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Introduction   

External fixators are orthopedic devices used to stabilize fractured or osteotomized bones and correct their position and orientation [1][36]. These devices consist of transosseous elements, such as pins or wires that pass through the bones, interconnected with a stabilizing structure outside the body [1][36]. Unlike open reduction and internal fixation, which aligns bone segments using attached pins and wires, external fixation methods allow realignment without surgically exposing the bones [36].  

External fixation is a fundamental tool in traumatology and reconstructive orthopedic surgery. Its primary goal is to maintain the length, alignment, and rotation of the fracture [1]. For over 2000 years external fixation has treated fractures, first described by Hippocrates as a method to immobilize fractures while preserving soft tissue integrity [1]. Soviet doctor G.A. Ilizarov developed the Ilizarov System in 1951 in Kurgan, Siberia [2]. The ILIZAROV method lengthened and/or straightened bone and soft tissue, often saving limbs that might otherwise require amputation [2][3][17]. By separating the two bone halves millimeter by millimeter, the Ilizarov method leverages the body’s natural ability to regenerate bone, enabling the correction of deformities or the extension of bone length [2][3][33]. 

Nursing care plays a fundamental role in the successful implementation of external fixation. Nurses provide essential support to patients by educating them and their families about proper pin site care, infection prevention, and the management of external fixator devices [24]. They assist in monitoring the healing process, identifying potential complications, and ensuring adherence to treatment protocols. Through comprehensive patient education and continuous support, nurses help optimize outcomes and enhance the overall patient experience with external fixation. 

Types & Construction  

Different pin morphologies, such as self-drilling pins, trocar tip pins, and hydroxyapatite-coated pins, offer variations in performance and stability [1]. Enhancing the strength of the construct involves increasing the diameter of the rods or positioning them closer to the bone. External fixators include several subtypes, such as uniplanar, multiplanar, unilateral, bilateral, and circular fixators [1]. Multiplanar constructs, created by adding pins in different planes (perpendicular to each other), provide enhanced stability compared to uniplanar devices [1][4][13]. Bilateral frames, with pins on both sides of the bone, offer additional stability [1][5]. Circular fixators, used for limb lengthening procedures, are effective in allowing patients to bear weight and maintain some joint motion during treatment [1][5].  

Hybrid frames, which combine elements of various constructs, offer flexibility in achieving the desired level of stability for optimal healing [1][6]. Carbon fiber is the preferred material for bars today, as it is 15% stiffer than stainless steel bars [8]. Balancing stability with a biological environment conducive to healing is crucial for successful outcomes. Hybrid external fixators combine unilateral or bilateral fixators with circular external fixators (CEFs). These devices utilize transosseous pins and tensioned wires, which attach to both circular and unilateral frame elements, providing structural support [36]. This combination facilitates multiplanar fixation, offering greater versatility than individual frame types. Hybrid external fixators provide the ability to stabilize complex fractures typical of CEFs, while also offering better access to soft tissue, similar to unilateral fixators [36].  

Various adjustments to the external fixation construct can alter the stability of the fracture. The mode of fixation and the level of stability affect the physiology of fracture healing. Bone fracture healing is a complex and dynamic regenerative process aimed at restoring the damaged bone to its pre-injury state and cellular composition [12]. A fracture disrupts the structural continuity of the bone cortex and injures the surrounding soft tissues [11]. Following a fracture, secondary healing begins, consisting of four stages: hematoma formation, granulation tissue formation, bony callus formation, and bone remodeling [11][12]. 

Absolute fracture stability, achieved through methods like compression plating, leads to primary intramembranous bone healing [1][11]. In contrast, relative fracture stability, such as that provided by external fixation, results in secondary endochondral bone healing [11].  

While external fixation stabilizes different bones across the body, the overall application technique remains the same.  

Benefits  

External fixation offers numerous benefits compared to internal plates and intramedullary nails [13]. One of the primary advantages is that external fixators cause less disruption to the soft tissues, osseous blood supply, and periosteum [13][16]. This characteristic makes fixators suitable for managing soft tissue in acute trauma with skin contusions and open wounds, in chronic trauma with thin skin grafts and muscle flaps, and in patients with compromised healing potential due to conditions like rheumatoid disease, peripheral vascular disease, diabetes mellitus, and Charcot disease [14][15]. 

