VOL: 97, ISSUE: 24, PAGE NO: 66
Mary Wood, RGN, is teaching sister (orthopaedics), Charing Cross Hospital, LondonExternal fixators are increasingly being used in orthopaedics to stabilise fractures, treat non- or mal-union fractures and in reconstructive surgery for congenital deformities and limb-lengthening.
External fixators are increasingly being used in orthopaedics to stabilise fractures, treat non- or mal-union fractures and in reconstructive surgery for congenital deformities and limb-lengthening.
A common complication associated with their use is skeletal pin reactions. In addition to being physically and psychologically distressing, pin reactions can lead to complications such as osteomyelitis, delayed fracture-healing and increased length of hospital stay (Mandzuk, 1991).
Sims (1996) argued that pin-site care is a basic skill and that reaction is an end result of poor aftercare. However, research in support of methods of care tends to be limited and inconsistent (Olson, 1996). The readmission of a patient with infected pin sites to one orthopaedic unit highlighted the need to standardise pin-site care. Team analysis of this event as a critical incident led to the development of a protocol to promote best practice.
Diana Brown is a fit and well 16-year-old who has stunted growth as a result of a chromosomal abnormality called Turner's syndrome. She was admitted to hospital to undergo elective surgery to lengthen the tibias in both her legs. This was to be achieved using the Orthofix external fixator. Limb-lengthening is achieved through a process of distraction osteogenesis: the bone is cut during surgery and gradually distracted (pulled apart), leading to new bone formation at the site of lengthening. Usually the fixators are in place for about nine months and patients can expect to gain approximately four inches in each tibia (Trivella et al, 1996).
The operation and Diana's recovery were uneventful. While the fixators were in place Diana would get around in a wheelchair. Before discharge she was taught how to transfer independently, care for her pin sites and lengthen the frames. Adjustments are made to the apparatus four times a day by turning the frame. This results in the bone ends being separated at a rate of one millimetre per day.
Two months after discharge it was noted in outpatients that Diana's pin sites had become infected, and she was readmitted to hospital for the administration of intravenous antibiotics. She was very upset to be back in hospital, particularly as she had been conscientious in caring for her pin sites as instructed.
Diana is typical of most patients undergoing limb-lengthening. They are often between 16 and 18 years old, live with their families and have few, if any, other medical conditions that would adversely affect healing. They are not usually taking medication.
On admission to hospital all patients are seen by the consultant and are given an extensive explanation of the procedure. They are also given the opportunity to meet other patients who have undergone limb-lengthening. If the surgery and recovery is uneventful they are discharged home and seen once every two months in the outpatient clinic. To ensure the smooth running of this system it is vital that the patient is aware of how to care for the pin sites and has a full understanding of pin reactions.
On discussion with Diana it became apparent that a staff nurse had advised her that she could shower and had shown her how to clean around the pin sites with cotton buds and saline. Diana had also been instructed to massage around the pins 'to stop them sticking' and to cover them with gauze if they oozed. When her pin sites became red and sore Diana decided to rub antiseptic cream around them as this is what she had done when she had her navel pierced.
Having established a need to standardise pin-site care and discharge advice a literature review was undertaken to examine the evidence for actions taken.
Is routine care necessary?
A skeletal pin is an external metal pin that has been inserted through a bone and protrudes through the skin (Mandzuk, 1991). While it is in situ the patient will have an open wound site in the inflammatory stage of healing.
Trigueiro (1983) believes that the risk of infection increases in line with the amount of intervention and suggests that if pin sites are dry they should be left untouched. This idea is supported by a study by Jones-Walton (1988), where patients who received no pin care did not develop pin reactions. However as this was a small study (n=3), these results cannot be generalised.
Jones-Walton (1991) found that many surgeons recommended two-hourly care, and Nance and Mandjetko (1994) suggested that pin-site care should be carried out three times a day for limb-lengthening devices.
Myers (1996) suggested that wounds should not be cleaned unnecessarily, as this reduces the temperature of the wound. He stated that it would take 40 minutes for the wound to regain its original temperature after cleaning and three hours for mitotic and leucocytic activity to return.
At my place of work pin sites are treated daily, which is consistent with studies by Goldberger et al (1987), Celeste et al (1984) and Henry (1996). However, it could be argued that the frequency of pin-site care should be assessed on an individual basis and be related to the amount of exudate.
Which cleaning solution?
It is common practice to clean wounds to remove debris that might provide a focus for infecting micro-organisms. In the past hydrogen peroxide was a popular cleaning agent in pin-site care. However, more recent studies into the effects of hydrogen peroxide, povidine-iodine and chlorhexidine not only suggest that they do not prevent pin site reactions but that they may be harmful (Collier, 1994; Gilchrist, 1994; Sproles, 1985; Jones-Walton, 1988; Celeste et al 1984).
An alternative cleaning agent is tap water, but research in support of its use in pin-site care is limited. Animal studies which compared the use of tap water and saline in open traumatic wounds showed a similar reduction in bacterial contamination between the two (Moscati et al, 1998a; 1998b). Riyat and Quinton (1997) achieved similar results when they examined the use of water in wound-cleansing in humans. The results of these small studies cannot be generalised, but water has been used to clean leg ulcers for a number of years (Gilchrist, 1994).
