VOL: 96, ISSUE: 48, PAGE NO: 46
Melanie Sims, BSc, RGN, is clinical nurse specialist, limb reconstruction service, Northern General Hospital NHS Trust, Sheffield
Julie Whiting, RGN, ONC, is senior practice support nurse, practice development support team, Northern General Hospital NHS Trust, SheffieldExternal fixators are used to stabilise or immobilise bones. They are attached with pins or wires, which are inserted through the soft tissues and into the bone.
External fixators are used to stabilise or immobilise bones. They are attached with pins or wires, which are inserted through the soft tissues and into the bone.
The treatment of pin sites is mainly prophylactic and aims to prevent or minimise infection (Olson, 1996). However, there is little evidence-based practice on pin-site care and practitioner preference is often the deciding factor in care choices.
The main aspects of care that need to be addressed include:
- Massage of pin sites - is it beneficial?
- Crusts - should these be removed?
- Cleaning - how often should pin sites be cleaned and what solution should be used?
- Dressings - what dressings should be used and how should they be applied?
Table 1 shows a number of different pin-site care methods that have been identified in the literature. These recommendations are significant as they are based on observation and professional judgement, but there is often little evidence to support them.
Building on the evidence available and the recommendations of a working party organised by the Forum for Research in Orthopaedics, a paper setting out consensus guidelines for pin-site care was presented at the RCN Society of Orthopaedic Nursing's conference in Brighton earlier this year.
The advantage of this consensus is that it was arrived at using the professional judgement of about 50 nurses at the conference who represented a diversity of backgrounds and experiences. However, it is based on current evidence and will need to be reviewed as new data becomes available.
A diverse number of factors influence the risk of pin-site infection, making it difficult to evaluate accurately the effectiveness of any single intervention. The best way to assess pin-site care is therefore to establish the effectiveness of overall care by measuring infection rates.
To establish the infection rate for a given population, data collection needs to cover all the variables. Patient variables include: age, gender, pre-existing medical conditions and smoking (Ward, 1997). Variables related to the fixator include: type, location, reason for fixation, if and when performing corrections, time in fixation and the number of wires and/or screws and their location.
Traditionally, the infection rate is presented as the percentage of infected pin sites (De Bastiani et al, 1984; Checketts and Otterburn, 1991). Sims and Saleh (2000) presented a more patient-focused approach by showing the percentage of fixators that developed an infection. This revealed that the infection rate was related to where the fixator was located and whether corrections were being performed.
Many variables affect the infection rate of pin sites. What needs to be established is the influence of the pin-site care method used. Extensive data collection, using standardised classifications for infection and presenting the results in a standardised way, should encourage more meaningful dialogue on infection rates and care methods.