BLISTERING

1
BLISTERING

• Epidermis is separated from dermis due to
  repeated friction of skin
• Also caused by infection, allergy, or edema
• Dressings could have lack of elasticity and
  applied with tension
• Dressings should be low adherent or non adhesive
  and be absorbant to prevent blistering
• Could cause infection or prolonged healing
• When present do not de-roof or burst, just
  protect

2
BLISTERING
3
CONTACT DERMATITIS

• Can occur when there is an allergy
• Adhesive
• Tape
• Do not use tape to secure dressings
• Should use stockinette, spandage

4
TISSUE NECROSIS

• Tissue becomes non-viable at incision line
• Dusky skin color
• Mottled/purple discoloration
• Dry or Wet Gangrene
• Slough
• Can result in wound breakdown soon after surgery
  or weeks later
• Non-viable ischemia is usually cold and very
  painful to touch
• Should differentiate between bruising
• Contact surgical team if suspected

5
TISSUE NECROSIS
6
TISSUE NECROSIS
7
INFECTION

• Wound must be monitored to assess for signs of
  infection
• Can result in increased drainage from incison and
  possible breakdown
• Severe infection can lead to total dehiscence,
  tissue necrosis, and need for further surgical
  intervention
• Diabetics are approximately 5Xs more likely to
  develop a post amputation infection

8
PREVENTION OF INFECTION

• Prophylactic systemic antibiotics
• For diabetics education to control blood sugar
  levels
• Wound care (cleansing, debridement as needed,
  proper dressing changes)
• Topical antimicrobial dressings (silver, iodine)

9
POST AMPUTATION DRAINAGE

• Note amount and document daily
• Note color of drainage
• Serous clear to yellow tinged
• Sanguinous red, blood tinged
• Serosanguinous clear to pink with tinge of red
  or brown
• Purulent yellowish/brownish
• Infected pus hues of yellow, green, blue
• If excessive, then needs to be managed
• Note if an odor
• May indicate infection
• Sweet, fruity, fishy, foul, ammonia-like

10
TISSUE DIFFERENTIATION

• Viable Non-viable
• - Healthy - Necrotic
• - Vascular - Avascular
• - If hit, will bleed - Will not have pain
• - If hit, will have pain with removal

11
WOUND CARE TREATMENTS

• Standard cleansing
• Pulsatile lavage with suction (PLWS)
• Negative Pressure Therapy (wound VAC)
• PLWS with wound VAC
• MIST (low frequency, non contact, non thermal
  ultrasound)
• Electrical Stimulation

12
Mechanical DebridementWhirlpool

• Contraindicated for
• Venous Insufficiency
• Many disadvantages
• Nonselective and may potentially damage healthy
  tissue
• Traumatizing to wound and surrounding tissues by
  mechanical forces
• Inability to control irrigation pressure of the
  turbine
• Likely exceeds recommended PSI of 4-15, as
  recommended by the 1994 AHCPR guideline (Agency
  for Health Care Policy Research)

13
Mechanical DebridementWhirlpool

• Other disadvantages
• Wounds are at risk for waterborne contamination
  despite efforts to disinfect the WP tanks
• Water content of the skin may increase to 55-70
  following a 20 minute immersion in the WP, which
  could cause maceration
• Has little effect on adherent fibrous tissue
• Time consuming and labor intensive
• Inability to treat irregular body surfaces
• Places patient in dependent position which
  increases edema

14
WOUND CARE TREATMENTS

• Negative Pressure
• (Wound VAC)

• Pulsatile Lavage
• with Suction (PLWS)

15
Mechanical DebridementPulsatile Lavage with
Suction (PLWS)

• PTs have been using since the late 1980s
• A method which provides pulsed irrigation for
  cleansing and suction for removal of exudate and
  debris in wound
• The negative pressure provided by the suction
  stimulates growth of granulation tissue
• Pressure of irrigation can be chosen (4-15 PSI)
• Suction can be chosen (60-100mmHg)

16
Mechanical DebridementPulsatile Lavage with
Suction (PLWS)

• Indications
• any type of wound, whether it be infected,
  necrotic, or granulated
• Contraindications None
• Precautions
• Must know anatomy
• Wounds near major vessels
• Wounds near an exposed vessel, nerve, tendon, or
  bone (may need to change PSI and suction)

17
Aerosolization

• Possible aerosolization of microorganisms
• Pt should be treated in a private room with walls
  and doors, not curtains
• Must wear PPE
• Face mask with eye shield, gloves, water proof
  gown, hair net, shoe covers
• Cover all pt. IV sites and other portals of entry
  with a towel
• Clean/Disinfect all horizontal surfaces in room
• Remove all linens exposed during treatment

18
Mechanical DebridementPulsatile Lavage with
Suction (PLWS)

• lt50 necrotic tissue once daily
• gt50 necrotic tissue purulent drainage or foul
  odor with sepsis twice daily
• Recommended impact pressure
• 2-6 PSI for tunneling
• 8-12 PSI for most wounds
• 12-15 PSI for infected wounds (bacterial counts
  significantly reduced at this level
• Treat until ready for surgical closure or wound
  closed by secondary intention

