The most common and even expected problem with external fixation treatment is pin site infection. Pin site infection begins superficially (at the level of the skin) and if left untreated will progress to the deeper soft tissues and eventually to the bone. It is therefore important to identify pin site infection and treat it early. We would rather you over-diagnose and over-treat pin site infection than delay the diagnosis and treatment. Because pin site infections do not occur immediately after surgery, they are not present when you leave the hospital. It is therefore important for you (the patient or parent) to know the signs and symptoms of a pin site infection so that you can diagnose and treat it early.
The first sign of pin site infection is usually redness with tenderness around the pin in an area that was previously not tender. Tenderness means that the skin around the pin site is sore to the touch. It is not unusual to have some redness around the pin; not all redness indicates pin site infection. However, if there is redness with tenderness, it is probably the beginning of infection. Expanding inflammation of the tissue is called cellulitis and should be treated immediately.
The other common sign of infection is drainage from the pin site. Again, not all drainage indicates infection. Drainage can be of any thickness and color. Clear watery drainage is often due to swelling rather than infection. Clear yellow drainage may be due to infection or swelling or both. The most obviously infected drainage is white, yellow, or green cloudy or opaque drainage that looks like pus. This may be red tinged if there is some bleeding associated with it. Frank red blood coming from a pin site is not due to infection. It is usually due to aggressive physical therapy with minor tearing of muscle or skin or even bone around the tethering pin. Obviously, a combination of redness, tenderness, and drainage is very suspicious for infection.
Fever and a sense of not feeling well are later signs of infection and usually do not occur. When fever is present, one should rule out other causes of fever, such as the flu, ear infection, upper respiratory infection, urinary infection, etc.
Having treated thousands of patients with thousands of pin sites and thousands of infections, we have developed a protocol for how you can diagnose and treat your own pin site infection. We will teach you this before discharge from the hospital.
You will be discharged with a prescription for oral antibiotics. These are not to be taken unless you develop a pin site infection. If you develop some of the signs and symptoms listed above, in particular tenderness with redness with or without increased drainage from one or more pin sites, we recommend that you begin to take the antibiotics. If it is your child who is undergoing treatment, then as the caregiver, you should diagnose and treat accordingly. The tenderness and drainage should improve within 24 to 48 hours. If they do not, then please call the office and discuss the situation with one of our nurses or physician assistants. You may need to come in and have a culture swab taken of the drainage. The purpose of the culture swab is to determine whether the bacteria that is causing the infection is sensitive to the antibiotic that you or your child is receiving. If not, the antibiotic will need to be changed.
You do not need to call the office the moment you diagnose the pin site infection. That can often lead to delay in treatment while you wait for a return phone call. Delaying treatment by 1 or 2 days can lead to advanced pin site infection that is more difficult to treat.
Occasionally, either because of late treatment or despite early treatment, a pin site infection requires removal of the pin and/or surgical treatment. This can often be done in the clinic without going to the operating room. Admission to the hospital for treatment of pin site infection is rare, and the need for the intravenous administration of antibiotics at home is also uncommon.
If you strictly follow this protocol, you will probably over-diagnose pin site infections. This means that you may treat what you think is a pin site infection when it is not. As mentioned above, it is better to over-treat than to under-treat.