Managing the Patient With an External Fixator
External fixators are used to manage open fractures with soft tis-sue damage. They provide stable support for severe comminuted (crushed or splintered) fractures while permitting active treat-ment of damaged soft tissues (Fig. 67-2). Complicated fractures of the humerus, forearm, femur, tibia, and pelvis are managed with external skeletal fixators. The fracture is reduced, aligned, and immobilized by a series of pins inserted in the bone. Pin po-sition is maintained through attachment to a portable frame. The fixator facilitates patient comfort, early mobility, and active exer-cise of adjacent uninvolved joints. Complications related to dis-use and immobility are minimized.
It is important to prepare the patient psychologically for applica-tion of the external fixator. The apparatus looks clumsy and for-eign. Reassurance that the discomfort associated with the device is minimal and that early mobility is anticipated promotes ac-ceptance of the device.
After the external fixator is applied, the extremity is elevated to reduce swelling. If there are sharp points on the fixator or pins, they are covered to prevent device-induced injuries. The nurse monitors the neurovascular status of the extremity every 2 to 4 hours and assesses each pin site for redness, drainage, tenderness, pain, and loosening of the pin. Some serous drainage from the pin sites is to be expected. The nurse must be alert for potential problems caused by pressure from the device on the skin, nerves, or blood vessels and for the development of compartment syn-drome. The nurse carries out pin care as prescribed to prevent pin tract infection. This typically includes cleaning each pin site separately three times a day with cotton-tipped ap-plicators soaked in sterile saline solution. Crusts should not form at the pin site. If signs of infection are present or if the pins or clamps seem loose, the nurse notifies the physician.
The nurse encourages isometric and active exercises within the limits of tissue damage. When the swelling subsides, the nurse helps the patient to become mobile within the prescribed weight-bearing limits (non–weight bearing to full weight bearing). Adherence to weight-bearing instructions minimizes the chance of loosening of the pins when stress is applied to the bone–pin in-terface. The fixator is removed after the soft tissue heals. The frac-ture may require additional stabilization by a cast or molded orthosis while healing.
The Ilizarov external fixator is a special device used to correct angulation and rotational defects, to treat nonunion (failure of bone fragments to heal), and to lengthen limbs. Tension wires are attached to fixator rings, which are joined by telescoping rods. Bone formation is stimulated by prescribed daily adjustment of the telescoping rods. It is important to teach the patient how to adjust the telescoping rods and how to perform skin care. Gen-erally, the nurse can encourage weight bearing. After the desired correction has been achieved, no additional adjustments are made, and the fixator is left in place until the bone heals.
The nurse teaches the patient toperform pin site care according to the prescribed protocol (clean technique can be used at home [McKenzie, 1999]) and to report promptly any signs of pin site infection: redness, tenderness, in-creased or purulent pin site drainage, or fever. The nurse also in-structs the patient and family to monitor neurovascular status and report any changes promptly. The nurse teaches the patient or family member to check the integrity of the fixator frame daily and to report loose pins or clamps. A physical therapy referral is help-ful in teaching the patient how to transfer, use ambulatory aids safely, and adjust to weight-bearing limits and altered gait pat-terns (Chart 67-6).