Information for Physiotherapists with

patients undergoing limb reconstruction

surgery using external fixators

Information for Physiotherapists (Trees & Johnston 2008)

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This information is for physiotherapists treating patients

undergoing limb reconstruction procedures by the use of
external fixator frames. The information provided is
intended to act as a guide only, and if in any doubt, seek
advice from the consultant or an experienced colleague. In
particular it is aimed at physiotherapists who have limited
experience in treating patients with external fixators.
Types of external fixators
Ilizarov frames

- a circular external fixator

Taylor Spatial
Frame (TSF)

- a circular fixator with six struts, has

a computer generated programme for
deformity correction / lengthening

Limb
Reconstruction
System (LRS)

- a rail fixator attached to the bone

with half pins, may also have hinges
to allow joint distraction or deformity
correction

Other fixators are used and may include the Sheffield Ring
fixator (previously called the Sheffield Hybrid frame) or the
Hoffman fixator (a rail fixator).

Information for Physiotherapists (Trees & Johnston 2008)

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Commonly used limb reconstruction words

Corticotomy

- the site where the bone is cut

Half pins

- screws to fix the frame to the bone,

only going half way through the bone

Wires / olive wires - wires that fix the frame to the bone,
going all the way across the bone
Distraction

- the time when the bone is being

lengthened / corrected

Dynamisation

- when the frame is destabilised to

allow firming up of the new bone

Exogen

- an ultrasound machine which may be

used to help stimulate new bone

Physiostim

- an electric current which may be

used to stimulate new bone

Information for Physiotherapists (Trees & Johnston 2008)

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Common uses for external fixators

There are many reasons that patients may have external
fixators, this list is not exhaustive.
Trauma

- Open fracture fixation +/- plastic

surgery
- Closed fracture fixation +/- plastic
surgery

Elective

- Non union fractures

- Mal union fractures
- Joint arthrodesis
- Correction of soft tissue
- Correction of bony defects
- Infection / disease
- Post tumour resection

Congenital

- Deformity correction
- Short stature
- Limb abnormalities

External fixators will often remain in situ for a significant

period of time.

Information for Physiotherapists (Trees & Johnston 2008)

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The role of the physiotherapist in limb reconstruction

To assess, advise and treat pre-operatively where
possible, to ensure good baseline knowledge of the
patient including any existing deformity / limitations.
To provide in-patient physiotherapy to promote active
exercise regimes and mobility.
To provide out patient physiotherapy services to
maintain and improve movement, strength and
function. To continuously asses and evaluate
treatments and to monitor and highlight concerns.
To provide information and support to patients,
carers and other professionals involved in the care.
Information for Physiotherapists
Pre-operatively
Wherever possible patients should be fully assessed
pre-operatively by a physiotherapist. This should
include a full examination of joint ranges, muscle
power and gait assessment etc.
Patients should be advised of post-operative regimes
and any potential complications (see below).
Patients could be started on a pre-op exercise
programme if appropriate.

Information for Physiotherapists (Trees & Johnston 2008)

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Post operatively
Patients should commence an active exercise regime
as soon as possible post operatively. This will be
dictated by the site and type of fixator.
Patients should be mobilised as soon as possible
post operatively. The weight bearing status will be
dictated by the operating surgeon depending on each
units regimes and the patients condition.
Prior to discharge patients should be able to self
manage exercise regimes (or with carer assistance).
Wherever possible, patients should be independently
mobile, with walking aids as appropriate. Some
patients may continue to require supervision whilst
walking (for example children).
Prior to discharge, patients should be provided with
an out patient physiotherapy appointment or an
urgent referral should have been made to local
physiotherapy services.
Out Patient Physiotherapy
All patients should attend for out patient physiotherapy as
soon as possible following their discharge home, ideally
within a week of discharge.
Patients should be seen regularly throughout the whole
time the external fixator is in situ and after its removal until
they achieve full potential function and joint range.
Patients should be continuously assessed and exercise
regimes and mobility should be progressed regularly.
However, it is acknowledged that clinical caseloads may
determine how often it is possible to treat the patient.