Based on the available evidence it does seem possible that patients with an external fixator can take a shower, particularly as the pressurised delivery of the water may help to clean the wounds (Lawrence et al, 1994; Williams, 1996).
Diana was instructed to clean her pin sites with saline and cotton buds. This would have lacked the pressure necessary to deslough infected areas (Oliver, 1997), and the fibres from the cotton buds can get lodged in the wound, causing a reaction. Ideally the pin sites should have been irrigated with saline while she was on the ward. When she went home she should have been given pressurised saline in a can to continue with this care. While this is not used in hospital due to the potential risk of cross infection when used on multiple patients, it is ideal for use at home.
Diana was told that she could take a shower a couple of times a week with her fixator on, as it was felt there were unlikely to be any detrimental effects. However, she had not been told that the use of shower gel or shampoo could cause a pin-site reaction. Similarly, it would have been helpful to advise her not to use any other solutions or ointments, such as antiseptic cream, on the pin sites.
Should crusts be removed?
The literature concerning the removal of crusts is more consistent. Nichol (1993) suggested that crusts should be removed, as fluid accumulates beneath the pin and can become trapped, leading to secondary infection. This is reinforced by Celeste et al (1984), Sisk (1983),Wallis (1991) and Henry (1996). While Sproles (1985) recommended leaving crusts in situ around a Steinmann's pin, she approved of crust removal around external fixator sites as there is more muscle tissue around them.
Diana had been taught that fluid accumulating around the pin is normal and indicates that the wound is still in the inflammatory stage of healing. While this is correct, she should have been given guidance to enable her to distinguish between normal exudate and that due to infection. She should also have been directed to remove crusts to prevent the build-up of fluid around the pin sites.
Covered or exposed?
The optimum environment for natural wound-healing is a warm, moist, non-toxic environment (Winter, 1975). Dressings are used to increase the temperature at the wound interface and to maintain a moist environment.
Trigueiro (1983) believes that 'dressings may decrease the incidence of airborne infection and finger contamination'. However, Sisk (1983) felt that pin sites 'should be left exposed unless there is soft tissue damage or excessive tissue movement around the pin'.
It appears that most nurses cover pin sites with gauze (Mandzuk, 1991). To minimise the risk of fibres lodging in the pin site, thereby providing a focus for infection (Oliver 1997), Henry (1996) suggested that only woven gauze should be used and that this should be wrapped around the pin rather than being cut to fit.
It is possible that Diana's pin-site reaction may have been caused by gauze fibres, particularly as she had been taught to cut the gauze to fit around the pin site.
When choosing a wound dressing, nurses should consider the site of the wound and the primary treatment objective (Collier, 1996). In Diana's case the dressing chosen should have reflected the fact that pin sites are difficult to dress and that the primary objective was to control exudate and prevent a reaction rather than to promote healing.
Based on the literature it seems that, if a dressing is necessitated by the presence of exudate, a foam dressing is the most appropriate (Williams, 1999). Foam dressings come in a variety of presentations, are non-adherent and will not shed fibres into the wound. Alginates are also a useful wound-contact material, appropriate for use on exuding and infected pin sites.
Massage refers to pushing the skin away from the pin and is commonly used to stop the skin adhering to the pin and to keep it supple (Henry, 1996). This action is supported by Trigueiro (1983) and Ward (1998), who suggested that normal capillary blood flow can become compromised by the presence of the pin. Sisk (1983) also advocates massage to encourage exudate to come to the surface.
Diana was advised to massage around her pins daily when they were not oozing but to leave them alone when they were.
There is a correlation between rate of infection and the following:
- Age (Ward, 1998);
- Smoking (Ward, 1998);
- Length of time the pin is in situ (Ward, 1998), but this is challenged by Henry (1996);
- Multiple pathology (Sproles, 1985);
- Low serum protein (Ward, 1998);
- Patient's personal hygiene (Sims, 1996);
- Patient compliance (Sproles, 1985; Wallis, 1991).
Despite a lack of consistent evidence in support of pin-site care, by reflecting as a team on the care Diana had received and reviewing the literature, recommendations for a change in practice could be made.
We decided to write a local standard of care for pin sites to ensure that all staff consistently maintained a high standard (Box 1). Its development was based on research findings, experience and team discussion. One of the nurses on the unit also volunteered to develop a booklet for patients, describing how to care for their pin sites to reinforce the verbal information they were given at discharge.
Pin-site care is especially important for patients undergoing limb lengthening, as they are in hospital for only a few days before being discharged to manage their own care. Nurses caring for them must have the knowledge and skills necessary to ensure they have a full understanding of what is required.
There is a lack of recent research on pin-site care, and it is an area that needs revisiting. The implementation of a ward protocol is a good starting point for this as, once in place, it can be audited to ascertain its effectiveness.
- The patient's name has been changed.