TRACTION / PIN CARE

 

Early Greek traction device, from a Byzantine edition of Galen's work in the 2nd century AD.

Definition

Traction is force applied by weights or other devices to treat bone or muscle disorders or injuries.

 Purpose

Traction treats fractures, dislocations, or muscle spasms in an effort to correct deformities and promote healing.

 

The purpose of traction is to:

  • regain normal length and alignment of involved bone
  • lessen or eliminate muscle spasms
  • relieve pressure on nerves, especially spinal and
  • prevent or reduce skeletal deformities or muscle contractures

In most cases traction is only one part of the treatment plan of a patient needing such therapy. The physician's order will contain:

  • Type of traction
  • Amount of weight to be applied
  • Frequency of neurovascular checks if more frequent than every four hours
  • Site care of inserted pins, wires, or tongs
  • The site and care of straps, harnesses and halters
  • The inclusion of any other physical restraints / straps or appliances (e.g., mouth guard)
  • the discontinuation of traction

 

Description

Traction is referred to as a pulling force to treat muscle or skeletal disorders. There are two major types of traction: skin and skeletal traction, within which there are a number of treatments.

Skin traction

Skin traction includes weight traction, which uses lighter weights or counterweights to apply force to fractures or dislocated joints. Weight traction may be employed short-term, (e.g., at the scene of an accident) or on a temporary basis (e.g., when weights are connected to a pulley located above the patient's bed). The weights, typically weighing five to seven pounds, attach to the skin using tape, straps, or boots. They bring together the fractured bone or dislocated joint so that it may heal correctly.

In obstetrics, weights pull along the pelvic axis of a pregnant woman to facilitate delivery. In elastic traction, an elastic device exerts force on an injured limb.

Skin traction also refers to specialized practices, such as Dunlop's traction, used on children when a fractured arm must maintain a flexed position to avoid circulatory and neurological problems. Buck's skin traction stabilizes the knee, and reduces muscle spasm for knee injuries not involving fractures. In addition, splints, surgical collars, and corsets also may be used.

Skeletal traction

Skeletal traction requires an invasive procedure in which pins, screws, or wires are surgically installed for use in longer term traction requiring heavier weights. This is the case when the force exerted is more than skin traction can bear, or when skin traction is not appropriate for the body part needing treatment. Weights used in skeletal traction generally range from 25–40 lbs (11–18 kg). It is important to place the pins correctly because they may stay in place for several months, and are the hardware to which weights and pulleys are attached. The pins must be clean to avoid infection. Damage may result if the alignment and weights are not carefully calibrated.

Other forms of skeletal traction are tibia pin traction, for fractures of the pelvis, hip, or femur; and overhead arm traction, used in certain upper arm fractures. Cervical traction is used when the neck vertebrae are fractured.

For tibial traction, a pin is surgically placed in the lower leg (A). The pin is attached to a stirrup (B), and weighted (C). In cervical traction, an incision is made into the head (D). Holes are drilled into the skull, and a halo or tongs are applied (E). Weights are added to pull the spine into place (F). (Illustration by GGS Inc.)

For tibial traction, a pin is surgically placed in the lower leg (A). The pin is attached to a stirrup (B), and weighted (C). In cervical traction, an incision is made into the head (D). Holes are drilled into the skull, and a halo or tongs are applied (E). Weights are added to pull the spine into place (F). ( Illustration by GGS Inc.)

Proper care is important for patients in traction. Prolonged immobility should be avoided because it may cause bedsores and possible respiratory, urinary, or circulatory problems. Mobile patients may use a trapeze bar, giving them the option of controlling their movements. An exercise program instituted by caregivers will maintain the patient's muscle and joint mobility. Traction equipment should be checked regularly to ensure proper position and exertion of force. With skeletal traction, it is important to check for inflammation of the bone, a sign of foreign matter introduction (potential source of infection at the screw or pin site).

Preparation

Both skin and skeletal traction require x rays prior to application. If skeletal traction is required, standard pre-op surgical tests are conducted, such as blood and urine studies. X rays may be repeated over the course of treatment to insure that alignment remains correct, and that healing is proceeding.

Normal results

There have been few scientific studies on the effects of traction. Criteria (such as randomized controlled trials and monitored compliance) do exist, but an outcome study incorporating all of them has not yet been done. Some randomized controlled trials emphasize that traction does not significantly influence long-term outcomes of neck pain or lower back pain.