19
Negative Pressure Wound Therapy

• Device comprised of a pump which is attached by
  tubing to a foam dressing that is placed in the
  wound, to create a vacuum of negative pressure to
  remove fluid

20
Negative Pressure Wound Therapy

• Enhanced wound contraction or closure
• Management of dead space
• Reduces interstitial edema
• Helps to stimulate granulation growth
• Increases blood supply
• Decreases bacterial colonization
• Maintains a moist wound bed
• Prevents contamination of the wound site from
  outside bacteria

21
Contraindications of NPWT

• Necrotic tissue gt 30
• Untreated osteomyelitis
• Malignancy in wound margins

22
Electrical Stimulation Indications

• Stage III or IV pressure ulcers
• Neuropathic foot ulcers
• Arterial Insufficient ulcers
• Venous Insufficient ulcers
• Ulcers that have not responded to normal or
  standard care usually treatment over 30 days

23
MIST Ultrasound Therapy
24
MIST Therapy

• Painless ultrasound
• Non-contact
• Low-intensity
• Low-frequency
• Light mist of saline solution applied 0.5-1.5 cm
  from the wound bed
• Purpose
• Promotes healing through cell stimulation,
  fibroblast stimulation, maintenance debridement
  and reducing bacterial load
• Decreases biofilm

25
Benefits of MIST Therapy

• Easy set up
• Short treatment time
• Easy clean up
• Painless treatment
• FDA approved
• No aerosolization
• Does not affect good tissue or periwound

26
Benefits of MIST Therapy

• ? average of days NPWT used
• ? use of enzymes, silver dressings, topical
  antibiotics
• ? use of WP, PLWS, E-stim, PEMI
• ? LOS

27
MIST Therapy

• Indications
• Any wound that needs cleansing or debridement

• Contraindications
• Cancer

28
E-stim Rationale for treatment

• Antibacterial effects
• Enhanced scar tensile strength
• Improved collagen synthesis epithelial
  migration
• ?ed cutaneous O2 transport blood flow
• Possible angiogenesis to support healing
• ?ed edema
• Faster wound contraction

29
E-stim Specific Effects

• Negative Polarity
• Bacteriostatic effects
• Destruction of bacterial cell membrane
• Dissolve necrotic tissue or softens tissue

• Positive Polarity
• Acceleration of wound healing
• Increases fibroblastic formation
• Increases epithelialization
• Stimulation of protein and DNA synthesis

30
E-stim Contraindications

• Basal or squamous cell cancer
• Osteomyelitis
• Ion residues of silver or iodine
• Electronic pacing implants
• Directly over the heart or carotid sinus

31
E-stim Protocol

• Day 1-5
• Negative polarity
• 50-80 pps
• 100-150V
• 45-60 minutes
• Daily for inpatients
• 3X/wk for outpatients

• Day 6-closure
• Positive polarity
• 80-100 pps
• 100-125V
• 45-60 minutes
• Daily for inpatients
• 3X/wk for outpatients

32
PHASES OF REHAB

• Pre-prosthetic to prosthetic care

33
GOALS OF PRE-PROSTHETIC (Post-Operative)
TREATMENT

• Healing without complication
• Increase strength
• Increase activity
• Improve balance
• Stimulate proprioception
• Begin controlled ambulation
• Empower your patient through education

34
PRE-PROSTHETIC REHAB PHASE ONE

• Edema control to assist in creating and
  maintaining an ideally shaped residual limb for
  preparation of and usage with a prosthesis.
• Positioning
• Ace wrapping
• Diagonal x wraps or figure 8, not in circles
• Increased pressure distally
• No windows or wrinkles
• Most residual limbs will require two wraps.
  Reapply every 4 hrs.
• TTA should be wrapped above the knee with the
  knee cap exposed to encourage ROM
• TFA should be wrapped up to groin to avoid
  adductor roll

35
Positioning Below knee amputee

• Positions to promote
• prone (stomach) lying as much as possible or as
  tolerated by patient
• lie with pelvis level and hip in neutral rotation
  and knee straight

36
Positioning Below knee amputee

• Positions to avoid
• Knee flexion
• Hip flex,abd, ext. rot
• Pillows under residual limb
• Limit the amount of time in the seated position

37
Positioning Above knee amputee

• Positions to promote
• Lie with pelvis level and neutral rotation of hip
  
• prone lying as tolerated
• Support outside of residual limb when using
  wheelchair and in seated position
• Rest in adduction in supine
• Keep legs together as much as possible

38
Positioning Above knee amputee

• Positions to avoid
• Hip flex, abd, ext. rot
• Pillows under residual limb
• Prolonged sitting or lack of limb support

39
ACE WRAPPING

• 4 inch BK. Wrap to above knee, can leave the
  knee open for ROM
• 6 inch AK. Wrap up into the groin to prevent
  adductor roll create hip spica. Recommend use
  of 4 wraps and spandage or stretch net to secure
  dressing.
• Use two ace wraps, double layers
• Cover all areas of skin and double wrap all areas
  to prevent windows
• Wrinkles and kinks can cause blisters
• Education is important for proper wrapping. If
  patient cannot do himself, educate caregiver.

