| Skill 9-19 | Caring for a Patient With an External Fixation Device | ||||||||||||||||||||||||||||||||||||||||||||||||
External fixation devices are used to manage fractures with soft tissue damage and complicated fractures, correct defects, treat nonunion, and lengthen limbs (Hinkle et al., 2022). External fixators consist of one of a variety of frames to hold pins that are drilled into or through bones. External fixators provide stable support for severely crushed or splintered fractures and access to, and treatment for, soft tissue injuries. The use of these devices allows treatment of the fracture and damaged soft tissues while promoting patient comfort, early mobility, and active exercise of adjacent uninvolved joints. Complications related to disuse and immobility are minimized. Nursing responsibilities include reassuring the patient, maintaining the device, monitoring neurovascular status, promoting exercise, preventing complications from the therapy, preventing infection by providing pin-site care, and providing teaching to ensure compliance and self-care. A growing evidence base supports effective management of pin sites, but with no clear consensus (Cam & Korkmaz, 2014; Ktistakis et al., 2015; Lagerquist et al., 2012; Lethaby et al., 2013). There remains considerable diversity of practice in caring for pin sites (Abbariao, 2018; Kazmers et al., 2016; Lethaby et al., 2013: Walker et al., 2018). Pin-site care varies based on prescribed interventions and facility policy. Dressings may be applied for the first 48 to 72 hours, and then sites may be left open to air (Abbariao, 2018). Pin-site care may be performed frequently in the first 48 to 72 hours after application, when drainage may be heavy; other evidence suggests pin care should begin after the first 48 to 72 hours (Abbariao, 2018). Pin-site care may be done daily or weekly or not at all (Georgiades, 2018; Lagerquist et al., 2012; Timms & Pugh, 2012). Pin-site care is completed using aseptic technique in the immediate postoperative period. Refer to specific patient prescribed interventions and facility guidelines. Nurses play a major role in preparing the patient psychologically for the application of an external fixator. The devices appear clumsy and large. In addition, the nurse needs to clarify misconceptions regarding pain and discomfort associated with the device. Delegation Considerations The care of a patient with an external fixator device may not be delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, care for these patients may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A. Equipment Equipment varies with the type of fixator and the type and location of the fracture, but may include:
Assessment Review the patient's health record and care plan to determine the type of device being used and prescribed care. Assess the patient's pain and need for analgesia before providing care. Assess the external fixator to ensure proper function and position. Perform skin and neurovascular assessments. Inspect the pin-insertion sites for signs of inflammation and infection, including swelling, cloudy or offensive drainage, pain, or redness. Assess the patient's knowledge regarding the device and self-care activities and responsibilities. Actual or Potential Health Problems and Needs Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include: Outcome Identification and Planning The expected outcome to achieve when caring for a patient with an external fixator device is that the patient shows no evidence of complication, such as infection, contractures, venous stasis, thrombus formation, or skin breakdown. Additional outcomes that may be appropriate include that the patient shows signs of healing, the patient reports an increased level of comfort, and the patient is free from injury. Implementation
Evaluation The expected outcomes have been met when the patient has exhibited an external fixation device in place with pin sites that are clean, dry, and intact, without evidence of infection; the patient has remained free of complications, such as contractures, venous stasis, thrombus formation, or skin breakdown; the patient has reported an increased level of comfort; the patient has remained free of injury, and the patient has demonstrated knowledge of pin-site care. Documentation Guidelines Document the time, date, and type of device in place. Include the skin assessment, pin-site assessment, and pin-site care. Document the patient's response to the device and the neurovascular status of the affected area. Sample Documentation 7/6/25 1020 External fixator in place on left forearm. Pin-site care performed. Pin sites cleaned with normal saline and open to the air. Sites slightly red with serosanguineous crusting noted. Neurovascular status intact. Instruction given regarding ROM exercises to left fingers and elbow; patient verbalizes an understanding and is able to demonstrate.Developing Clinical Reasoning and Clinical Judgment Special Considerations
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2. Perform hand hygiene. Put on PPE, as indicated.
3. Identify the patient. Explain the procedure to the patient. Assure the patient that there will be little pain after the fixation device is in place. Reinforce that the patient will be able to adjust to the device and will be able to move about with the device, allowing them to resume normal activities more quickly.