 

Balanced suspension traction is used to stabilize fractures of the femur. It can be the skin or skeletal type. If it is skeletal, a pin or wire is surgically placed through the distal end of the femur. If it is skin traction, tape and wrapping or a traction boot of the kind described under Buck’s traction is used.

The patient is in the supine position, with the head of the bed elevated fro comfort. As the name suggests, the affected leg is suspended by ropes, pulleys, and weights in such a way that traction remains constant, even when the patient moves the upper body.

Two important components of balanced suspension traction are the Thomas splint and the Pearson attachment. The Thomas splint consists of a ring, often lined with foam, that circles and supports the thigh. Two parallel rods are attached to the splint and extend beyond the foot. A Pearson attachment consists of a canvas sling that supports the calf.

Parallel rods lead from the pin sites on the distal and of the attachment for the rope. Traction to the femur is applied through a series of ropes, pulleys, and weights. These weights hang freely at the foot off the bed.

The skin should be inspected frequently to identify problems early. The ring of the Thomas splint can excoriate the skin of the groin. Special padding may have to be used. Again, the foot should always be at a right angle on the footrest to prevent footdrop. If pins are used for fixation, aseptic technique must be used around pin sites until they have healed. From then on, clean technique can be used. The pin sites are cleansed carefully with soap and water and rinsed thoroughly, unless this varies from policy. An antiseptic, such as povidone-iodine ointment, may then be applied. Dressings are usually not required. You should, however, constantly assess for infection at the pin sites. Indications include redness, heat, drainage, pain, or fever.

Skull Tongs Traction

Skull tongs are used to immobilize the cervical spine in the treatment of unstable fractures or dislocation of the cervical spine. Although Crutchfield tongs were used almost exclusively in the past, Gardner-Wells skull tongs are in wide use. Some think these are less likely to pull out than the Crutchfield tongs. The patient is prepared for either type with a local anesthetic to the scalp. The tongs are surgically inserted into the bony cranium, and a connector half-halo bar is attached to a hook from which traction can be applied.

The patient is supine and is usually on a special frame instead of the regular hospital bed. If a hospital bed is used, two or more people are required to assist the patient with any turning movements. The head of the bed may be elevated to provide counter traction.

Because patients remain in this type of traction for an extended period, observe the precautions taken for the patient in other types of skeletal traction. Difficulties with the performance of activities of daily living, infection at the tong sites, and restlessness and boredom are common. It is useful to teach the patient range-of-motion exercises, provide good nutrition and suggest recreational or occupational activities.

Halo Traction

Halo traction provides stabilization and support for fractured cervical vertebrae. The surgeon inserts pins into the skull. A half circle of metal frame connects the pins around the front of the head. Vertical frame pieces extend from a halo section to a frame brace that rests on the patient’s shoulders. The halo traction allows the patient to be out of bed and mobile while stabilizing the cervical vertebrae could injure the spinal cord.

Buck’s traction: This is straight traction placed on the lower extremity to help reduce a hip or femur fracture. Buck’s traction can also reduce or prevent muscle spasms caused by a hip or femur fracture. Buck’s traction can be applied with adhesive tape secured with an elastic bandage and attached to a pulley and weight. A manufactured “boot” is also available. The boot wraps around the leg and is secured with straps. It is then attached to the pulley and weight system in the same way as the adhesive traction. Care must be taken to maintain alignment and watch for any skin breakdown that may occur. Maintenance of the pulley system is very important. The line must not become tangled in the bed linen and the weights must hang freely.

Bryant’s traction: This is very similar to Buck’s traction and is used for reduction of femur fractures or to immobilize the hip joints in children who weigh less than 40 pounds. In Bryant’s traction both the child’s legs are wrapped and a spreader bar is placed to separate the limbs. Two sets of pulleys and weights are then attached overhead to lift the child’s buttocks off the mattress by about 1–2 inches. This traction maintains alignment, helps reduce any fracture, and immobilizes the child. Bryant’s traction places the child’s skin at risk in several areas. The client’s back, elbow, coccyx, and head are vulnerable to skin irritation and breakdown and must be closely monitored. This position also raises concerns regarding elimination, feeding, and hydration. All these basic needs must be met, as well as the child’s mental and emotional needs related to immobility, and the need for stimulation.

Russell’s traction: This is a balanced traction arrangement of pulleys, lines, slings, and weights used to treat knee or hip injuries in adults and to reduce femur fractures in children.