40
SKIN CARE

• Goal to prepare the residual limb for prosthetic
  usage, while providing protection to the incision
  and maintaining an optimal environment for wound
  healing.
• Hydration- to prevent dry skin formation which
  reduces pliability and facilitates skin openings
• Intact limb care- reduce factors which may lead
  to sound limb amputation in the vascular disease
  population

41
POOR HYDRATION OF HEELS
42
SKIN CARE

• Wash leg daily with mild soap and warm water
• Pat dry
• Make sure skin is fully air dried before covering
  
• Wait at least 5 minutes before wearing prosthesis
  or shrinker
• Use a non-vaseline type lotion daily, but avoid
  open wounds

43
SKIN INSPECTION

• Look for openings and redness after wearing your
  prosthesis, or after removing the shrinker or
  acewrap
• Use mirror to help inspect the leg
• Check the bottom of stump, behind the knee, and
  the front of the leg
• Touch your skin to feel for blisters, skin
  openings and increased warmth
• Call your doctor if any new skin openings appear,
  or if redness lasts longer than 30 minutes
• Do not wear prosthesis if you get a blister or a
  new open wound.

44
SKIN MOBILIZATION

• Purpose To keep your skin and scar tissue loose
  in order to prevent blisters when you use a
  prosthesis.

45
SKIN MOBILIZATION

• Start with the skin over the bones of your stump.
  Press two fingers firmly on an area of skin
• Move the skin beneath your fingers back and forth
  across the bone for 1 minute
• Fingers stay in same place. Repeat to all skin
  around the bone
• Once your incision is healed, take two fingers
  and place them firmly across your scar. Loosen
  the deeper tissues by moving your fingers up and
  down (vertical motion) for 1 minute
• Fingers stay in the same place. Repeat on entire
  scar

46
SCAR MANAGEMENT

• Purpose to achieve a well approximated and
  mobile scar, to aid in attenuating forces at the
  scar/ socket interface
• Open/recently approximated incision
• Steri strips
• Transverse friction massage
• Healed incision/well approximated incision

47
DENSENSITIZATION

• Purpose to increase your legs tolerance of
  touch and pressure. This will prepare your leg
  for the prosthesis, and also help decrease the
  sensation of phantom pain
• Progressive fabric brushing
• Progression silk, cotton, velour, felt,
  corduroy, paper towel, terry cloth
• Tapping- using finger tips to decrease
  sensitivity of limb. Increase as tolerance
  increases.
• Weight bearing
• Air splints, pressure on stool
• Skin mobilization

48
PHANTOM LIMB PAIN AND SENSATION

• Phantom sensation
• Sensations perceived
• as coming from the
• missing limb
• Usually disappears after a
  
• few months
• Phantom pain
• Pain perceived in
• missing limb
• Can be debilitating
• Described as burning,
• cramping, shooting or
• aching

• Residual limb pain
• Try desensitization techniques such as rubbing,
  tapping or squeezing.
• Start with light fabrics and pressure and
  increases as limb accommodates

49

• ROM
• AROM/AAROM
• Ankle pumps, LAQs, SAQs, hip abd/add, bridging
• PROM to prevent or reduce contracture
• Positioning
• Contracture management
• Static stretching
• Prolonged low load stretch
• Dynamic stretching
• Contract relax, joint mobilization, transfriction
  massage
• Modalities
• Serial casting

50

• Strengthening
• Isometrics
• Quad and glut sets
• Balance coordination
• Seated mat activities
• Wand and trunk exercises
• Placement trunk rotation
• Balloon activities
• Balance board sitting
• Sit to stand activities

• Endurance
• Seated exercise
• Gait
• Wheelchair management skills
• Ambulation in parallel bars or with assistive
  device
• Curbs, stairs and ramps
• Functional activities
• Bed mobility
• Basic transfers

51
PRE-PROSTHETIC REHAB PHASE TWO

• ROM
• AROM, static stretching, self stretching
• Strengthening
• Isometrics, PRE to extremities, trunk
  strengthening
• Balance coordination
• Sitting activities
• Balance board, heavy ball catch, balloon toss,
  PNF with T-band/sport cord, physioball, balance
  board with perturbation or ball toss

52

• Endurance
• UE ergometer, LE ergometer, w/c propulsion, Nu
  step
• Gait
• With assistive device on levels curbs, ramps and
  stairs
• Functional activities
• Kitchen, bathroom, dressing
• Transfers

53
PRE-PROSTHETIC REHAB PHASE THREE

• ROM
• Independent self stretch program
• Strengthening
• PRE for extremities and trunk, ball rolling with
  sound limb, step ups
• Balance and coordination
• Standing weight shifting forward, backward,
  laterally diagonal patterns
• Rocker board in standing, ball rolling under
  sound limb
• Dynamic reaching, placement activities, stool
  stepping with sound leg

