SUSPENSION OF BURNED LIMBS USING TRANSOSSEOUS PINS, AS EXPERIENCED BY THE NURSE AND THE PATIENT

Palanque A.R.

Rangueil University Hospital, Toulouse, France

SUMMARY. An unusual and controversial technique is described in which burned limbs are suspended by means of transosseous pins. The technique can be used for circumferential bums, bums of the posterior aspect of the limbs and bums of the thighs, perineum and buttocks. The use of the technique is described in 9 patients, together with the implications for both the patient and the nurses involved in patient monitoring. A comparison is made between the advantages and disadvantages of the technique.

This is an unusual technique, which is not often employed. It may perhaps appear cruel and it is certainly open to question, but it can be useful.

Position of the pins: the burned limbs are suspended using transosseous pins (these may be transradial, transtibial, or transcalcaneal) connected to Rieunau's stirrups. The limbs are thus suspended by a system of pulleys, cords and weights.
Insertion of the pins: the surgeon fits the pins on to an electric motor, and then he "skewers" the patient. Before the pin appears on the other side of the limb, the physician makes an incision in the skin with a cold knife.

Removal of the pins: this is carried out without local anaesthesia. The surgeon uses a metal handle, called an "American handle".

Pinning is indicated in the following cases: - circumferential bums - burns of the posterior aspect of the limbs - burns of the thighs, the perineum, or the buttocks.

This technique helps to: obtain better and quicker graft take, by avoiding pressure on weight-bearing areas avoid maceration of debrided areas and to make positioning of the lower limbs easier.

From August 1989 to August 1990, pins were used in 9 of the 89 patients admitted to our Severe Bums Unit.
There were 7 men aged from 16 to 60 years, and 2 women aged 28 and 78 years.
Four of the patients were under ventilatory support, which brought them sedation and relief from pain. The other five patients were conscious.
The percentage of TBSA burned ranged from 18% to 87%. (Three patients had an average of 50% TBS.)
The units of burn surface ranged from 56.5 to 246. (For three of the patients, this index of gravity was 207.)
For this study, we noted for each of these 9 patients:

• the site of pin insertion
• the time when the pins were inserted, in relation to the first session of escharectomy or autograft
• the duration of pin fixation
• the patient's feelings during the time the limbs were suspended, and when the pins were removed.

We also defined what was involved in the surveillance of pin fixation by the nurse, and approached the question of how this technique was experienced by the staff, in particular by the nurse.

Two patients had one transradial pin, two had a left and a right transradial pin, two had a left or a right transtibial and transcalcaneal pin, five had a double transtibial and transcalcaneal pin, and two patients underwent complete pinning, that is, transradial, transitibial and transcalcaneal both left and right.

It was carried 'out:

• on the day of the first session of escharectomy, or 3 to 10 days after the first session of escharectomy
• on the day of the first autograft, or 5 to 20 days before the first autograft.

Transradial pins are kept in place for an average of two weeks, and transtibial and transcalcaneal pins for about four to eight weeks.
The duration of suspension by transosseous pins depends on the time taken for almost complete local coverage to be achieved.

The following points must be carefully watched:

1. The suspension. The limbs are suspended in Rieunau's stirrups. The weight used depends on the position to be taken by the limbs.
2. The position of the shoulder. As far as possible, the shoulder must be in abduction and in external rotation.
3. The position of the elbow. This is a major drawback to pinning. In fact, it is very difficult to position the elbow and flexion therefore leads to contracture while calcification limits pronosupination. Ideally, the elbow would be in extension and resting on the bed.
4. The position of the wrist. The wrist should be in extension at 15', which is difficult because of the transradial pin. The thumb is in abduction and/or in opposition, with the thumb-pad towards the palm and the first web space extended. The interphalangeal joints are in complete extension. The metacarpophalangeal joints should be in flexion at 60' to 90*.
5. The position of the hip. Abduction should be induced and flexion should be adjusted according to the needs of the patient and of the nursing staff. The position of the knee. The knee should not be hyperextended but only stretched out. The weights which are supported by the stirrups of the transtibial pins are used to raise the lower limb.
6. The position of the a~h'kle. The ankle must be placed perpendicularly at 90'. In order to avoid any weight-bearing area on the stirrup, a pad is placed on the stirrup. The foot must be in dorsiflexion. Here, the role of the weights is to maintain the position of the knee.
7. Surveillance of the extremities. Any circulatory troubles must be detected and attended to. In addition, it should be remembered that even infra-red lamps can cause burns!
8. The entry and exit points of the pins. These are disinfected with povidone-iodine or with hydrogen peroxide, during wound dressing. They are protected by tulle gras with Aurcomycin or with a sheet of Betatulle.
9. Patient comfort. The patient may complain of cold feet, in which case bedsocks should be used.
10. Cramp and stifthess may be relieved by temporarily lowering the suspension, and at the same time encouraging the patient to move his limbs. When the graft has taken, the suspension can be lowered.