Russell’s traction is applied to the client’s lower leg. A sling is placed under the client’s knee and two pulley and weight setups are applied to support the knee sling. Assessment of the skin is critical in this type of traction because of the possibility of skin breakdown on the coccyx, back, elbows, head, and parts of the noninjured extremity, especially the heel. Footdrop is also a risk and exercises as well as foot support should be used. A client in this type of traction is  also at risk for deep vein thrombosis, respiratory complications, and constipation.

Cervical traction: Cervical traction can be applied in several different ways. Medics often  apply a hard cervical collar on clients with suspected cervical injury. This type of collar is generally used only for short periods of  time. Care must be taken to maintain good alignment when placing this type of collar. The soft cervical collar or Philadelphia collar is used primarily for soft tissue or ligament damage. It is often prescribed for comfort and support of the neck and head. It is not used for fracture alignment or immobilization.

Care should be taken to properly fit this collar. It can cause skin breakdown if not fitted correctly and will not provide proper support if it is too large or too small.

Cervical traction can also be applied using a cloth collar attached to a weight and pulley system. It is primarily used to relieve muscle spasms and nerve compression in the neck.

Neurologic assessment and skin assessment are extremely important in this type of traction due to the vulnerability of the area. The client is not usually placed in this traction for long periods of time.

Pelvic belt or girdle: This type of traction is used to relieve pain caused by muscle spasm or  nerve impingement in the lower back. A girdle is placed around the client’s hips and a pulley and weight system is then attached to the girdle, extending down over the foot of the bed. This maintains alignment of the back, hips, and legs and provides gentle pulling on the lower back. Pelvic traction can be used in the home setting. The nurse should reinforce client teaching regarding the proper use of this type of traction.

Humerus traction: Humeral traction is used to stabilize upper arm fractures and shoulder dislocations. The upper arm is held at a 90° angle from the body and the forearm is flexed. Traction is placed to pull on the hand and the elbow. This allows for a gentle pull to realign the fracture or dislocation. Any client in traction is at risk for skin breakdown at the injury site and also in areas with a thin layer of skin over bony prominences such as the shoulder, back, coccyx, heels, and head. A thorough skin assessment must be performed regularly to prevent skin breakdown.

ASSESSMENT

1. Assess skin integrity to evaluate and treat any actual or potential skin breakdown in the traction area.

2. Assess neurovascular status in the affected  areas to evaluate any potential or actual neurovascular compromise.

3. Assess the client’s understanding of and need for the treatment to provide any client education and support needed.

4. Assess for complications of traction and immobility in order to determine a plan of treatment.

DIAGNOSIS

Ø     Pain

Ø     Impaired Physical Mobility

Ø     Risk for Impaired Skin Integrity

Ø     Anxiety

Expected Outcomes:

1. The affected body part will have adequate neurovascular perfusion as evidenced by color, capillary refill, movement, and sensation.

2. The client will understand the reason for the traction and be able to cooperate in his care and treatment.

3. The client will experience a minimum of discomfort and trauma secondary to the traction.

Equipment Needed

• Pain medication, if necessary

• Overhead traction bars if needed

• Weights in various pounds

• Traction line and pulleys

• Skin traction device as ordered by the physician or qualified practitioner

• Adhesive traction tape and elastic bandage, if appropriate

• Razor, if needed

Benzoin solution, if needed

CLIENT EDUCATION NEEDED:

1. Explain the need for the traction. Discuss the continuing injury to the tissues, muscles, and blood supply that can occur without immobilization.

2. Assure the client that this is a necessary, but usually temporary, procedure that will aid in the healing process and that every measure will be taken to make the client as comfortable as possible during the procedure.

3. Explain the procedure step by step and ask questions. This will help the client anticipate what will occur. Asking questions will provide a sense of control and help alleviate anticipatory anxiety.

4. Explain that some discomfort may occur, and outline options for pain control.

5. Explain the possible complications of traction and prolonged immobilization. Teach the client to self-assess for these complications and to report them to the staff. This increases the client’s sense of autonomy and control.

6. Teach the client appropriate range of motion exercises to prevent muscle atrophy as much as possible.

SKIN TRACTION

Skin traction requires pressure on the skin to maintain the pulling force across the bone. A maximum of 5 kg of weight may be applied using this method. More than 5 kg of weight will result in the skin becoming excoriated with blister formation and pressure sores caused by slipping of the tightly wrapped strapping. Wrapping the straps more tightly to prevent slipping increases the risk of creating a compartment syndrome in the injured extremity.