54
Energy Expenditure and Amputation

• The costs of residual limb length and cause of
  amputation

55
CORRELATION BETWEEN LIMB LENGTH AND TORQUE VALUES
AT THE HIP

• Femur length
• Distal ¼ to 1/3
• Distal 1/3 to ½
• Mid femur
• Proximal 1/3
• James U 1973

• of strength reduction
• 35 of all movements
• 45 of all movements
• 60-65 of flexors/add
• 70-75 ext/abd
• 80-85 flex/adductors

56
ENERGY EXPENDITURE AND VELOCITY

• Factors influencing the metabolic costs of
  walking
• Length of residual limb
• Between levels of amputation
• Within levels of amputation
• Causes of amputation
• Traumatic vs. vascular
• Age
• Linear regardless of disability

57
ENERGY EXPENDITURE AND VELOCITY

• Level/Cause VO2 Velocity
• TTA trauma 15 10
• TTA vascular 30 30
• TFA trauma 40 20
• TFA vascular 65 40
• Esquenazi, 1994 Gailey, 1994
• Ertl,2005

58
PROSTHETIC GAIT

• Emphasis should be on proper mechanics at the
  trunk, pelvis, hip, knee, foot/ankle
• Need to evaluate anteriorly, posteriorly, and
  laterally on prosthetic side
• Need to evaluate for proper fit and height
  staticly in standing before beginning
• Important to be observant and provide your
  observations early on to break the habits that
  your patient has developed with unilateral
  activities post amputation

59

• Early stages of gait training should focus on
  weight bearing through the prosthesis with
  ambulation and transfers
• Remember that your patients body will adjust
  from bilateral stance, COG through center of
  trunk, to unilateral stance during pre-prosthetic
  phase
• Once your patient has received the prosthesis,
  he/she must revert back to proper bilateral
  stance in order for proper balance to be achieved

60

• Your patient, their family, the physician and
  insurance companies will want and expect
  immediate results with ambulation. Despite this
  pressure, it is important to realize the
  difference between walking and walking properly.
• Early stages should also focus on balance in the
  prosthesis. If your patient does not properly
  weight bear through the prosthesis, weight
  bearing will not be symmetric and proper balance
  cannot be achieved. Proper weight bearing and
  balance are critical.

61
BASICS OF GAIT TRAINING

• Insure proper habits from the beginning. Pt.
  will start with many bad habits which were
  learned either prior to limb being amputated or
  after amputation.
• Sit to stand transfers- correct way is with equal
  weight through bilateral limbs. Usually see
  patient place prosthetic limb anterior to sound
  limb.
• Perform weight shifting to accommodate to
  pressure of the pylon
• Lateral, ant./post., and diagonal shifts

62

• Progress to dynamic lower extremity activities
  such as forward/lateral step ups, rolling ball
  underneath sound limb, kick ball.
• Further progression with perturbation activities.
• Advance out of parallel bars only if patient can
  safely and properly advance and wt. bear through
  prosthesis with little or no cueing.

63
PRE-GAIT TRAINING

• Standing balance
• Stand in parallel bars with feet 2-4 inches apart
• Once the patient feels comfortable with balance,
  instruct to remove unaffected hand from bar.
  This will result in increased pressure due to
  increased wt. bearing
• Instruct to remove both hands from the bars after
  feeling comfortable with one hand on the bar.

64
WEIGHT SHIFTING

• Side to side
• Stand in parallel bars with feet 2-4 inches apart
  with hands on bars.
• Instruct patient to shift side to side to note
  the pressure changes and the capabilities of the
  prosthesis
• Move hand on sound side off bar.
• Move both hands from bar

65
WEIGHT SHIFTING

• Forward/Backward
• Stand in parallel bars with both hands on bars
  with feet 2-4 inches apart
• shift body weight forward backward. Start with
  small movement and progress to larger degrees of
  movement
• Remove hand on sound side from bar and continue
  wt. shifts
• Remove both hands from bars and wt. shift

66
DIAGONAL WEIGHT SHIFTING

• Stand with feet 2-4 inches apart.
• Shift body weight from the prosthetic heel to the
  sound side toe in a diagonal pattern.
• Begin with small movements and progress to larger
  degrees of movement
• Note the increase in weight bearing

67
STOOL STEPPING

• Stand in parallel bars with both hands on bars
  and feet 2-4 inches apart with step stool in
  front of the affected leg
• Step onto the stool with the sound leg as slowly
  as possible
• Progress to same movement with hand on unaffected
  side off the bar
• No hands on bars do movement slowly.

