Clinical Guidelines (Nursing)

Pin site care for the child with an external fixator

  • Introduction

    Aim

    Definition of Terms

    Patient Group

    Physical Assessment

    Discharge planning/Education Needs

    Family Care

    Follow up/Review

    Special Considerations

    Companion Documentation

    Links

    Evidence Table

    Introduction

    Pin site care is a dressing procedure used to reduce the incidence of infection in patients undergoing treatment with an external fixator. External fixation is used for limb lengthening correction of deformity or to treat complex fractures of the limb.  The patient requires preparation for the procedure, as many children can find this procedure distressing. A positive early experience can contribute to a smooth transition and successful subsequent dressings at home.  This guideline aims to simplify the process by providing a guide for the clinician to easily complete this task with confidence.  There is little concrete evidence in the literature to inform practice, however many similar processes have slowly been adopted in many centres around Australia and indeed the world.

    Aim

    • To provide a standard guideline for the pin site care process for nursing staff and improve the patient experience of the procedure
    • To minimise risk of pin site infection and complications
    • To ensure aseptic technique is maintained when performing procedure
    • To ensure all children undergoing treatment with an external fixator are treated in a safe, effective and standard manner 
    • To clarify escalation process in event of pin site irritation or infection 
    • To provide principles to support education of family so that they may safely perform pin site care and recognise complications

    Definition of terms

    Related documents

    Patient groups

    • All children with external fixation

    Physical assessment

    Initial / acute

    • Link to Neurovascular observations nurisng guideline 
    • Nursing assessment  - Link to Musculoskeletal Nursing assessment
    • Pain assessment and administration of analgesia prior to procedure commencement
    • Consider need for more complex pain relief e.g. Nitrous Oxide
    • Assess the patient’s and family’s emotional state – calm / anxious / irritated 
    • Assess any open wounds or grafts that may require specific care
    • Location of pin site, therefore influencing the type of dressing required e.g. tibia, femur, humerus, forearm, 
    • Post-operative orders – anything specific surgeon requests
    • Identification of equipment required
    • Requirement for assistance from other staff members e.g. Educational Play Therapy / Nursing staff 

    Pin site care dressings

    Assessment of pin site / wounds

    • Note pin site for signs of irritation or infection – use table below
    Grade Characteristics Treatments
    1 Minor infection: slight redness, little discharge Improve pin site care
    2 Minor infection: redness of the skin, discharge, pain and tenderness in the soft tissues  Improve pin site care, oral antibiotics
    3 Minor infection: Grade 2 but not improved with oral antibiotics
    Affected pin/s re-sited
    4 Major infection: severe soft tissue infection involving several pins. There may be associated loosening of the pins   External fixation must be abandoned
    5 Major infection: Grade 4 involved with involvement of the bone. Visible on radiographs External fixation must be abandoned
    6 Major infection: occurring post removal of the fixator. Initially may/will subsequently break down and discharge at intervals. Radiology shows new bone and sometimes sequestra Curettage of the pin track
    Ref: W- Dahl, A. & Toksig-Larsen, S. (2004). Pin site in external fixation sodium chloride or chlorhexidine solution as a cleaning solution. Orthopaedic Trauma Surgery, 124: 555-558

    Ongoing assessment and Care

    • Observation of patient pain tolerance during the procedure – change plans if too distressed to complete procedure and document outcome (completed or not completed
    • Once completed – assess for patient comfort
    • Plan for anticipated date of next dressing change. This will be dictated by the location of the pins e.g. Femur performed twice per week, tibia once per week.
    • Consider need for regular checking of child’s temperature

    Management of Irritation and Infection

    • Pin site irritation – grade 1 : Increase frequency of pin site dressing to 2 – 3 daily. Use polyurethane foam dressing. 
    • Pin site infection – grade 2 and above: 
    • Commence oral antibiotics (Flucloxacillin 50 mg / kg qid) as per “Clinical Practice Guideline for Infection”
    • Notify Limb Reconstruction team, Limb Reconstruction fellow (via switchboard) or on call registrar of intention to commence antibiotics.
    • Dress sites more frequently – 2 – 3 daily. Use polyurethane foam dressing +/- Silver 
    • Chlorhexidine Irritation - Intense urticarial reaction due to sensitivity to the alcoholic chlorhexidine used. If this occurs, then the dressing must be removed, and the limb showered down to remove the solution.
      • In mild reaction, the dressing should be changed to a normal saline compress.
      • In severe reaction, a Hydrocortisone cream or ointment is prescribed daily and the sites left exposed, except when they need to be covered to absorb excess ooze.

    Discharge Planning / Education Needs

    • Referral to Post Acute Care for pin site care education for the family. Weekly/ twice weekly pin site care for a period up to four weeks (extended by negotiation). Family to agree to participate in education with the aim to be independent in pin site care at completion of four week period. 
    • Ongoing education to family as to recognition of signs and symptoms of infection
    • Written educational information given to family on discharge to assist with pain management plan

    Family care issues

    • Assess if the parent able to support child
    • Assess for need for referrals for allied health input including social work 
    • Family to purchase dressing stock from Equipment Distribution Centre. https://www.rch.org.au/edc/
      Cost is approx. $60.00 for starting pack (as of Dec 2017, contact EDC for current pricing.) Dressing stock ordered via EDC in EMR. If unable to purchase, refer to Social Work. These must be purchased prior to patient discharge. 

    Follow up / Review

    • Outpatient  appointment to be made prior to discharge into Limb Reconstruction Active clinic (Tues pm) (unless instructed otherwise)
    • Contact details given to family of Nurse coordinator, Limb Reconstruction fellow, On Call Orthopaedic registrar, and Physiotherapist
    • Contact details of Post-Acute Care provided to family

    Special Considerations

    • Patient safety alerts /social issues affecting home visits
    • Minimise distress to patient during procedure – consider creating an alert on EMR for plan when requires assistance and support with dressings e.g. Nitrous Oxide, Educational Play Therapy or procedural support 
    • Family education 
    • Potential adverse events
    • Pin site irritation or movement
    • Pin site infection 
    • Chlorhexidine reaction / sensitivity 
    • Transport of patient with a frame 

    Companion Documents

    Links

    Evidence Table

    Evidence table: Pin Site Care Evidence Table

     

    Please remember to read the disclaimer.  

     

    The development of this nursing guideline was coordinated by Cheryl Dingy, Nurse Co-ordinator Limb Reconstruction, Orthopaedic department, and approved by the Nursing Clinical Effectiveness Committee. Updated December 2017.