If more than 5 kg of weight is needed to control the fracture, use skeletal traction instead.

Do not apply traction to skin with abrasions, lacerations, surgical wounds, ulcers, loss of sensation or peripheral vascular disease.

Technique

1 Clean the limb with soap and water and dry it. If available, use a commercial traction set, which will contain adhesive tapes, traction cords, spreader bar and foam protection for the malleoli. This is usually not available, so improvise the apparatus as described below.

2 Measure the appropriate length of adhesive strapping and place it on a level surface with the adhesive side up. Ask the patient about adhesive tape allergy before applying.

3 Place a square wooden spreader of about 7.5 cm (with a central hole) in the middle of the adhesive strapping (Figure 17.1).

Figure 17.1

 

4 Gently elevate the limb off the bed while applying longitudinal traction. Apply the strapping to the medial and lateral sides of the limb, allowing the spreader to project 15 cm below the sole of the foot (Figure 17.2).

Figure 17.2

 

5 Pad bony areas with felt or cotton-wool. Wrap crepe or ordinary gauze bandage firmly over the strapping (Figure 17.3).

Figure 17.3

 

6 Elevate the end of the bed, and attach a traction cord through the spreader with the required weight (Figure 17.4). The weight should not exceed 5 kg.

Figure 17.4

 

Complications

1  Allergic reactions from the adhesive material

2       Blister formation and pressure sores from slipping straps

3       Compartment syndrome from over-tight wrap

4       Peroneal nerve palsy from wraps about the knee.

 

SKELETAL TRACTION

 

Apply skeletal traction by placing a metal pin through the metaphyseal portion of the bone and apply weight to the pin. It is important to place the pin correctly to avoid injury to vessels, nerves, joints and growth plates. The amount of weight to be used depends on the fracture but, generally, between 1/10 and 1/7 of body weight is safe and adequate for most fractures.

 

Technique

 

1       Wash the skin with antiseptic solution and cover the surrounding area with sterile drapes. Infiltrate the skin and soft tissues down to the bone with 1% lidocaine on both the entrance and exit sides.

2       Make a small stab incision in the skin and introduce the pin through the incision horizontally and at right angles to the long axis of the limb. Proceed until the point of the pin strikes the underlying bone (Figure 17.5). Ideally, the pin should pass through the skin and subcutaneous tissue, but not through muscles.

Figure 17.5

 

3       Insert the pins with a T-handle or hand drill (Figure 17.6). Advance the pin until it stretches the skin of the opposite side and make a small release incision over its point (Figure 17.7).

Figure 17.6

 

Figure 17.7

 

4       Dress the skin wounds separately with sterile gauze. Attach a stirrup to the pin, cover the pin ends with guards and apply traction (Figure 17.8).

Figure 17.8

 

5       Apply counter-traction by elevating the appropriate end of the bed or by placing a splint against the root of the limb.

Sites of pin placement

Proximal tibia

Insert the pin 2 cm distal to the tibial tubercle and 2 cm behind the anterior border of the tibia (Figure 17.5). Begin on the lateral side to avoid the common peroneal nerve.

 

Calcaneus

Insert the pin 4.5 cm inferior and 4 cm posterior to the tip of the medial malleolus (Figure 17.9). Begin on the medial side to avoid damage to the posterior tibial artery and nerve and to avoid entering the subtalar joint.

Figure 17.9

Distal femur

Insert the pin from the medial side, in the mid-portion of the bone, at the level of the proximal pole of the patella. This should be just proximal to the flare of the femoral condyles and posterior to the synovial pouch of the knee joint.

Olecranon

Insert the pin from the medial side of the ulna 2 cm from the tip of the olecranon and 1 cm anterior to the posterior cortex. This should avoid the ulnar nerve which passes through the groove inferior to the medial epicondyle of the humerus (Figure 17.10).

Figure 17.10

Complications

Pin tract infection is common:

The skin will look inflamed with drainage about the pin; the pin will eventually loosen

Control the infection with wound cleansing, dressing changes and antibiotics

If this fails, place a new pin at a different site or discontinue traction

 

Joint stiffness is prevented by active and active-assisted exercise.