68
SOUND LIMB STEPPING (PARTIAL WEIGHT BEARING)

• Patient takes repetitive steps forward and
  backward with the sound limb (heel rise to heel
  strike)
• Observe for forward pelvic rotation, knee
  flexion, stride length and foot placement
• Can place hands on ASIS to feel for forward
  pelvic rotation and assist as necessary

69
PROSTHETIC LIMB STEP (PARTIAL WEIGHT BEARING)

• Same as sound limb step except leading with
  prosthetic limb.

70
PROSTHETIC LIMB STEP (FULL WEIGHT BEARING)

• When satisfied with biomechanics with 2 hands of
  support, progress to hand on affected side only
  on bar.
• Progress to no support
• Note the increased weight bearing
• Continue to assess for pelvic rotation

71
SOUND LIMB STEPPING (FULL WEIGHT BEARING)

• Step forward and backward with the sound limb
  beginning with both hands on the bars and
  progress to removing hand on sound side
• Instruct patient to concentrate on control of
  prosthetic limb, improving balance and weight
  bearing to increase prosthetic stance time
• Progress to no hands

72
STRIDE LENGTH AND CONTROL

• Step forward and backward with the prosthetic
  limb with both hands on parallel bars
• Instruct patient to take different size steps
  until a normal step length is determined.
• When comfortable with step length, progress to
  hand on affected side only on the bar and finally
  no hands.

73
BASICS OF GAIT TRAINING

• Emphasize symmetrical weight bearing with balance
  exercise
• Start with static standing with unilateral
  support.
• Progress to static standing without upper
  extremity support. Eyes open and then eyes
  closed.
• Progress to dynamic upper extremity reaching
  activities ipsilateral and contralateral to body,
  below and above shoulder level

74
COMPLIANT SURFACE

• Patient stands on compliant foam pad. Patient
  needs to be able to maintain comfortable standing
  balance
• Instruct on lateral weight shifts with two handed
  support, Progress to one handed support and
  eventually no hands
• Incorporate UE activity and change compliance of
  pad as patient improves.

75
BALANCE BOARD

• Initially work to establish equilibrium on the
  balance board
• Ability to balance dynamically may be promoted by
  re-educating the patient to maintain the center
  of gravity over the base of support
• As confidence and balance develops, add
  perturbations to move outside base of support

76
BALANCE WITH BALL

• Use softball sized ball
• Place sound limb on top of the ball.
• Keep foot on top of the ball and roll it forward,
  backward, side to side or in circles

77
STEPPING OVER OBJECTS

• Walk forward stepping over objects of varying
  heights placed appropriate distances apart.
• Emphasis is placed on maintaining gait
  biomechanics, balance and control of the
  prosthesis. Stepping over the objects with the
  prosthetic and sound limb should be alternated.

78
BASEBALL/GOLF

• The patient swings the baseball bat or golf club
  in an attempt to make contact with the ball.
• Emphasis is placed on trunk rotation, weight
  shifting and maintenance of balance

79
BOWLING

• Emphasis is placed on stepping and shifting
  weight onto the forward lower limb, while
  rotating the trunk and throwing the ball with the
  contralateral arm

80
STAIRS

• Use a crutch or cane in the hand opposite the
  rail
• Going up Step up with the intact limb first.
  Next step up with the prosthesis.
• Going down place cane or crutch down the step
  first then step down with the prosthesis. Next
  step down with the intact limb.

81
RAMPS HILLS

• Use a cane, crutch, or walker to go up and down a
  ramp, hill, or incline
• Going up Place the crutch, cane or walker
  forward. Lean forward and step up with the
  intact limb first. Then step up with prosthesis.
• Going down Place the crutch, cane or walker down
  first. Then lean slightly back and step down
  with the prosthesis first. Bring the intact limb
  down.
• For steep inclines or hills it is easier to go up
  and down side ways. To go up, stand with the
  prosthesis on lower surface and lead with the
  intact limb
• Lead down with the prosthesis first.

82
CURBS

• Use a cane, walker or crutch to go up and down a
  curb.
• Going up Place the walker, crutch or cane up
  onto the single step first.
• Step up with the intact limb first. Then step up
  with the prosthesis
• Going down Place the cane, crutch or walker down
  first. Step down with the prosthesis first
  followed by the intact limb.

83
SOCK PLY MANAGEMENT

• Teaching your patient the correct amount of sock
  ply with prosthetic usage

84
SOCK PLY MANAGEMENT AND SKIN INSPECTION

• Education is very important during the early
  stages of weight bearing activity.
• Proper sock ply will provide proper fit and
  control of the prosthesis. If not enough ply is
  used, a loose fit will occur resulting in
  possible shear forces on the limb and poor
  control/clearance.
• If too great of a sock ply is used, the
  prosthesis will not be applied to the limb
  properly which may result in pressure to
  intolerant areas.

