“Over the past two decades, extensive research all over the world has shown that laughter has a positive impact on various systems of the body. Most noteworthy is laughter’s ability to unwind the negative effects of stress: the catalyst for many of our health problems.” – Dr Madan Kataria, Laugh For No Reason
Orthopaedic care often involves the utilization of external frames to support the feet as bone conditions are treated. These frames are secured to the bones via pins that protrude through the skin as connections between the internal and external sections of the frame. Cleanliness is the baseline of health, and as foreign objects are introduced to the body, there is the potential for infections to develop at the interface between the pins and the skin. There are differing classifications of the types of infections that can develop, as well as the appropriate treatment method for these conditions. Medical science is always evolving, and the state of pin site management is a topic that is worth discussing.
There are best practices in place that will ensure that pin-sites are managed well during the process of post-operative care. If all medical practitioners are aligned in the treatment plan, then the rate of incidence of infection can be controlled during treatment. External frames are quite effective in limb treatments, and pin site infection is one of the most common problems that are experienced during the treatment process.
The importance of pin-site management is beneficial to both the patients and the orthopaedic specialists. Manageable treatments are the ones that will be offered as a treatment to the wider public. In the worst case scenario, if pin sites are not properly managed, the patient will have to utilize internal methods such as antibiotics or undergo corrective surgery. The external frame may have to be removed before its scheduled time.
For this reason, there are plans in place to develop a gold standard for the management of pin sites. Typical questions considered in the answering of these questions include:
1)What is external fixation and why is it important?
2) Why is infection associated commonly with external fixation and what are the challenges?
3) What is infection and how is it measured?
As external fixations gain popularity, various types of orthopaedic conditions are prescribed for this care. This versatility is what makes the treatment a first resort for orthopaedic care. With the added benefit of less trauma induced to the tissue and blood supply of the limb, external fixation is a clear winner in the field. Infections occur via the mechanism of infection. The classification of infections include: Reaction, Colonisation, and Infection. The definition of these classifications is [1]:
- Reaction represents normal changes that occur post-surgery, which are expected to resolve within 72 hours, including skin redness, pin-site heat and minor levels or serous fluid or blood discharge.
- Colonisation involves further redness and warmth post 72 hours and accommodates for pain and exudate occurring at one or more of the pin-sites.
- Infection involves purulent discharge and potential loosening of the pin.
The benefit of the classification is that it creates an ideal starting point for the identification of the severity of infection. As a patient, if you are to experience any infection of your pin site, these are one of the three likely classifications of infection that you will receive. Your orthopaedic surgeon will then determine how to treat your condition according to this initial diagnosis. With additional tests, the severity of the condition can be confirmed, and the treatment process can then begin. Mild treatments range from cleaning with appropriate solutions, while more advanced treatments will often require both internal and external treatments. Internal treatments include the utilization of oral antibiotics. In the case of bone infection, your orthopaedic surgeon may opt for the removal of the external frame. The six step treatment plan is highlighted in the reference article below.
General Care
Prevention is always better than cure, so to ensure that pin-sites are well maintained, it is important to treat the site with clean hands in order to minimize transfer of germs to the pins. Hands must be clean at all times, in order to conduct the dressing of the site, washing of the site, and massaging of the site for improvement of circulation. Utilize separate gauzes and sanitize equipment between each site to avoid cross contamination. If scabbing takes place at the site, indicate this to your health care practitioner, who will ensure that they are removed.
Cleaning Solutions
There are a variety of sterile cleaning solutions that can be utilized in treating the wound site. The best recommended solutions include sterile chlorhexidine, betadine, alcohol and hydrogen peroxide. Non-sterile solutions include saline, soap and warm water. Utilize the options that work best for you, as studies have shown that there is no significant difference in the health of the pin site as you work through the list. Avoid alcohol usage where possible as it is damaging to the skin, and can cause pain. Investigate the pros and cons of each option, and discuss the best cleaning solution for your pin care. When dressing your site after cleaning, ensure that you cover the area appropriately with your prescribed dressing. This may or may not include gauze covering.
Conclusions
Within the patient care cycle for patients with external frames an appropriate pin-site management strategy is one that will have to be discussed with the orthopaedic surgeon. During post operative care, the patient may or may not do a great job of cleaning their pin-sites. Onset infections can develop, which the orthopaedic specialist will have to classify and treat. Pin-site management strategies are being developed to ease the process of care as patient healing progresses. Coupled with the physical healing process, the mental health of the patients is also being considered in medical care. With limited mobility, patients may not always feel the most confident and they must be motivated through their process.
Research Article:
Current Thinking in Pin-Site Management in External Hexagonal Frames Gordon Slater1* and Luke Mathen2 1MBBS (UNSW) FRACS FA Ortho A Private Practice Double Bay Sydney 2 Lead research assistant, Department of biomedical engineering, Sydney University