The temporary nature of the pins and wires in external fixators is ideal for providing bony stability in cases of osteomyelitis, where internal implants can complicate infection eradication [17]. The ability to avoid placing fixation in the infected area is another significant benefit. As fixed-angle devices, external fixators offer superior fixation in compromised bone, and the use of fixed-angle pins in multiple planes provides the versatility needed to optimize stability while minimizing tissue damage [13]. Many external fixators offer excellent stability, allowing for early weight-bearing and joint motion exercises [35].

Complications  

External fixation treatment can lead to several complications, including pin site infection, osteomyelitis, and the failure or loosening of the frame or pins/wires, placing a significant burden on both the patient and the healthcare system [22]. Patients can often differentiate between various pin site conditions by comparing the severity of inflammatory symptoms and identifying specific symptoms that are indicative of infection [30]. An irritated pin site may be due to a different pathological process, such as contact dermatitis, rather than an infection [30]. 

Additional complications include malunion or non-union of the fracture, soft-tissue impalement, neurovascular injury, compartment syndrome, and refracture around the pin site [18]. There is a risk of soft-tissue impalement, neurovascular injury, and compartment syndrome [18]. Each of these complications requires careful monitoring and management to ensure optimal patient outcomes.  

A recent prospective study involving 39 patients with trauma, limb deformity, and bone infection treated with external fixation reported a pin site infection rate of 30%, affecting 92.5% of the patients. Although most pin site infections are superficial, this complication often causes patient pain and necessitates increased pin site care or antibiotic treatment [20]. These infections progress through four stages: Stage I involves seropurulent drainage, Stage II includes superficial cellulitis, Stage III entails deep infection, and Stage IV results in osteomyelitis [19] [21]. These infections increase the number of clinic visits required during a patient’s course of treatment, may necessitate additional interventions such as antibiotics and surgery, and can compromise patient outcomes if osteomyelitis or instability results from pin loosening or the need for pin or complete construct removal [18]. Factors influencing the development of pin site infections include patient-specific risk factors, surgical technique, pin design characteristics, use of prophylactic antibiotics, and the post-operative pin care protocol, which encompasses cleansing, dressing changes, and showering [18]. The use of antiseptics may not provide any significant benefit for routine pin site care in Ilizarov external fixation. Furthermore, daily pin site care is not superior to weekly pin site care. For early and low-grade pin site infections, empirical therapy should focus on Staphylococcus [32]. 

Factors associated with an increased risk of pin site infection include multiple comorbidities, poor soft tissue structure, inadequate general hygiene, and poor nutritional status. Systemic conditions such as diabetes and immunodeficiency also elevate the risk of infection [23]. Most pin site infections are treatable with improved wound care and a short course of oral antibiotics. However, deep tissue infections and osteomyelitis may occur in up to 4% of cases, which are serious complications [22]. Pin loosening can lead to increased pain, greater use of pain medications, and delayed mobilization [22].  

Due to the high incidence of pin site infections in patients undergoing external fixation and the morbidity and costs associated with the sequelae, clinicians need to educate patients to recognize the signs and symptoms of pin site infections to initiate treatment. 

Nursing Considerations  

The role of the orthopedic nurse encompasses identifying patients’ concerns and addressing their expectations about care. The nurse provides expert support to patients during periods of change and adjustment, helping to reduce the risk of non-acceptance of the frame and non-adherence to treatment. When planning discharge from the hospital, it is important for nurses to address factors such as depression and destructive behavior [24].  

External fixation comes with several complications impacting patients’ lives and relationships. Nurses are responsible for developing educational plans that teach patients and their relatives about pin-site care, thereby enabling effective self-care of external fixation systems [24]. Maladaptive coping leads to depression, anxiety, and poorer psychological and social well-being [34]. Patients who struggle post-discharge may benefit from additional community support and more frequent follow-up. Self-management programs can aid in developing effective coping strategies [25].  

Nurses play a crucial role in supporting patients with external fixator devices and in caring for pin sites. Clear and consistent assessment and documentation enable nurses to monitor the condition of pin sites and distinguish between new and recurrent pin site infections. Patients often notice subtle changes in symptoms first, making their perceptions of potential infections a key part of the assessment.  

By providing both verbal and written information, nurses help patients understand the importance of proper pin site care and early infection detection. Patients with external fixator devices should undergo regular review by the orthopedic team to assess healing progress and check the position and stability of the frame [19]. Depending on the device, adjustments such as tightening elements or changing struts may be necessary. The orthopedic team and nurse can provide patient-specific advice on managing the device throughout the treatment period. Regular reviews of pin sites are essential to check for signs of inflammation, irritation, infection, or pin loosening. Assessment of pin sites and surrounding tissue can be subjective and vary between clinicians [19].  

