| Reference |
Source of Evidence
|
Key
findings and considerations |
| Campbell F and Watt E (2020) An Exploration of Nursing Practices Related to Care of Orthopaedic External Fixators (pin/wire sites) in the Australian Context. International Journal of Orthopaedic and Trauma Nursing. (36). https://doi.org/10.1016/j.ijotn.2019.100711 |
Expert Opinion
|
Australian study via on-line questionnaire which compares to the UK Consensus guideline Continues conjecture about which cleansing solution to use to clean pin site Compared several authors/ studies in discussion Agreement upon need for light compression at site. Contention about role of crusts – to leave or remove
|
| Ceroni, D., et al. ( 2016). Prevention of pin-tract infection to treatment of osteomyelitis during paediatric external fixation. Journal of Child Orthopaedics. 10(6), 605-612 |
Expert Opinion
|
Silver dressings have increase in antibiotic resistant pathogens.
Use of a silver dressing reduced microbial contamination of wounds from environmental sources.
These dressings are attractive due to ability to be left in place for up to 7 days
|
Clint, S. A., Eastwood, D. M., Chasseaud, M., Calder, P. R., & Marsh, D. R. (2010). The “Good, Bad and Ugly” pin site grading system. Injury. 41(2), 147–150. https://doi.org/10.1016/j.injury.2009.07.001
|
Expert Opinion
|
Most systems grade pin site reactions by the response to treatment and can vary extensively in their complexity.
Clinical pin site grading system is a reliable and reproducible method to describe pin site reactions. We have found it to be easy to recall and use in a busy out-patient setting. It is probably the simple nature of the grading system, with just 3 components, which allows such good inter-observer and intra-observer agreement.
There is a lack of any easy method to label individual sites. This obviously had an impact in monitoring the natural history of a specific pin site. With some frames having 20 or more pin sites even the patient was often unable to recall which pin site had been causing trouble the week before highlighting a need for a clear method of labelling pin sites on any ring fixator construct, regardless of its configuration
|
| Georgiades, D.-S. (2018). A Systematic Integrative Review of Pin Site Crusts. Orthopaedic Nursing, 37(1), 36–42. https://doi.org/10.1097/nor.0000000000000416 |
Systematic Review
|
This review has examined how pin site crusts have the ability to prevent pin site infection. On the basis of the evidence in the area of pin site care, the results of this study indicate that pin site crusts could be left in place, as there is evidence that retaining pin site crusts may decrease patients' risk of pin site infection.
|
| Grand, Z., Rasmussen, J., Solis, A., Sharpe, T., Shae, J., Murambadoro, A., & Frasier, K. (2025). Dermatological Complications of External Fixation Devices in Orthopaedic Trauma Patients. American Journal of Clinical and Medical Research. 5(1). DOI: 10.71010/AJCMR.2025-e180 |
Expert Opinion |
There is a need for personalized care plans for each patient, and the need for improved guidelines and dermatological competency of orthopaedic surgeons. Management strategies that can improve outcomes include surgical techniques used during pin insertion, new pin materials, antimicrobial-coated implants, regular skin assessments, and patient education.
Standardized, evidence-based protocols based on interdisciplinary collaboration should be prioritized, as current research demonstrates significant gaps in the knowledge regarding external fixation surgical site management, optimal dressing types, cleansing regimens, and beneficial hardware composition. Conflicting evidence currently leaves clinicians reliant on their own personal judgment and training experience.
Integrating dermatologic expertise into the field of orthopaedic trauma is central to developing an approach that best addresses the use of percutaneous hardware while reducing skin related adverse outcomes. This collaborative, multidisciplinary approach, paired with advances in research, will drive the development of evidence-based protocols to improve outcomes and reduce the dermatologic burden of external fixation procedures globally.
|
| Hadeed A, Werntz RL, Varacallo M. (2023). External Fixation Principles and Overview. https://www.ncbi.nlm.nih.gov/books/NBK547694/ |
Textbook |
Pin site care is essential to reduce infection rates but the technique of which varies considerably. There are several different methods, and there have not been conclusive data to support that one approach is superior to another. Postoperatively, the pins are sometimes wrapped with xeroform or iodine impregnated gauze. Motion around the skin-pin junction is known to increase the risk of infection. Compressive garments under the external fixator bars can help reduce the motion while the skin is healing around the pins. Studies suggest that routine pin-tract care is unnecessary as long as the patient performs daily hygiene in the shower. If skin drainage or erythema surrounds the pins, then providing pin care three times a day should commence until the infection clears.
|
| Heidari N, Shields DW, Iliadis AD, Kelly E, Jamal B.(2022). Pin-site Infection: a Systematic Review of Prevention Strategies. Strategies in Trauma and Limb Reconstruction. 17(2), p.93–104. https://pmc.ncbi.nlm.nih.gov/articles/PMC9357789/ |
Comparative Study |
There is no superiority between weekly and daily care. Low-energy pin-insertion technique had lower rates of infection. Sulphadiazine has positive results as a pin-care solution, but more research is necessary to determine the most effective care regime.