 

SKULL TRACTION

Use skull traction for traumatic and infectious conditions in the cervical spine. Apply it to the skin using head halter traction or to the skull bones using Gardner-Wells tongs or a halo device.

Technique: Gardner-Wells tongs

1       Place the pins below the brim of the skull in line with the external auditory meatus, 2–3 cm above the top of the pinna (Figures 17.11 and 17.12).

Figure 17.11

 

Figure 17.12

Figure 17.12

 

2       Prepare the patient’s scalp by shaving the hair and washing the skin with an antiseptic solution.

3       Position the tongs correctly and mark the pin entrance points.

4       Infiltrate the pin sites with 1% lidocaine and make stab wounds through the skin and down to the bone. Insert the pins by alternately tightening one side and then the other, until 3.6 kg of torque is applied. Determine the tightness with a special torque screwdriver or by tightening the pins, using two fingers only to grip the screwdriver.

5       Dress the wounds with sterile gauze and apply the appropriate traction weight. Tighten the pins again once on the following day, then leave them alone unless they are loose.

Technique: halo traction

1       Determine the ring size by measuring the head circumference or by trial. The clearance should be 1–2 cm at all points.

2       Carefully place the patient’s head off the end of the bed and hold it with a special headholder, or with an assistant. The halo should be just above the eyebrows and ears (Figure 17.13).

Figure 17.13

 

3       Use two pins posterior-laterally and two in the lateral third of the forehead. These may be placed as far back as the hairline for cosmetic reasons, but should be anterior to the temporal muscle (Figure 17.14).

Figure 17.14

Figure 17.14

 

4       Shave the hair under the selected sites for the pin holes, wash the skin with antiseptic solution and infiltrate with 1% lidocaine through the four holes selected.

5       Advance the pins to finger tightness while keeping the halo placement symmetrical. Ask the patient to keep his/her eyes closed during the procedure to avoid pulling the skin upward and preventing eye closure once the pins are tight.

6       Next, tighten the pins sequentially across the diagonals. If a torque screwdriver is available, tighten the screws to 34–45 cm/kg. If not, twist the screws tight while holding the screwdriver with two fingers.

7       Tighten the screws once after 1–2 days and thereafter only if loose. Traction can now be applied or the patient can be placed in a halo jacket.

 

EXTREMITY TRACTION

The following are examples of traction arrangements for the upper and lower extremities.

Figure 17.15: Dunlap’s traction

Figure 17.16: Olecranon traction

Figure 17.17: Perkin’s traction

Figure 17.18: Perkin’s traction

Figure 17.19: Russell’s traction

Figure 17.20: 90/90 balance suspension

 

Figure 17.15

 

Figure 17.16

Figure 17.16

 

Figure 17.17

Figure 17.17

 

Figure 17.18

Figure 17.18

 

Figure 17.19

Figure 17.19

 

Figure 17.20

Figure 17.20

NURSING TIPS

• Get adequate help when turning any client while in traction or in a supportive brace.

• Make certain that nutrition and elimination issues are addressed; many clients become constipated because of pain medication and inactivity, adding to their discomfort.

• Adequate pain relief is essential in dealing with clients in traction.Muscle spasms and bone pain can be excruciating if the pain is not being properly addressed.

• The basic principle of traction is proper alignment. If the body part is not in alignment the pain will increase considerably.Make certain that all lines are straight, all weights are free to move, all extremities are straight and, if indicated, client should be properly supported by pillows and other supportive devices.

• Make certain that body jackets or braces are properly fitted and no skin is caught in the sides or pinched where the jacket fits together.

• Gain client compliance by taking the time to teach all the important points of dealing with traction or a brace. Listen to the client’s concerns and take time to answer the client’s needs.

• Recreational therapy can offer diversional activities to clients who are in traction for long periods of time.

Maintaining Traction

ASSESSMENT

1. When assessing traction or preparing for the reapplication of traction, assess the client for pain, position, alignment, skin condition, overall health considerations, circulation, sensation, and movement of the injured extremity. This will help determine changes from baseline, and help detect  any emerging complications from the traction.

2. Assess pain location, intensity, and duration. Discuss steps the client has taken to relieve the pain. Allows pain management and client input into pain management.

3. Assess the client’s position to make sure that it supports the traction.

4. Assess alignment to reduce pain and support the extremity.

5. Conduct an initial assessment of the general skin condition of the injured extremity to establish the baseline parameters prior to and during traction. It is important to record any changes in the skin color, edema, skin breakdown, erythema, or

blisters.