85
SOCK PLY MANAGEMENT

• CORRECT AMOUNT OF SOCK PLY
• When standing the patient reports the leg feels
  snug
• No new pain felt after putting the prosthesis on
• No blistering or bruising after wearing the leg
• No discoloration lasting longer than 30 minutes
  to skin, following prosthetic use
• Pressure mark is located in patella tendon area

86
SOCK PLY MANAGEMENT

• INCORRECT AMOUNT OF SOCK PLY
• When standing the prosthesis feels tight or loose
• New pain felt on the patella, the top of the
  tibia or bottom of the stump
• Blistering or bruising found after wearing the
  leg
• Discoloration lasting longer than 30 minutes to
  skin, following prosthetic use
• Pressure mark on patella or on the tibia

87

• Ply thickness
• Yellow or white without color band 1 ply
• Sock with yellow color band 3 ply
• Sock with green band 5 ply
• Thin sheath no ply
• Check ply during the day in case of volume
  changes

88
PROSTHETIC SOCK CARE

• Wear only clean, dry prosthetic socks with your
  prosthesis
• Wash socks every 3-4 days, or if soiled with dirt
  or blood or if significant amount of sweat has
  gotten into the socks
• Hand wash socks in warm water with mild soap, or
  machine wash on gentle cycle only
• Lay the wet socks flat to air dry. Do not put
  socks in the dryer, on a radiator or dry in
  direct sunlight.
• Do not wear socks with holes or runs. Do not try
  to sew or repair the socks. Replace socks when
  necessary
• Contact prosthetist when new socks are needed.

89
DONNING/DOFFING

• Donning socks
• Pull sock on firmly
• No wrinkles
• Seam parallel to suture line
• Clean, dry socks
• Keep socks dry all day
• Donn/doff prosthesis correctly to avoid improper
  pressure and shear on the residual limb

90
PRESSURE SENSITIVE AREAS(TRANSTIBIAL)

• Patella Tibial tubercle
• Crest of tibia
• Anterior distal end of tibia
• Anterior tibia
• Head of fibula
• Hamstring tendons
• Lateral distal end of the fibula

91
PRESSURE TOLERANT AREAS(TRANSTIBIAL)

• Patellar tendon
• Lateral surface of the fibula between the head
  and the distal end
• Popliteal fossa

92
PRESSURE SENSITIVE AREAS(TRANSFEMORAL)

• Adductor tendon
• Groin
• Distal front and distal lateral areas of the
  femur bone

93
PRESSURE TOLERANT AREAS (TRANSFEMORAL)

• Quadrilateral socket
• Ischium
• Distal end of residual limb
• Total contact
• Ischial containment
• Total contact
• Distal end of residual limb

94

• When your patient initially weight bears through
  the prosthesis, check to insure that the limb is
  properly in the prosthesis.
• After several minutes of weight bearing, whether
  it is weight shifting or taking steps, stop and
  check the skin no matter how good they report
  they feel.
• After doffing the prosthesis, check that there is
  no pressure on intolerant areas.
• If pressure is on intolerant areas, check the fit
  and ply more closely.

95
PROSTHETIC CHECK OUT

• Purpose to determine the acceptability of the
  prosthesis
• General areas of inspection
• Cosmesis- contour, color, size, shape
• Function- alignment, knee unit
• Fabrication- construction, sturdy and safe
• Fit- socket comfort, weight bearing features
• Prescription

96
TRANSTIBIAL CHECK OUT

• Socket design
• Patella tendon bearing
• Principles
• Total contact
• Increased weight bearing over patella tendon and
  tibial condyles and reliefs over bony prominences
• Anterior wall- mid patella
• Posterior wall- slightly higher than patellar
  bar. Posterior wall forces patient forward on to
  patellar bar
• Medial/lateral walls- slightly higher than ant.
  wall

97

• Bench alignment
• Principles
• 5 degrees of flexion
• Inset ½ inch- foot inset ½ in relation to
  socket. Should see slight lateral thrust because
  lateral ligamentous structures are better able to
  handle stress
• Midline of socket is 1 and ½ inches anterior to
  the ankle bolt- allows for smoother rollover from
  heel strike to toe off

98

• Height check
• Position- feet shoulder width apart
• Hands down at the sides
• Erect trunk
• Iliac crest, ASIS, PSIS
• Use of lifts or phone book

99

• Static assessment
• Suspension
• Supracondylar- should see no gapping med/lateral
  when pt. is weight bearing
• Supracondylar cuff
• Waist belt
• Neoprene- should have 2 of skin contact for
  proper suspension
• Thigh corset- transmits 40-60 of wt. bearing
  forces to the thigh
• Silicone suspension sleeve

100

• Socket and trim lines- draw line over socket at
  post. trim line and watch line as they walk.
• Foot is flat on the floor and the prosthetic foot
  fits appropriately into the shoe
• Foot should be snug in the shoe. If too much
  room in the shoe, especially with SACH foot, may
  cause increased compression of heel and cause
  hyperextension.
• Top of foot should be parallel to floor.
  Changing shoes may tilt socket forward or
  backward secondary to heel height.

