Aftercare following external fixation
Proper pin insertion
To prevent postoperative complications, pin-insertion technique is more important than any pin-care protocol:
- Correct placement of pins (see safe zones) avoiding ligaments and tendons, eg tibia anterior
- Correct insertion of pins (eg trajectory, depth) avoiding heat necrosis
- Extending skin incisions to release soft-tissue tension around the pin/wire insertion (see inspection and treatment of skin incisions)
Various aftercare protocols to prevent pin tract infection have been established by experts worldwide. Therefore no standard protocol for pin-site care can be stated here. Nevertheless, the following points are recommended:
- The aftercare should follow the same protocol until removal of the external fixator.
- The pin-insertion sites should be kept clean. Any crusts or exudates should be removed. The pins may be cleaned with saline and/or disinfectant solution/alcohol. The frequency of cleaning depends on the circumstances and varies from daily to weekly but should be done in moderation.
- No ointments or antibiotic solutions are recommended for routine pin-site care.
- Dressings are not usually necessary once wound drainage has ceased.
- Pin-insertion sites need not be protected for showering or bathing with clean water.
- The patient or the carer should learn and apply the cleaning routine.
Pin loosening or pin tract infection
In case of pin loosening or pin tract infection, the following steps need to be taken:
- Remove all involved pins and place new pins in a healthy location.
- Debride the pin sites in the operating theater, using curettage and irrigation.
- Take specimens for a microbiological study to guide appropriate antibiotic treatment if necessary.
Before changing to a definitive internal fixation an infected pin tract needs to heal. Otherwise infection will result.
Unless there are other injuries or complications, mobilization may be performed on day 1. Static quadriceps exercises with passive range of motion of the knee should be encouraged. Early active range of motion of knee and ankle is encouraged.
The goal of early active and passive range of motion is to achieve a full range of motion within the first 4-6 weeks. Maximum stability is achieved at the time of surgery. A delay beyond a few days to allow swelling to subside is illogical and harmful.
If external fixation is considered as the definitive device, weight bearing should be encouraged early. The timing and how much weight may be taken through the fracture will be influenced by:
- Patient factors
- Fracture configuration
- Stability of the fixator construct
As soon as callus formation is visible and once there are no clinical signs of instability, the patient can start to bear full weight. After removal of the external fixator, it may be prudent to protect the leg temporarily in a splint or brace.
See patient 7-10 days after surgery for a wound check. X-rays are taken to check the reduction.
The patient should be seen every 4-6 weeks in follow-up with examination and x-rays until union is secure, and range of motion and strength have returned.
Inspection of external fixators every two weeks is optional.