6. Assess the client’s overall health condition to aid in determining the plan of care for the client.

7. Assess sensation and movement to note any change from baseline.

DIAGNOSIS

Ø     Impaired Physical Mobility

Ø     Pain

Ø     Risk for Impaired Skin Integrity

PLANNING

Expected Outcomes:

1. Client traction will be maintained for a given period of time.

2. Client will maintain body alignment while in traction.

3. Client will maintain good skin condition, circulation, and sensation in the extremity in traction.

Equipment Needed

• Pain medication

• Traction equipment

CLIENT EDUCATION NEEDED:

1. Explain to the client the need for traction, the  need for maintaining body alignment, and the overall care plan. If appropriate, remind the client  that the traction is a temporary measure prior to surgery.

2. Teach the client to report any changes in feeling and sensation in the limb, especially increases in pain, numbness, tingling, or coldness.

3. Discuss with the client common emotional feelings that can occur with immobility, including sensory deprivation, loss of control, and decreased socialization.

EVALUATION

• Client traction is maintained for a given period of time.

• Client maintains body alignment while in traction.

• Client maintains good skin condition, circulation, and sensation in the extremity in traction.

DOCUMENTATION

Nurses’Notes

• In addition to the assessment of the client and establishment of a baseline, describe the type of traction, type of pin inserted into the bone, the amount of weights placed on the traction device, and when the procedure was completed.

• Document any medication that was given for the procedure and how effective that pain medication was in decreasing the pain.

• Document what the insertion sites look like and that pin care was completed.

NURSING TIPS

• Organize the traction prior to application. Having all the parts of the traction set up at the bedside will make application easier and the process smoother.

Premedicate the client. This will aid in compliance, increase trust, and make the task easier for all participants.

• Educate the client prior to applying the traction. This helps in compliance and understanding goals.

• Perform routine pin care, or as ordered to reduce the risk of infection at the pin site, and reduce the client’s length of stay.

• Assess the pin site for redress, as needed.

• Pillows can be used generously to support the fractured limb, maintain the client’s position, and promote comfort.

 

PIN

Background

Metal pins are used to apply skeletal traction or external fixation devices in the management of orthopaedic fractures. These pins protrude through the skin and are therefore described as 'percutaneous' and much has been written on the management of the associated skin wound. The way in which percutaneous pins are treated may affect the incidence of pin site infection. Recommendations for care are not necessarily evidence based. This review set out to summarise the research evidence on the effect of pin site care on infection rates.

 

Objectives

To assess the effect on infection rates of different methods of cleansing and dressing orthopaedic percutaneous pin sites.

Search strategy

The following electronic databases were searched: Medline (from 1966), the Cochrane Central Register of Controlled Trials (2003 issue 1) and the Wounds Group Specialised Trials Register (March 2003). In addition reference lists of review articles and relevant trials were also searched and some handsearching undertaken.

Selection criteria

All randomised controlled trials (RCTs) in people comparing the effect on infection rates of different methods of cleansing or dressing orthopaedic percutaneous pin sites were evaluated.

Data collection and analysis

Two reviewers independently assessed the citations retrieved by the search strategies for reports of relevant RCTs.

Main results

Only one trial was eligible for inclusion in the review. Henry (1996) compared cleansing with 0.9% saline, cleansing with 70% alcohol and no cleansing and found significantly fewer infections in pin sites which had not been cleansed. There is very little evidence as to which pin site care regimen best reduces infection rates. Clearly there is a need for large RCTs to determine the best method of pin site management.

Synopsis

No strong evidence about insertion, care and removal techniques for pins used for attaching traction or other fixation devices into broken arms and legs. Metal pins are sometimes used to apply traction or other external fixation devices into broken arms or legs. These pins pierce through the skin. The way they are inserted, cared for and removed may affect the frequency of infection. Different solutions are used for cleaning around pins, scabs may or may not be removed and massage might be used to drain fluids around the pin. There are different kinds of pins, loosening regimes and removal techniques. However, the review of trials found that there is little strong evidence to show which pin care techniques have the best outcomes.

Management of pin sites

 

Care of pin sites can be split into a number of areas:

 

Immediate postoperative care Immediate postoperative dressings should be absorbent, easy to remove or non-stick, conformable, relatively cheap and available in both the hospital and the community. The dressing should not require tape to secure it.