By involving patients in care planning and evaluation, the nurse can foster a holistic, patient-centered approach, ensuring individualized care. Involving the multidisciplinary team in both acute and community settings equips patients with the skills and resources for effective self-care. 

Patient and Family Education 

Pin site care is essential for reducing infection rates, though techniques vary, and no universal protocol exists to completely eliminate the risk of pin site infections. In recovery, pins may use xeroform or iodine-impregnated gauze [26]. The use of compressive garments under the external fixator bars can help reduce motion around the skin-pin junction [26]. If skin drainage or erythema occurs, perform pin care three times a day until the infection clears [1]. To clean pin sites, recommend using chlorhexidine in an alcohol solution, except for patients with a known sensitivity to chlorhexidine or pre-existing skin conditions like eczema [27]. Use caution with chlorhexidine due to its potential to cause hypersensitivity, generalized allergic reactions, and anaphylaxis [28]. If irritation or allergy occurs, suggest using sterile saline [28].  

Pin Site Care 

Comprehensive guide to cleaning and caring for pin sites [29]: 

1. Wash Your Hands: Use soap and water. 
2. Prepare Cleaning Supplies: Gather your supplies 
   1. A cleaning solution prescribed by your doctor 
   2. Cups to hold the cleaning solution 
   3. Cotton swabs 
   4. Cotton gauze 
3. Wash Your Hands Again: Ensure cleanliness by washing your hands a second time before touching the pin sites. 
4. Massage the Pin Area: Massage the skin around the pin to detach any adhered skin and bring any fluid to the surface for easier cleaning. 
5. Clean Each Pin Site: 
   1. Use a new cotton swab for each pin site. 
   2. Dip the swab in the cleaning solution. 
   3. Clean around the pin site in a circular motion, moving away from the pin. Use fresh swabs until the site is thoroughly clean. 
   4. Dry the area with a new, clean swab. 
6. Clean the Pins: 
   1. Dip a swab or piece of gauze in the cleaning solution. 
   2. Clean the pin itself, paying special attention to any threaded areas. For each pin, ensure to use a fresh swab or a new piece of gauze 
7. Wrap the Pin Sites: Loosely wrap gauze around each pin site for the first few days. 
8. Clean the Fixator and Wires: For those with an external fixator, clean both the fixator and any connecting wires with gauze or cotton swabs dipped in the cleaning solution. 

Recognizing Signs of Pin Site Infection 

• Tenderness: Increased tenderness around the pin site that was not tender prior to the current assessment is often the first sign of infection. 

• Redness: Redness in the area compared to other areas; be careful not to confuse infection redness with the red or purple color from scar formation. 

• Warmth: Increased warmth in the affected area compared to other areas. 

• Swelling: Swelling that may feel hard or fluid-like. 

• Drainage: Varying characteristics such as consistency, color, and smell. Note that amber or tea-colored drainage in lesser amounts is normal. 

• Odor: A noticeable odor indicates that the infection has progressed. 

• Temperature: A fever of 101 degrees or greater taken by mouth or under the arm. Avoid taking your temperature within two hours of physical therapy. It is possible to have a pin site infection without an accompanying fever. 

Conclusion

External fixation is a pivotal tool in orthopedic surgery, used for over 2000 years to treat fractures while preserving soft tissue integrity [1]. The ILIZAROV method, introduced to the West in 1981, has advanced the field by enabling bone lengthening and deformity correction through the body’s natural bone regeneration process [1]. Despite its numerous benefits, such as minimal soft tissue disruption and suitability for patients with compromised healing potential, external fixation presents several complications. These include pin site infections, osteomyelitis, frame, or pin loosening, malunion, and non-union of fractures, as well as risks of soft-tissue impalement, neurovascular injury, compartment syndrome, and refracture around pin sites [18] [22][30]. Effective pin site care and patient education are key in mitigating these risks and ensuring optimal outcomes. 

Nurses play a critical role in supporting patients with external fixator devices and in managing pin sites. They provide essential education to patients and their families about proper pin site care, recognizing infection signs, and promoting self-care [31]. Regular reviews by the orthopedic team and nurses are necessary to assess healing progress and adjust the fixation devices as needed. By involving patients in care planning and utilizing a multidisciplinary approach, nurses ensure individualized, holistic care. Understanding the importance of proper pin site care and early infection detection helps patients achieve better recovery outcomes and reduces the overall burden on the healthcare system. 

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