Question 1. What is an Ilizarov frame/Ilizarov technique?

Ilizarov frame/fixation is used for fracture fixation and stabilisation, limb reconstruction, deformity correction, and limb lengthening, using wires instead of pins and a circular frame instead of bars (Santy et al. 2009).

Ilizarov technique: a bone-fixation technique using an external fixator for lengthening limbs, correcting pseudarthroses and other deformities, and assisting the healing of otherwise hopeless traumatic or pathological fractures and infections, such as chronic osteomyelitis. The method was devised by the Russian orthopaedic surgeon Gavriil Abramovich Ilizarov (1921–1992) (G.A. Ilizarov – Ilizarov Centre).

Question 2. Reflecting upon the nursing process and a model of care how would the children’s nurse prepare this young person and their family for application of an Ilizarov frame?

Activity of living: maintaining a safe environment.

Assess: determine the young person’s and parents’ level of knowledge in relation to all aspects of hospitalisation care.

Plan: the children’s nurse must ensure Patrick and his parents are given appropriate preoperative preparation at ward level, which will involve physical and psychological care, the induction of a general anaesthetic (GA), pain management, the actual surgical procedure, and what to expect post-surgery regarding application of the Ilizarov frame (as shown in Table 26.2). All planned care should adopt an appropriate model of nursing, for example Casey (1988) and Roper et al. (1990). Please note, even though Roper et al. (1990) addresses 12 activities of daily living (ADL) (refer to Chapter 1) this chapter will only address the problems in preoperative and post-operative care in relation to the ADL – maintaining a safe environment.

Implement/preoperative interventions:

• Patrick should be settled into an allocated bed space appropriate for his age, be comfortable with the ward surroundings, and introduced to the nurse assigned to his care.
  
• Globally the needs of children and young people differ to those of adults and an increasing expectation is that children and young people should participate in health care decisions that affect them (Clarke 2021). Therefore, the care should have Patrick at the centre and be inclusive of the family, for example consideration given to their views, open visiting, and access to tea-making and overnight facilities for a parent if required. Explain what an Ilizarov frame is, show pictures, models and if possible, introduce Patrick and parents to another child with a frame in situ.

• Facilitate Patrick and his parents to raise any concerns they have regarding application of the frame, complications, returning to school, social activity, and the effects of altered body image for a 14-year-old boy.
  
• Complete and record base line vital signs on a paediatric early warning score (PEWS) chart, for example – temperature, pulse, pain score, respirations, SAO₂, and blood pressure (BP).
  
• Complete a ward urinalysis, if nothing abnormal detected (NAD) record and proceed, otherwise report and send mid-stream specimen of urine (MSSU) to laboratory for organism and sensitivity (O&S).
  
• Record weight and height accurately.
  
• Apply patient identification armband(s).
  
• Complete baseline venapuncture (may be undertaken by nurse or doctor) and send to laboratory as ordered by anaesthetist, full blood picture (FBP), and urea and electrolytes (U&E), plus ‘group and hold’ (blood for transfusion usually not ordered as operation carried out using tourniquet with minimal blood loss).
  
• Teach an appropriate pain assessment tool, a scale of 0–10 would be appropriate for a 14-year-old young person, where 0 is ‘no pain’ and 10 is the ‘most imaginable pain’ (Clarke 2003a).
  
• Discuss potential pain management options:
  
  
  
  • – Patient controlled analgesia (PCA)
    
  • – Continuous epidural infusion (Clarke 2003b; Wheetman 2006)
    
  • – Intravenous paracetamol (Clarke & Richardson 2007) and step-down medication.
  
  
• Record full medical history, known allergies, establish if smoker/non-smoker, any family problems with a GA, etc.
  
• Facilitate informed consent (medical responsibility) through verbal, written, and visual display of an Ilizarov frame.
  
• Multidisciplinary approach and introduction to team: anaesthetist, consultant, named nurse, physiotherapist, occupational therapist (OT), and specialist Ilizarov nurse.
  
• Information on maintaining an Ilizarov frame, i.e. pin site care.
  
• Risk assessment using a dedicated tool, for example Waterlow (1998) score, and placed on appropriate pressure relieving device (bed and mattress).
  
• Plan discharge date.
  
• Preoperative fasting times as per anaesthetist’s instructions (normally two hours for fluids and six hours for solids), patient shower, clean bed, gown in situ, and premedication administration if prescribed.
  
• Check out system; confirm patient details are correct, weight, allergies noted, notes, blood results and X-rays available, confirm signed consent form, and pre-medication administered if ordered. Gaining Patrick’s verbal assent to the procedure, reinforces them as a service user and rights holder (UNCRC 1989). Also record if fasting times are adhered to and offer parents to accompany Patrick to theatre.
  