Although many nurses remove postoperative dressings 48 hours after surgery there seems to be no reason for this. Hence, for reasons of patient comfort and early assessment of potential problems, it is recommended that the pin-site entrance and exit wounds be inspected within the first 24 hours. Similarly, all pin sites should be re-dressed after 24 hours, as there is likely to be exudate in the initial postoperative period.

There is no reliable evidence to support the use of any of the cleansing solutions used to clean/dress pin sites. It is therefore recommended that no solution be routinely used in the immediate postoperative period. If necessary, normal sterile saline or water can be used to remove exudate or dried blood from the area around the pins.

Once the pin sites have been inspected, a dressing that applies a small amount of pressure to prevent tenting of the skin along the pin should be applied. The dressing should be kept in place and removed infrequently when required to inspect the wound, for example, if there is increased pain or exudate. An aseptic technique must be rigorously maintained at all times during pin-site care and observation.

Increased tenderness or pain at the pin site should always alert the carer to potential problems; as should an increased level of exudate, presence of pus, an odour from the site or increased inflammation. This should be coupled with general observations for infection, such as low-grade pyrexia, increased pulse and respiratory rate. The presence of other pathology or infections in other parts of the body, for example, urinary tract infection, should be of concern, as will a raised erythrocyte sedimentation rate, which may indicate the presence of chronic infection.

Subsequent care of the entrance and exit wound site

A range of solutions is available to cleanse the exit and entrance wound around the pin but those used in hospital are typically alcohol based or simple saline. Application of any cleaning fluid must be done with a non-shredding material, such as gauze.

It is vital that the wound is left dry after cleaning: alcohol evaporates after application but is toxic to healthy tissue. It is recommended that sterile saline be used to remove exudate or dried blood, if a cleaning agent is required. The wound itself should not be moistened.

While in hospital the patient should shower, rather than bath, and there seems little support for the practice of sterile cleansing of the pin sites after a shower. In addition, many patients attend hydrotherapy with fixators in place and do not seem predisposed to infections.

Gentle removal of the scabs is encouraged: this will make the wound visible and encourage free drainage of exudate, which may harbour infection if allowed to collect below the skin. This is considered useful with mono-frames and larger screws rather than fine wires, particularly when the fixator is applied to areas such as the pelvis.

Cleaning the pins and guidelines for daily living

 

Cleaning the metal work of the fixator both to remove social contamination and wound exudate is important. At home patients are taught to have a shower regularly and to dry around the pins and fixator frame with a clean towel used for this purpose only, which is washed after each use. If exudate remains after the shower, this can be removed using sterile saline or boiled water at home. Pins are cleaned by wiping in the direction away from the exit wound.

Alcohol and iodine-based products should be avoided as they will accelerate corrosion of the metal of the fixator and cause skin staining.

 

Definitions of infection and management

 

One of the most difficult aspects of pin-site care is recognising the differences between the normal healing process and the development of an infection.

 

Definitions developed from the consensus conference (Lee-Smith et al, 2001) are listed below:

 

Reaction

This describes the normal changes that occur at the pin-skin interface in the initial 72-hour period following insertion of the pin. Typically, these include a change in colour from the patient's normal skin tone, an increase in local heat and loss of serous fluid or blood. These changes are expected to subside.

 

Colonisation

Colonisation is indicated by a persistent change in skin colour (redness), increased warmth, increasing exudate or associated pain at one or more pin sites. Microbiological swabs will show a growth of local flora of between 103 and 104 organisms/cm2.

 

Infection

 

Infection is the presence of the symptoms described above, with a swab culture showing a growth of flora of between 105 and 107 organisms/cm2. There may also be visible drainage of pus and the pin may be loose. However, the presence of infection deeper in the tissues may not be apparent on the skin surface, so any patient with systemic symptoms of infection should be investigated.

 

Patient, carer and parental support, information and teaching

 

For many patients the external fixation equipment is applied as a result of trauma, so there is no time to give preoperative information. For others, including children, considerable time should be spent helping them and their families to understand what has and will happen.

 

Fixators appear grotesque and painful and this can have a considerable impact on self-image. Information needs to be available in written, oral and more visual formats, and needs to be consistent. Patients can be given information about specialist support groups, such as the Ilizarov-wearers' support group at www.ilizarov.org.uk. Meeting other patients may also be helpful, as is an increase in general public awareness.

