…Postoperative management of cases treated with ESF (External Skeletal Fixator) involves wound management, maintenance of the apparatus, control of activity, and follow-up examinations.

   A major controversy among surgeons regarding the postoperative care of ESF’s involves cleaning of the pin entry and exit points.  Some surgeons advocate daily cleaning regardless of appearance, and others advocate cleaning only when significant discharge is present.  Each perspective represented has its basis.  In general, we advocate daily observation of the pin sites to evaluate the amount and type of drainage present.  Pin sites typically will have a small amount of serous or serosanguinous discharge that will intermittently crust over and then drain again.
If the drainage extends beyond the pin site to the surrounding skin, we encourage gentle cleaning of the drainage (crusts) and pin site with… soap and water, or peroxide.

Fixation care:
…At home you need to clean pin sites twice a day
…Clean pin sites with gauze soaked with hydrogen peroxide… Clean pin sites in the direction from insertion to skin around pin.  Never touch one pin site with gauze used on another pin.

Pin site care:
   1. Pin site care should be done daily unless otherwise specified by your doctor
   2. Wash your hands with soap and water before beginning
   3. Gather materials you will need: hydrogen peroxide, cotton tipped applicators, gauze pads
   4. Use one cotton tipped applicator dipped in peroxide per pin site and clean around each site using a circular motion.
   5. Work hard to remove all crusting and dried drainage
Signs of infection:
     · Temperature over 101° F
     · Redness, warmth, or swelling at pin site
     · Thick white, yellow, or green discharge
     · Bad smell from pin site
     · Severe pain at pin site

William C. Oppenheim, MD Millburn, NJ
Andrew M. Hutter, MD Millburn, NJ
James C. Krieg, MD Iowa City, IA

A study was designed to develop a successful protocol for prevention of complications (with external fixators).
To reduce complication rate, a protocol was developed that involved daily hydrogen peroxide cleansing for two weeks, then washing with soap and water.  The authors found that limited manipulation of the interface and control of soft tissue motion is the optimal way of ensuring maintenance.

Moderator:  Lorraine J. Day, MD Rancho Mirage, CA

NOTE: Hydrogen peroxide is the routine method and should be used when physician order does not specify otherwise
1. Hydrogen Peroxide
a. Using applicators dipped in hydrogen peroxide, gently cleanse around each pin site, moving from pin outward and using a new applicator for each pin.  Repeat as necessary to remove crusts and exudates.
b. Rinse each pin site

Use of solutions:
The most commonly recommended solution is hydrogen peroxide, either in half or full strength (Ed. note; full strength hospital grade peroxide is over 6%.  Commercially available peroxide is limited to 3%, thus it is already half strength diluted) and in some cases followed by a rinse of either saline solution or water (Althoff 1984, Celeste et al 1984, Davis 1989, Morris et al 1988, Sisk 1983, Sproles 1985).  However, hydrogen peroxide in concentration above 6% is caustic.

Sproles (1985) only recommended alcohol for cleaning the pins, not the skin…
…normal saline (Farell 1986, Genge 1986, Gill and LaFlamme 1984)  This is a safe non-irritant and no-toxic solution and although it has NO ANTISEPTIC QUALITIES, it dilutes the concentration of bacteria (Morgan 1990).

Soap and water is another favoured solution by Green (1983) and Trigueiro (1983).  If a patient is agile can wash around the pins with soap and water in the shower (Green 1983)

Manipulation to clean the crust may be more important than the cleaning agent used (Fisher 1979, Green 1983)

The fluid that forms around pins in local tissue drains to the external surface, and if left there, forms crusts.
When there is increased tissue involvement, the formed is also increased (Fischer 1979).  By leaving crusts intact, a natural barrier to the outside environment is formed (Sproles 1985).  If crusts are allowed to accumulate around the pin a build up of fluid under the crusts occurs, which may cause a secondary bacterial infection (Mears 1980).

The only statement found consistently is that crusts should be removed to allow free drainage (Celeste et al 1984, Green 1983, Sisk 1983, Sproles 1985)

Daily:
· Wash hands thoroughly, using soap and water
· DO NOT use an antiseptic solution unless your doctor says so
· Using a new cotton tipped applicator, clean the site and skin around it.  All crusted matter must be removed completely
· Half strength peroxide may be used
· Always rinse site with Saline (Water) if Peroxide is used
· Push skin away from pin to prevent skin from sticking to pin
· Dry site with a clean cotton tipped applicator
Leave the site open to the air