A nurse is planning discharge teaching for a client who has an external fixation device

Introduction

Aim

Definition of Terms

Patient Group

Physical Assessment

Pin Site Care Dressings

Ongoing Assessment and Care

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 simplify and standardise the pin site care process for nursing staff and improve the patient experience of the procedure
• To minimise pin site infection
• To ensure asepsis is maintained whilst performing process
• To ensure all children undergoing treatment with an external fixator are treated in a safe, effective and standardised manner 
• To clarify process of what to do in event of pin site irritation or infection 
• To educate family to take on role of performing pin site care and recognition of complications
  

Definition of terms

• Pin site: A key site point of insertion of a screw, pin or wire through the skin, muscle and bone to guide or hold a bone or joint in a new position
  
• External Fixator: a mechanical device that either encircles or lies adjacent to the limb, which is attached to the skeleton by fine tensioned wires or screws. It is used to treat fractures or reconstruct bones and joints that are deformed or damaged
• Pin site care dressing: See Pin site Care Link 
• Limb Reconstruction pin site care:   
  • Limb reconstruction pin site care: All frame types
  • Limb reconstruction pin site care: All frame types - caregiver version 
    
  • Limb reconstruction pin site care: Tibial frame
    
  • Limb reconstruction pin site care: Arm frame
    
  • Limb reconstruction pin site care: Femoral frame
  • Limb reconstruction pin site care: Pelvic frame
    

Related documents

• Aseptic technique Procedure  (RCH access only)
  
• RCH Guides for Pin site care  
  
• RCH Nursing Guidelines:
  • Neurovascular observations 
    
  • Wound care 
    
  • Analgesia and sedation
    
  • Procedure management 
    
  • Nursing assessment
    

Patient groups

• All children with external fixation

Physical assessment

Initial / acute

• Link to Neurovascular observations nurisng guideline 
• Link to Nursing assessment  - See 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. Child Life Therapy / Nursing staff 
  

Pin site care dressings

• Link to Aseptic technique (RCH access only)
• Limb reconstruction pin site care: All frame types
• Limb reconstruction pin site care: All frame types - caregiver version 
• Limb reconstruction pin site care: Tibial frame
  
• Limb reconstruction pin site care: Arm frame
• Limb reconstruction pin site care: Femoral frame
• Limb reconstruction pin site care: Pelvic frame
  

Assessment of pin site / wounds

• Note pin site for signs of irritation or infection – see below

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 complete)
• 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
• Dressings

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    

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
  

Family able to purchase dressing stock from RCH's Equipment Distribution Centre. 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 for the Limb Reconstruction clinic (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, Child Life Therapy or procedural support 
  
• Family education 
  
• Potential adverse events
  
• Pin site irritation or movement
  
• Pin site infection   
  
• Transport of patient with a frame 
  

Companion Documents

• Parent information – https://www.rch.org.au/limbrecon/living_with_your_frame/
• RCH Guides for Pin site care 
• RCH CPGs and Nursing guidelines:
  • Neurovascular observations
  • Nursing Assessment
  • Aseptic Technique (RCH access only)
  • Antibiotics
  • Communicating procedures to families
  • Procedure Management
  • Analgesia and sedation
  • Nitrous Oxide Guideline
  • Wound care
• RCH Policy & Procedure
  • Aseptic Technique

Links

• www.rch.org.au/limbrecon
• https://www.rch.org.au/child-life-therapy/
  
• www.rch.org.au/comfortkids
• www.rch.org.au/anaes

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 January 2021.