 

Patient involvement

 

Patients may have different perspectives on health care processes, priorities and outcomes from health professionals. The involvement of patients or patient representatives in the development of guidelines is important to ensure that they reflect patients' needs and concerns. Patients also have an important role in promoting guideline implementation, and it is essential that they should have access to information on the recommendations of published guidelines

ASSESSMENT

1. Assess the client’s knowledge of the procedure. Answer questions regarding previous personal experiences or friends and family who have been placed in traction. Helps provide education about the procedure.

2. Assess knowledge base, discuss the risk of continuing injury to the tissue, muscles, and blood supply that can occur without the aid of immobilization. Helps the client accept the need for traction.

3. Assess the client’s general health, allergies, and skin condition. Inspect the skin for evidence of atrophy, abrasions, edema, and other circulatory disturbances.

Helps to decrease the risk of skin breakdown and infection.

4. Document the neuromuscular status of the extremity and any evidence of skin problems to record baseline assessments.

5 Assess the client’s current level of mobility. Consider how the pins will affect the client’s mobility  and self-care ability. Helps plan interventions to maintain as much independence in self-care as possible.

DIAGNOSIS

Impaired Physical Mobility, related to mechanical devices restricting mobility

Risk for Injury

Body Image Disturbance due to mmobility

PLANNING

Expected Outcomes:

1. Client will have pins placed under the direction of the medical caregiver.

2. Client will experience a decrease in the amount discomfort related to the fracture.

3. Client will be able to perform activities of daily living, positioning, and communication with assistance.

Equipment Needed:

• Pain medication

• Sterile pins (see Figure 10-8-2) and a sterile pin insertion kit

• Local anesthetic obtained from the pharmacy per physician’s or qualified practitioner’s orders

• A topical cleanser such as povidone-iodine for

CLIENT EDUCATION NEEDED:

1. Explain the need for the pins. Discuss the continuing injury to the tissues, muscles, and blood supply, which can occur without immobilization.

2. Assure the client that this is a necessary, but usually temporary, procedure that will aid in the healing process and that every measure will be taken to make the client as comfortable as possible during the procedure.

3. Explain the procedure step by step and ask questions. This will help the client anticipate what will occur. Asking questions will provide a sense of control and help alleviate anticipatory anxiety.

4. Explain that some discomfort may occur, and outline options for pain control.

5. Prepare the client for the procedure and explain that there will be discomfort and pain during the placement of the pin, but the pain is transitory. Discuss pain management measures.

6. Reinforce the need for frequent position changes and the need to give skin a chance to rest to reduce the risk of complications.

EVALUATION

• Client had pins placed, under the direction of the medical caregiver.

• Client experiences a decrease in the amount of discomfort related to the fracture.

• Client is able to perform activities of daily living, positioning, and communication, with assistance.

DOCUMENTATION

Nurses’Notes

• Pre- and post-evaluation of all observations previously discussed is vitally important for the oncoming shifts to give them a baseline for observations.

Documenting the condition of the traction, pins, weights, as well as the client’s emotional status, is important.

Medication Administration Record

• Type, amount, time, and route of pain medication used before and during pin insertion.

NURSING TIPS

• Maintenance pain medication may be different and may sustain the client over a longer period of time than initial procedure medications.

• Giving medication prior to any other procedure, i.e., bed changing, position changes, or x-rays, etc., is helpful in controlling pain problems.

• Make certain all lines of traction are not knotted or jammed in the bed or pulley and are not laying on the floor. These errors decrease the effectiveness of the procedure and may delay surgery.

• Always make certain that you have an adequate number of pillows available at all times for position changes and for comfort measures.

Premedicate prior to the procedure and during difficult bed changes or during x-rays.

• Use of overhead traction bars aids clients in helping themselves to reposition, to sit on a bedpan, and to maintain proper alignment of the affected leg.

• Stay with the client during the procedure, even if several physicians or qualified practitioners are there observing; it is important that you pay attention to the client and not the procedure, using the trust that you have already obtained to comfort and communicate with the client.

• Evaluate anxiety frequently. Although the procedure was successful the client may still be disturbed by the immobility and sensations imposed by the traction. It is important to show the client his abilities, and not focus on the limitations.

• If halo traction is used, keep traction removal equipment at the bedside in case rapid removal of the halo vest is necessary to perform cardiopulmonary resuscitation (CPR).