101

• Seated assessment
• Comfort in the popliteal area
• Should be able to place foot flat on the floor
• Skin assessment
• Look for color changes that dont go away,
  abrasions, or blisters
• Check pressure sensitive areas

102

• Dynamic assessment
• Check for pistoning with cuff suspension
• Check if pipe shaft is vertical at midstance
• Proper heel strike?
• Proper rollover?
• Proper pushoff?
• Examine the knee during heel strike, midstance
  and terminal stance

103
TRANSFEMORAL CHECK OUT

• Quad socket
• Ischial wt. bearing- post. wall lower than
  anterior wall
• Scarpas build up- anterior wall pushes pt. back
  on post. wall on ischium.
• Narrow front to back
• Lateral wall high as anterior wall to place
  abductors on stretch to increase control with
  gait
• Adductor relief
• Total contact

104

• Quadrilateral socket
• End of residual limb should touch the bottom of
  the socket but not have too much pressure
• Ischium should sit on the posterior wall of the
  socket
• Should be a relief for the adductor tendon
• Socket should feel snug
• No groin pain

105

• Ischial containment
• Ischial containment pubic ramus containment
• Narrow med/lateral dimensions
• High lateral wall
• Total contact

106

• Ischial containment
• End of stump should touch the bottom of the
  socket but not too much pressure
• Socket should enclose the inner thigh tissue
• Ischial bone sits within the back wall of the
  socket
• No groin pain

107

• Bench alignment
• 5 degrees of flexion in short TFA, 2-3 degrees in
  a long TFA
• Adduction of the lateral wall
• Socket anterior to the knee- creates ext. moment

108

• Height check
• Position- feet shoulder width apart
• Hands down at sides
• Erect trunk
• Iliac crest, ASIS, PSIS
• Use of lifts or phone book
• May be lower on the prosthetic side especially if
  walking with a locked knee to increase clearance
  with walking

109

• Static assessment
• Suspension
• Silesian band- should be between top of iliac
  crests and greater trochanter. If have too high,
  above iliac crest, may cause abduction
• Pelvic band- used for people with problem with
  hip control. Very difficult to donn. Metal band
  should be contoured to persons leg so as to
  prevent rotation
• Suction suspension

110

• Knee joint
• Stable in stance- alignment, muscle control and
  mechanical device
• Knee center- should be at same level as intact
  limb
• Foot in shoe
• Sitting
• 90,90,90 without rotation. If leg abducted
  (foot) either because prosthesis rotated or knee
  too high
• Comfort on anterior and medial walls
• Inspect skin

111
DONNING/DOFFING

• Transtibial
• Nylon sheath next to skin
• Apply proper sock ply
• Gently slide soft insert on to the limb with
  anterior wall of insert around mid patella until
  limb comes close to the bottom. Make sure that
  it is aligned properly
• Gently slide soft insert into hard socket
  matching anterior wall of hard socket with
  anterior wall of soft insert. A small amount of
  the soft insert may be above the hard socket.
• If limb is bulbous, use a pull sock

112
DONNING/DOFFING

• Transfemoral
• Rotation- with suspension belt systems, start in
  external rotation because when tightening belt,
  socket will interiorly rotate
• Use a wall for support when tightening belt

113
DAILY REMINDERS FOR YOUR PAIENT
114
RESIDUAL LIMB CARE

• Wash limb daily and massage skin
• Inspect skin after wearing prosthesis
• Desensitize your stump daily, if necessary
• Wear shrinker or ace wrap when not wearing the
  prosthesis
• Wash shrinker every 3-4 days unless soiled

115
INTACT LIMB CARE

• Inspect your foot each day
• Mirror
• By touch
• Wash and dry your foot properly
• Avoid burns and test water with body part with
  intact sensation
• Use thermometer
• Moisturize your skin
• Perfume free lotions
• Protect the foot from injury
• Check inside of shoes for objects or rough edges
• Wear proper fitting shoes
• Wear shoes or slippers at all times
• Have physician or podiatrist examine regularly

116
USING YOUR PROSTHESIS

• Put leg on and increase wearing time daily
• 30 -60 minutes per day as tolerated
• Gradually increase to a full day of usage
• Clean your sock daily

117
CARING FOR THE PROSTHESIS

• Clean the inside and the outside of the hard
  socket with warm soap (mild) and water.
• Do the same for soft insert
• Clean the socket and insert at the end of the day
  to allow them to air dry overnight.

118
USING YOUR PROSTHETIC SOCKS

• Check your sock ply daily
• Always wear clean socks (wash socks every 3-4
  days unless visibly soiled)

119
YOUR HOME EXERCISE PROGRAM

• Follow your home exercise program daily
• Walk each day, within safety guidelines

120
PROSTHETIC PRESCRIPTION

• What is good for the goose is not always good for
  the gander

121
PROSTHETIC PRESCRIPTION

• Many factors weigh when it comes to prosthetic
  prescription. They include
• Insurance plays a major part in what a patient
  will receive despite a patients potential as an
  ambulator
• If insurance is not a factor, components should
  be chosen based on weight and degrees of freedom
  of joints. Energy expended is related to
  prosthetic componentry.
• Schmalz T, Blumentritt S

