Make sure that the skin is not under tension from the pin. Incise the skin if necessary to release it. With a small incision no sutures are necessary. Some antibacterial ointment and a sterile dressing are applied over the pin site. The cast is applied, by rolling plaster smoothly up to and incorporating the pin on each side with a thick cuff of plaster (2 cm) around each pin. Be careful not to pull the plaster tightly from one end of the pin to the other, since there should be no extra pressure on the skin. Excessive pin length can be removed with a pin cutter, but at least 2cm or so of pin should be incorporated in the plaster, both medially and laterally.
Note: The transfixion pins can be used as reduction aids. Traction, rotation, and angulation of the pins can be used to correct deformities. This is done before plaster application. Then, with the fracture held reduced, POP is applied, incorporating the pins as described. Once hard, the cast functions as the frame of an external fixator, using the transfixion pins to maintain fracture alignment.
This procedure is usually done under general or regional anesthesia.
Initially the cast should be extended above the knee for better stability and comfort. It can later (3-4 weeks) be shortened to a below knee plaster, still maintaining the pins incorporated in the plaster.
Once the fracture is likely to be sticky (approximately 6 weeks), remove the cast and pins and apply a new cast. At this point it may be appropriate to begin progressive weight bearing.