|
| Iliadis, A., Shields, D., Jamal, B., & Heidari, N. (2022). Current classifications of pin site infection and quality of reporting: A systematic review. Journal of Limb Lengthening & Reconstruction. 8(3), 59. https://doi.org/10.4103/jllr.jllr_31_21 |
Systematic Review |
This review highlights the lack of a clear definition and a universally accepted classification system for pin site infections. Existing classifications have offered valuable insight into various aspects of managing this commonly
encountered complication. They are, however, subjective, demonstrate varying degrees of reproducibility, and fail to offer any prognostic inference.
|
| Kazmers, N., Fragomen, A., & Rozburch, R. (2016). Preventions of pin site infection in external fixation: a review of the literature. Strategies Trauma Limb Reconstruction. 11(2), 75-85. |
Systematic Review |
Conclusion that dressings reduce pin tract infection rather (trauma patients) more so than a gauze dressing
|
| Nelitz M. (2018). Femoral Derotational Osteotomies. Current Reviews in Musculoskeletal Medicine. 11(2):272–9. https://link.springer.com/article/10.1007%2Fs12178-018-9483-2 |
Literature and Case Study Narrative Review |
Provides a comprehensive review of the indications, techniques, and outcomes associated with femoral derotational osteotomies, particularly in adolescents and adults with symptomatic increased femoral torsion.
|
| Ogbemudia, A., Bafor, A., Ogbemudia, E., & Edomwonyi, E. (2015). Efficacy of 1 % silver sulphadiazine dressings in preventing infection of external fixation pin-tracks: a randomized study. Strategies Trauma Limb Reconstruction. 10(2), 95-99.
|
Randomized Study |
Silver is a very highly effective topical antimicrobial used in burns dressings with capacity to decrease bacterial colonization. Dressing results in a slow and sustained release of silver ions, inhibiting growth and multiplication of bacterial cells.
|
| Rozbruch, S. R., Kazmers, N. H., & Fragomen, A. T. (2016). Prevention of pin site infection in external fixation: a review of the literature. Strategies in Trauma and Limb Reconstruction. 11(2), 75–85. https://doi.org/10.1007/s11751-016-0256-4 |
Systematic Review |
There is no strong evidence to guide choice of dressing type, cleansing regimen, or other aspects of pin site care. There is suggestion that chlorhexidine may be superior to saline as a pin site cleansing solution and that daily cleansing with saline is not superior to weekly cleansing. With regard to pin site dressings, there is suggestion that polyhexamethylene biguanide dressings, and possibly silver sulphadiazine dressings, may reduce pin track infection rates. However, there are several other trials showing the effect of dressing type to be negative and the question remains as to whether post-operative pin site dressings are important. With regard to pin site care, commencement of dressing changes on POD 2–3 may be convenient, as the drainage associated with pin site reaction normally decreases by this time. Clinicians should use personal judgement and experience until better evidence is available and, especially in the light of weak evidence, should consider the cost–benefit ratio of any pin site care regimen used.
Surgeons and nursing staff should adopt a uniform pin care protocol that works for their patients and that can be taught to everyone involved in that patient’s care. Using a consistent protocol will help to ensure that the patient is not getting different information from different members of the healthcare team, a common problem that can lead to confusion and loss of confidence. Providing patients with a handout describing the pin site care protocol is an effective way to communicate to home nursing and family members that are involved in the pin site care. Audits of the protocol with a review of the latest studies on pin infection and prevention will allow for updating the protocol and delivering high-quality care.
|
| Santy, J. (2010). A review of pin site wound infection assessment criteria. International Journal of Orthopaedic and Trauma Nursing, 14(3), 125–131. https://doi.org/10.1016/j.ijotn.2009.11.002 | Systematic Review | Overall, the problem with all of the reviewed infection identification and classification systems is that they are not based on a systematic approach to identifying the signs and symptoms of infection and they have not been studied in terms of their validity and reliability or diagnostic accuracy. All of the tools also lack discriminating criteria enabling clinicians to clearly identify changes in the nature of symptoms such as pain, redness and discharge. |
| Santy-Tomlinson, J., Jomeen, J., & Ersser, S. J. (2019). Patient-reported symptoms of “calm”, “irritated” and “infected” skeletal external fixator pin site wound states; a cross-sectional study. International Journal of Orthopaedic and Trauma Nursing. (33) 44–51. https://doi.org/10.1016/j.ijotn.2019.01.002 |
Cross-Sectional Study |
The findings provide greater depth of understanding of the symptoms of pin site infection and irritation. Patients may be able to differentiate between different pin site states by comparing the magnitude of the inflammatory symptoms and the presence of other specific symptoms that relate solely to infection and no other clinical state. The irritated state is probably caused by a different pathological process other than infection and may be an indication of contact dermatitis.
|
| Walker, J. A., Scammell, B. E., & Bayston, R. (2017). A web-based survey to identify current practice in skeletal pin site management. International Wound Journal. 15(2), 250–257. |
Quantitative Study |
Pin site management strategies remain variable, with significant differences existing in some aspects of care. Areas of agreement were identified with regards to the frequency of care, crust management and use of dressings and compression, although unanimous practice was not identified in any of the areas surveyed.
|
Westmead Children’s Hospital Homecare Guideline (2024). Pin Site Care. https://resources.schn.health.nsw.gov.au/policies/policies/pdf/2006-8253.pdf
|
Clinical Guideline
|
Dressing Care
Skin and wound assessment
|