122

• Prior level of function and general health should
  be considered. If a patient was a very limited
  household ambulator, top of the line componentry
  should not be prescribed until the patient proves
  otherwise.
• Age plays a factor because most people in the
  geriatric population prefer a stable joint versus
  a free moving joint
• The condition of the intact limb also should be
  considered. Prosthetic design, fitting and
  training play a role in the net joint forces on
  the intact limb at the ankle knee and hip. If
  less energy is expended moving a prosthesis
  through space, less demand placed on the intact
  limb in stance for stability. Componentry and
  fit will directly affect the ease of movement
  through space
• Nolan L, Lees A

123

• Should also consider the overall health of the
  patient in terms of cardiac and pulmonary status
  considering the energy demands of using a
  prosthesis. Of course amputation level will play
  a role in this determination
• Wheelchair is a more energy efficient mode of
  transportation and should be strongly considered
  especially with bilateral amputees
• Also should consider cosmesis, mental status and
  assistance will have at home. Should not
  prescribe certain prostheses if patient lives
  alone and patient cannot donn independently.
• Dubow LL, Witt PL

124
K CODES

• A set of prognostic patient categories initially
  developed within the Medicare system

125

• K0-patient does not have the ability or potential
  to ambulate or transfer safely with or without
  assistance and a prosthesis does not enhance
  their quality of life.
• K1- patient has the ability or potential to use a
  prosthesis for transfers or ambulation on level
  surfaces as a fixed cadence. Typical of the
  limited and unlimited household ambulator.
• K2 patient has the ability or potential for
  ambulation with the ability to traverse low level
  environmental barriers such as curbs, stairs, or
  uneven surfaces. Typical of the limited
  community ambulator.

126

• K3 patient has the ability or potential for
  ambulation with variable cadence. Typical of the
  community ambulator who can traverse most
  environmental barriers and may have vocational,
  therapeutic, or exercise activity that demands
  prosthetic use beyond simple locomotion.
• K4 has the ability or potential for prosthetic
  ambulation that exceeds basic ambulation,
  exhibiting high impact, stress, or energy levels.
  Typical of the prosthetic demands for the child,
  active adult or athlete.

127
THINGS TO REMEMBER

• It is important to constantly educate the patient
  and or family on proper skin inspection and sock
  ply management to prevent adverse consequences in
  the future
• Many of your patients will be diabetics or have
  skin healing issues. Your patient may take
  several months to properly heal post amputation
  leading up to the big day of receiving the
  prosthesis.
• In one session you could set your patient back
  days, weeks or months if you do not check for
  proper fit of the prosthesis

128

• Understand the population you are dealing with.
  Most of your patients will have amputations due
  to vascular issues. Many of these amputations
  could have been delayed or avoided with proper
  education or compliance
• Listen to your patients. If you listen closely
  enough they will tell you what is wrong in their
  own way. Most of the time you will have the most
  intimate contact with the patient. It is
  important to evaluate for any changes.
• If arterial changes are present distally there is
  a good chance that it is present proximally.

129

• Work closely with your prosthetist
• Exercises and activities should be enjoyable,
  varied, goal-oriented and realistic
• Have fun and be creative!!!!

130
REFERENCES

• 1. Esquenazi A Analysis of Prosthetic Gait.
  Phys Med and Rehab, vol 8, no. 1, February 1994
• 2. Ertyl J, Janos P Amputations of the lower
  extremity. E-medicine, January 30 2005 section
  1-11
• 3. Frykberg R, Armstrong D Diabetic Foot
  Disorders, A clinical practice Guidline for the
  American college of foot and ankle surgeons
• 4. Gailey R, Comparison of metabolic cost
  during ambulation between the contoured
  trochanteric-controlled alignment method and the
  quadrilateral socket. Prosthetic orthotic Int
  172, 95-106, 1993
• 5. Hung CT Amputation energy cost of
  ambulation. Arch of Phys Med Rehab 1979, 60,
  18-24

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REFERENCES

• 6. Levin ME Total Contact Casting in The
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• 7. Pagliarlo MA Energy cost of walking of
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  Phys Ther 595, 538-543, 1979
• 8. Sarkar P Ballantyne S Management of leg
  ulcers. Post grad. Med J 200076674-682
• 9. Sinacore Total Contact Casting For Diabetic
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• 10. Smith D Transfemoral Amputation Level, 2.
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• 11. McCulloch JM, Boyd VB The effects of
  whirlpool and the dependent position on lower
  extremity volume. J Orthop Sports Physical
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• 12. Nolan L, Lees A The functional demands on
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  transfemoral and transtibial amputees. Prosthet
  Orthot Int. 2000 Aug24(2)117-25
• 13. Devlin M, Sinclair LB Patient preference
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  Arch Phys Med Rehabil. 2002 Feb83(2)246-9
• 14. Schmalz T, Blummentritt S Energy
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  components. Gait posture. 2002 Dec16(3)255-63
• 15. Dubow LL, Witt, PL Oxygen consumption of
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