouraging for myself, as I could see how I help within their recovery, albeit in a very small way. This has never occurred to me until now, how I help in a patients recovery, with imaging whether Plain film or Image Intensifying.

I now see myself playing major role within the patient recovery, and how much other professionals rely upon my practice. This has lead me to think along the lines of how the other professionals would like to see what is requested on the card and the position of the limb. Knowing what type of professional is requesting will let me know how too do the image and why the image was requested.

This was my last day with Mr R and Mr D's teams and with the Advanced Practice Nurses, I have learnt so much with regards to the Ilizarov Frame, but also how an Orthopaedic team work together. I can honestly say It has been the best three weeks I have had in ages, thoroughly enjoyed the trip.

Week 3, day 14

No theatre today, but a whole day within the Orthopaedic Clinic with Mr R and the Advanced Practice Nurses. There are frames every where, whether they are for the MOT or to see Mr R for a check up of their new bone growth, or even some new patients with specific problems.



I became involved with the removal of wires and in the afternoon the removal of the whole frame with the Advanced Practice Nurses. This was a very difficult time for the patient, they have been aware for some time that their frame must come of, and for some today was the day.

If the patient can not tolerate the removal of their frame, it can be removed under a general anaesthetic (GA). It is recommended that they try to tolerate it so they can leave hospital within the half hour after removal, if a GA is used then they have to wait until the anaesthetic has wore of enough to leave.

Week 3, Day 13

A slow morning really, I attended the Fracture clinic this morning, not much frame work to see at all. I was asked if I wanted to go to the Physio Department, to see some frame patients being put through their paces. This was enlightening, with respect to the Physios role within the Ilizarov Frame treatment. I saw all ages of patient doing more or less the same range of exercises, this was to achieve bone growth after the application of the frame.

This afternoon was Trauma theatre for Mr R, so went to see if there was anything of interest in the way of a frame. No, but Mr R had heard of a patient being brought into A/E with a distal tibia and fibula fracture, but to what extent was unknown at that time. He told me I could scrub with the Ilizarov Fellow, to aid in the Application of a DVR plate (Distal Volar Reduction Plate), for a distal radius fracture.

I was thrilled to be doing something surgical, albeit not a frame. Mr K (fellow), allowed me to remove some of the fixing grommets which allow a smooth passage for the drill and to help pull skin from the drill site, as not to friction burn the skin. Mr R then came back to see how we was getting on, and to let us know the patient in A/E was to be prepped for the application of a

mono-lateral fixator, as I have said before this is to allow the re-position of the bone and to allow the limb to rest whilst further treatment is being planned.

Week 3 Day 12, Scrub Day

I attended the Trauma meeting as I have done for the last three weeks , mainly just to see if there had been any new patients that could be possible frame patients. One patient that had been rested over the weekend from a crush injury, was possibly due to be framed tomorrow. I confirmed this, and I will be allowed to attend his theatre.

My main concern was would i still be allowed to scrub today, and the answer is yes. I have never scrubbed before so this was a new practice to contend with. The scrub nurse explained how to wash accordingly and the different ways of donning the robe and gloves. Once I had managed this I walked into theatre, and stood next to the Ilizarov Fellow attending my hospital at this time. The Procedure was explained to me and I watched intensely, during the course of the procedure I was allowed to adjust and place some of the nuts and bolts including the posterior adjuster bars to help this Lady's reconstruction.




I originally thought this was a Club Foot reconstruction, but the lady had suffered Compartment Syndrome, and was rushed to theatre for a fasciotomy.




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During the course of her treatment she was placed in a cast, this was a procedure done over sea's whilst on holiday. once she had arrived back into England she attended casualty and the cast was taken off.

She thought recovery was going well and the stiffness was par for the course, but her swelling had caused her foot movement to fail and eventually she lost it all and the foot remained stuck in one position. Ligaments had to be cut to release the foot, and a frame applied with posterior adjusters. Over extension of the foot by the adjusters will eventually stretch the ligaments and muscle to compensate for a generally well maneuverable foot.

Being allowed to scrub made my whole PBM module worth while, originally I was unsure of my topic, as it has only been recognised in Europe over the last 25-26 years, relativly new. Information is not very available, but it is there if you search in a wider topic area.

Ilizarov Equipment.