a) Advantages:

Main advantages: the nurse can apply the dressings under better conditions, in particular dressing of the posterior aspect of the limbs.
Daily spraying of hexamidine on grafted areas is more effective, in particular on the posterior aspects of the limbs and in the perineal area.
All acts of nursing care are made easier.
These advantages all tend to give the nurse greater autonomy in local care.
Secondary advantages: When the patient must be turned over, the stirrups are useful for taking a hold.
The positive effects of suspension and the use of a fluidized bed make it easier to handle the patient (e.g. local care of the perineal area or the buttocks, use of bedpan, or changing a vesical catheter).

b) Disadvantages:

Whenever the patient has to be moved in his bed, the suspension system has to be totally or partially removed.
When the patient is turned on to his side, or during transport on a stretcher, there is a risk of further wounds from the points of the pins.
The lower limbs cannot be suspended in the operating theatre: the ceiling is not suitable and would not bear the weight!
In practice, it is difficult to carry out constant surveillance of all these aspects of pin fixation.

a) The conscious patient

Advantages:

• pin fixation causes little or no pain
• the patient realises the aims of pin fixation relatively well and quickly
• his confidence in the nursing staff increases.

Disadvantages:

Subjective disadvantages:

• at first sight, the patient is afraid of having fractures
• he has a poor understanding of the technique of pin fixation
• the apparatus gives him a rather traumatic view of his burns
• he cannot move and is obliged to sleep on his back
• too often, the patient has too little or no information about his pin fixation. This lack of medical information before pin insertion is in general not too harmful, as the nurse and the physiotherapist will be the first to ensure the education of the patient afterwards!

Objective disadvantages:

Pin fixation as we have described it, and in particular when several pins are inserted, makes the patient completely dependent, and causes cramp and stiffness (sometimes with pain of the muscles, nerves, tendons and bones), pins and needles, some pain when the pins are removed, osteitis and arthritis. However this is exceptional (there was only one case of osteitis among our nine patients). There may also be axillary contractures, a hunched position of the shoulders, and difficulties in prono-supination.

b) The unconscious patient

Advantages:
The patient cannot see his technical environment, which can seem rather inhuman.

Disadvantages:
These are the same as those mentioned above.

the present time:

• the nurse, carrying out local care and nursing care, is very satisfied with the technique of pin fixation of burned limbs
• however, the physiotherapist has reservations concerning the suspension of the upper limbs
• they must both be extremely attentive in the permanent close surveillance of pin fixation
• it is their role to educate the patient
• the nurse must respect the feelings of the patient concerning pin fixation
• everyone concerned must work to reduce the negative effects and feelings aroused by pin fixation.

the short term:

• the medical team intends to reduce the duration of pin fixation
• the indications and the time when the pins are inserted (in relation to the moment when the autograft is done) are being discussed.

will this type of pin fixation still be used? Or will other more effective and less "barbaric" techniques be developed to improve the survival of the autograft, which is so important?

RESUME. On d6crit une technique peu us6e et tr&s discut6e selon laquelle les membres brfil6s sont tenus en suspension par des broches transosseuses. La technique peut 8tre employ&e pour les brfilures circonf6rentielles, les br6lures de Vaspect post6rieur des membres, et les br6lures des cuisses, du perin6e et des fesses. Lemploi de la technique est d6crit chez 9 patients, avec les implications soit pour les patients soit pour les infirmi&res qui doivent les surveiller. Les avantages et les inconv6nients de la technique sont compar&s.