Information for Physiotherapists (Trees & Johnston 2008)

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Depending on their ability on discharge from hospital,

patients may require a higher level of input at the
beginning of treatment which may be able to be reduced
with time. However, patients should ideally be treated on a
weekly basis initially.
It may be helpful to treat these patients in a gym
environment because equipment available can be suitable
for use with external fixator patients. It may also be
beneficial for patients to be treated in a group
environment.
Patients with external fixators can also be treated in a
hydrotherapy pool. It is not advisable to treat a patient with
an active pin site infection in the hydrotherapy pool (see
complications). On exiting the pool patients should shower
and dry their pins as per their normal routine.
Following removal of fixator the patient may be treated in
plaster for a while and weightbearing status may be
altered for a short period. Advice should be sought
regarding this from the patients surgeon. Caution should
be taken at this time as the new bone is vulnerable and
there will still be areas of weakness where the pins and
wires were sited in the bone. Patients should avoid
twisting and jumping wherever possible at this stage.
Contact sports should be avoided for around 6-9 months
following removal of the fixator as advised by the patients
surgeon.

Information for Physiotherapists (Trees & Johnston 2008)

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Physiotherapy considerations
Joint range of movement should be monitored closely.
Those patients who are undergoing deformity correction /
lengthening have a limb that is constantly changing due to
the surgical process and therefore need regular review.
Specific attention should be paid to the joints above and
below the fixator site looking at range of movement and
power.
Caution should be paid during soft tissue stretches where
joint range is compromised, particularly following removal
of the external fixator due to the potential vulnerability of
the bone.
Mobility and function should be reviewed regularly and
progressed as the patient is able and permitted. Many
patients can fully weightbear at some point whilst the
fixator is in situ.
Rehabilitation activities could include things such as
wobble board work, step ups, balance pad work, treadmill,
exercise bikes and cross trainers along with basic
physiotherapy activities such as core stability, muscle
strengthening exercises and patella mobilisations etc. All
activities will be dependant on weightbearing status or any
restrictions placed by the patients surgeon.

Information for Physiotherapists (Trees & Johnston 2008)

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Complications / problems
Pin site infections- (usually treated with flucloxacillin)
can cause a dramatic loss of range of movement,
pain and decreased mobility. These symptoms may
present prior to any visible signs of infection
(redness, swelling, discharge). These symptoms will
generally settle with the treatment of the pin site
infection.
Pain some patients may experience problems
controlling pain. It may be helpful to get the patient
reviewed as soon as possible. Some analgesics may
be inadvisable for patients with external fixators (for
example, Non-Steroidal Anti-Inflammatory drugs).
Non-compliance there may be lots of reasons for
these
patients
to
be
non-compliant
with
physiotherapy, such as pain control, travel issues,
taking time off work or school. These issues may
often be resolved by involving other agencies. Every
effort should be made to keep the patient engaged
whilst undergoing this treatment.
Joint contractures if not monitored closely patients
may develop joint contractures, this can be a result of
limb lengthening +/- poor positioning. At the first sign
of a joint contracture physiotherapy should be
increased, positioning should be addressed and the
patient should be referred back to their consultant.
Muscle shortening patients may have a reduction in
joint ranges during their time in the external fixator
especially if they are having their limb lengthened.
However every effort should be made to maintain as
much range as possible.

Information for Physiotherapists (Trees & Johnston 2008)

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Abnormal gait patterns patients may continue to

mobilise with abnormal gait patterns / foot postures.
Whilst the fixator is in situ patients often mobilise with
their leg abducted due to the position of the fixator.
Foot postures may change during the course of
treatment as a result of correcting a higher deformity;
this is something to be aware of but not necessarily
for physiotherapy intervention. N.B. this would be
different to an equinous deformity as a result of
tightening which must be treated.

If the patient is experiencing any of these complications

and it is felt that it isnt being managed effectively as an
out patient it may be possible to admit the patient back to
the referring hospital for intensive physiotherapy and multi
professional reviews.

Amanda Trees
Clinical Specialist Physiotherapist
James Cook University Hospital
Middlesbrough

Tracy Johnston
Clinical Specialist Physiotherapist
Sheffield Childrens NHS Foundation Trust
Sheffield

December 2008

Information for Physiotherapists (Trees & Johnston 2008)

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