Aftercare following external fixation
External fixation of distal tibial fractures is often extended to include the foot, to avoid an equino-varus deformity. Otherwise consider a splint to support the foot and ankle.
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 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/wire 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.
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
See patient 7-10 days after surgery for a wound check. X-rays are taken to check the reduction.
Once the fracture is deemed to be sufficiently stable for the external fixator to be removed, the surgeon may choose to apply a cast or functional brace before leaving the ankle completely unsupported.
At 3 months, if there are symptoms of lateral instability, either inversion stress x-rays or MRI can be used to investigate lateral ligament integrity.