• Prepare Patrick’s bed space to ensure a safe environment following his return from surgery – collect appropriate documentation, check oxygen and suction equipment is working, and gather any necessary monitoring or infusion devices.
  
• Evaluate all nursing interventions and complete all appropriate documentation as per hospital policy.

Question 3. Discuss the nursing care of Patrick in relation to the immediate post-operative period (first 24 hours), having returned to the ward

Activity of living: maintaining a safe environment.

Assess and plan post-operative interventions:

• Person-centred approach inclusive of parents, i.e. consider the parents when collecting Patrick from recovery and returning to the prepared bed space.

Implement post-operative interventions:

• Attach Patrick to appropriate monitoring and infusion equipment as per hospital policy.
  
• Read medical and nursing notes, adhering to anaesthetist and surgeon instructions.
  
• Ensure Patrick is comfortable, using appropriate tool, i.e. assess pain score (0–10), reposition Patrick, review risk assessment, for example Waterlow (1998).
  
• Observations to be completed and recorded on dedicated post-operative chart with appropriate action as per hospital protocol:
  
  
  
  • – TPR, SAO₂ (oxygen saturations), and BP
    
  • – Neurovascular observations of the operated lower limb are imperative, inclusive of pain intensity as he is at risk of developing acute compartment syndrome (RCN 2014)
  
  
• Check actual Ilizarov frame (as above), pin sites for ooze, bleeding, and signs of infection.
  
• Hospital protocol must be adhered to regarding care of cannula, i.e. patency and management of intravenous (IV) fluids
  
• Record all input and output on a fluid balance chart.
  
• Administer analgesia as ordered by anaesthetist. Patrick would most likely receive either a morphine based PCA, or an epidural infusion with a local anaesthetic. Both would be in conjunction with regular IV paracetamol. Nurse to observe for potential side effects of opioids. Analgesia can be used in conjunction with non-pharmacological methods, for example music.
  
• Monitor IV fluids and cannula site (as per hospital protocol). Patrick may also tolerate sips of water later in the day as directed by the anaesthetist . Also monitor output on fluid balance chart, reporting any concern to anaesthetist. Patrick may also have an indwelling urinary catheter – this often accompanies an epidural infusion (Wheetman 2006) which associated with orthopaedic surgery.
  
• Patrick to be reviewed by pain management team and physiotherapist.
  
• Occupational therapist to review Patrick to make foot splint which aims to prevent neurovascular complication, i.e. dropped foot.
  
• Consider Patrick’s altered body image and privacy needs of a young person.
  
• Patrick to be reviewed by Ilizarov team: orthopaedic consultant, anaesthetist, physiotherapist and specialist nurse.
  
• Administer IV prophylactic antibiotics as per hospital protocol.
  
• Complete check X-ray as per consultant’s instruction.

Evaluate all nursing interventions and documents.

Question 4. In an attempt to prevent pin site infection, how will Patrick be educated and supported to undertake pin site care/management

A review by Georgiades in 2018:36 states, ‘the goal of pin site care is to reduce, or where possible, prevent pin site infection’. The author also reports on the care of external fixator pin sites to remain debated and researched among scholars, this has highlighted a number of variances and issues in pin site care. There is an absence of high-quality data and research to support any one particular type of dressing in reducing pin site infection, including the use of pin site crusts (Lethaby et al. 2013; Timms & Pugh 2012). The use of multiple pins has increased the risk of complications such as intractable pain, tethering and tenting of the surrounding skin, muscle spasm, swelling and soft tissue tension, and infection at the pin site, which is the main concern and can result in loosening of the pin, loss of fixation and osteomyelitis (Patterson 2005). In the UK the expert British nursing consensus group on pin site care (Lee-Smith et al. 2001) differentiate clearly between the term’s ‘reaction’, ‘colonisation’, and ‘infection’ when discussing pin site care. Pin site care which is identified by Santy (2000) as requiring specialised nursing care is a psychomotor skill initially undertaken by the nurse and then executed by either the child or parent following appropriate education and a period of supervised practice. The most up-to-date Cochrane review on site care for preventing infections associated with external bone fixators and pins remains by Lethaby et al. in 2013 is presented in Table 26.3.

Like the first edition, Clarke and Richardson (2008) demonstrate the contemporary ‘Russian’ method (Table 26.4). Variations continue to be adopted by UK practitioners, for example figure of eight bandaging – recurring steps include weekly cleansing, use of pressure at pin sites, no showering of limb in-between showering and cleansing solution. This information should be used in conjunction with local guidelines for wound care, infection control and following discussion and agreement with other relevant members of the healthcare team and reviewed on an on-going basis.