External fixation: living with an external fixator and caring for pin sites

An external fixator is a device that holds bones steady from outside the body. A hospital patient leaflet explains that it is used to treat fractures, and to reconstruct or fuse bones and joints that are deformed or damaged. Instead of a plate or nail placed inside the limb, the support is a frame outside the skin, connected to the bone by fine tensioned wires or metal pins that pass through the soft tissues.

There are two broad kinds, according to the leaflet. A circular external fixator encircles the leg, while a monolateral external fixator lies next to it. When you leave hospital, each pin or wire will have a sponge and clip attached, where the sponge helps protect the pin site and the clip keeps the sponge in place.

External fixation is used in different situations. It may be applied urgently to stabilise a serious fracture or soft tissue injury, or it may be planned over a longer period for correcting deformity, lengthening or reconstructing a limb. How long the frame stays on depends on the reason it was applied, and your surgical team will explain the plan for your case, including any adjustments and when it will be removed.

Pin sites are the places where each wire or half pin passes through the skin. A national orthopaedic hospital patient leaflet explains that because the wires and half pins pass through the skin and muscles into the bone, an infection on the skin can spread down into the bone. A second NHS hospital leaflet says pin site infections range from minor inflammation to a serious bone infection called osteomyelitis, which is why identifying and treating them early matters.

You will be taught how to care for your pin sites before you leave hospital, and leaflets are intended as a reminder. Looking after the fixator at home can feel daunting, and teams say it is normal to feel this way. Written instructions vary slightly between hospitals, so use the ones your own team gave you and ask if anything is unclear.

The hospital leaflets describe three categories, which affect how often the sites are cleaned and when to ask for help.

The details differ between units, so this is a general outline of what the leaflets describe rather than a set of instructions. Hand washing is described as the single most important step in preventing bacteria reaching the pin sites. Teams usually ask you to gather the equipment first, wash and dry your hands, and use a clean gauze swab for each site, wiping the skin around the wire and then cleaning the wire from the skin upwards. A scab or crust between the wire and the skin should not be picked off, as it will lift and fall away by itself.

Cleaning solutions mentioned include chlorhexidine in alcohol or saline for people who are sensitive to chlorhexidine. Sometimes people are allergic to the solutions or dressings, and a skin reaction should be reported to the team. Once the skin is dry, a new sponge or foam dressing is placed and secured with the clip, with enough padding between the clip and the skin to avoid a pressure sore.

• Remove dressings before showering and use a mild soap.

• Use one towel for the body and a separate one, washed at a high temperature, for the affected limb.

• Swimming or hydrotherapy is generally recommended on the day you clean your pin sites, and not if the sites are inflamed or infected.

• Always check your pin sites when you clean them, and in between if you are worried.

A national orthopaedic hospital leaflet says that if the signs of infection are present, you should clean and redress the pin site, start oral antibiotics and keep the limb elevated, and that if you do not have antibiotics or are unsure whether a site is infected you should see your GP. If it does not improve after taking antibiotics, or you want advice, contact the limb reconstruction team. The second leaflet says to contact the limb reconstruction service as soon as possible if you have signs of infection.

If you are in severe pain, the limb is very swollen and red and you feel unwell, both leaflets advise attending your local Urgent Care Centre or Accident and Emergency department. If you cannot reach your team and have an urgent problem, you should see your GP, an Urgent Care Centre or your local emergency department. Always tell staff about any medicine allergies.

Frames are bulky, and the first weeks can be tiring. You may have physiotherapy to maintain movement in nearby joints and muscle strength, and your team will tell you how much weight you may put on the limb. Irritated pin sites near the knee, ankle or elbow can ooze after exercise or increased activity, which leaflets note is common; extra padding can reduce the movement of skin around the wire.

Sleep, clothing, travel and work can all be affected. Loose clothing that fits over the frame, padding to protect others and the frame from knocks, and planning for transport are practical matters to raise in advance. Support from the occupational therapist and the specialist nurse can help, and talking to others who have had a frame can be reassuring.

External fixation is carried out in NHS trauma and orthopaedic units, and complex limb reconstruction is concentrated in specialist centres. Private orthopaedic surgeons also apply and manage frames. Whichever route, make sure you know the name of the nurse or service to contact for pin site problems, how to reach them out of hours and what to do if you cannot reach them.