There are over 600 different ways of applying an Ilizarov Frame, the patients fracture and limb size will dictate the way the surgeon will apply the frame. Although there are only a few pieces of equipment that enable the technique. I will show some images of the various pieces of equipment with a brief explanation;

Ilizarov Ring's

This is the half ring that is built around the limb, you would attach another ring to the opposite side to form the full ring, note the indentation on the end's of the ring this were the other ring would lye within the other make a neat finish.

Types of Wire.

This is the Bayonet Wire, this wire would be used for the cortical aspect of bone. A Trocar Wire would be used for spongy bone. The recommended wire insertion technique would be to push the wire to the surface of the bone and then to start the drilling process, once into the medulla of the bone, feel for the wire surfacing the opposite side, then to use a hammer through the rest of the soft tissue.

The Olive Wire.

This is a wire that will only go through the bone so far due to the olive within the middle of the wire. This wire is used to manipulate segmented pieces of bone into position of the fractured area. It can also be used to pull proximal and distal fragments in line with each other so the bone can heal faster. This wire is machined down from the thickness of the olive, so the olive is secure within the whole wire it's self, if the olive was applied onto the wire, the risk is it would not be Strong enough to hold the bones from movement. The whole process of the producing the wire from the manufacturer makes it very expensive, one wire would range in the region of £36.

The Equipment tray.

This is how the equipment would be presented to the theatre from the auto-valet. What ever is used within the operation, it would be re-stocked whilst in theatre and then sent back to

Auto-valet for sterilisation.

The application of the wires within the ring must perform the rigidity of the fracture, therefore the wires must lie 90 degrees to each other. Obviously, anatomically this is very unlikely due to vessels, nerves etc, but as near as. One wire must be fixed superiorly on the ring to the other inferior.

Dynometric Wire Tensioner.

This is the piece of equipment that will pull the bone fragments together via the olive wire, the tension can be monitored by the guide that is set on the side of the tool. Using the normal wires this tool would be used just to tighten the wires for the comfort of the patient and as said before this is also is an aid to prevent the spread of infection via the wire.

Week 2 Day 10, Vacuum Assisted Therapy Dressings.

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Or Vac Sat dressings are for the treatment of the "Open Traumatic Fracture" situation. this is becoming a very popular way of treating the open wound after debridement of the fractured bone and soft tissue.



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Application of the dressing can become very fiddly, but it is far more patient friendly to the wound it's self. An asceptic sponge is cut to size and placed within the open wound itself and covered with the manufactors air tight adesive covering (opsite) a small incision is made above the opsite for a tube to be resting above the incision and again this is air tight sealed. The sponge has a small tube attached within, as to allow Antibiotics to flow over the wound for an hour, then the drip is stopped by the pump and suction is applied to with draw all the remaining fluids from the wound for 3 hours. Results can be seen after a few days, with this system being applied whilst the new external-orthofix is in place it is a good start for the initial healing to take place before the Ilizarov Frame is applied (if this is the choice of treatment).

Week 2 day 8

I attended Fracture clinic today, and I was given a message from the Senior Scrub Sister in charge of theatre 4. It read " Tony, there is a foot and ankle Ilizarov chronic reconstruction next Tuesday, you are more than welcome to scrub with Mr R and Mr F and I, if you wish to do so. "

More than pleased with this, I now know other Health Professionals are more than willing to help if they can see students are willing to learn and become involved with what is happening around them.

The Reconstruction is of Congenital Talipes Equinovarus (Club foot), there seems to be some Metatarsal malformation with this patient as well, but until I am able to see the images this is all I know.

Physio with applied Ilizarov Frame.

Today a patient called into the fracture clinic at short notice, and was lucky enough to be seen by the Advanced Practice Nurse. He was instructed last week to start physio on his Radius and Ulna frame, by removing the support bolts from time to time.

This would allow him to gently mobilise his wrist and help to generate new bone growth. He came in to say it was giving him increased pain throughout his Forearm, with neurology in the hand. This is very common due to physiological disruption within the forearm, either from the trauma or the surgery.

He was supposed to remove them for a few hours at a time, and then place them back for support. He made the mistake of leaving them out for longer and even over night, were he received a very disturbed sleepless night. Information and councelling is given to all patients who recieve this treatment, so if they wish to ignore this, it can only be one persons fault.