WOUNDS AND SCARS IN AMPUTEES AN OVERVIEW

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WOUNDS AND SCARS IN AMPUTEESAN OVERVIEW

• SANZIDA HOQUE
• SENIOR INPATIENT REHABILITATION PHYSIOTHERAPIST
• NEPEAN HOSPITAL

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AIM

• Improve understanding of wound healing and scar
  formation
• Improve knowledge of possible complications in
  amputee wound healing and better recognition and
  management of these
• Learn and clarify the best practices for wound
  healing and scar management in amputee care

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OVERVIEW

• Pathophysiology of wound healing and scar
  formation
• Complications with wound healing
• Wound management in amputees
• Scar management in the amputee population

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WOUND HEALING

• Complex process
• Basic outline in 3 phases
• 1 Inflammatory
• Usually 2- 5 days
• Hemostasis achieved through vasoconstriction,
  platelet aggregation and clot formation by the
  thromboplastin
• Vasodilation and phagocytosis leads to
  inflammation

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WOUND HEALING contd

• 2 Proliferative phase
• Varies 2 days to 3 weeks
• Granulation occurs with formation of new collagen
  and capillaries and the cicatrix reddens during
  this period
• Wound edges pull together/ contraction occurs
• Epithelialization occurs as the epithelial cells
  crosses the moist surface and forms a barrier
  between the wound and environment

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WOUND HEALING contd

• 3 Remodelling phase
• 3 weeks to 2 years
• Collagen remodels to better resist strain
• Reduction in vascularisation with the cicatrix
  whitening

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WOUND HEALING contd

• 2 types of healing primary and secondary
• Primary healing usually seen in surgical wounds
  causes minimum tissue damage with minimal
  inflammation and demand on tissue
• Secondary healing is when an open area remodels
  with granulation tissue and a thin layer of
  epithelium. Usually slower and forms scars with
  high risk of infection and adherences

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SCAR FORMATION

• 13 of BKA and 2 of AKA have adherent scars
• Scars are influenced by 3 factors
• Surgical technique
• Post op care
• Skin type

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SCAR FORMATION contd

• Scar formation is a normal part of the healing
  process
• Composed of fibrous tissue
• In the remodelling phase a scar thins by the
  process of collagen lysis exceeding the rate of
  collagen deposition
• Hypertrophic or keloid scars formed when this
  alters

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SCAR FORMATION contd

• HYPERTROPHIC SCAR
• Raised, thick, rough, red and irregular, remains
  within the limits of the original wound.
• More in dark skin and deeper wounds
• KELOID SCARS
• Thick, puckered, itchy cluster of scar tissue
  that grows beyond the edges of the wound.
• The scar can also be very nodular
• Keloid scarring occurs due to the continuous
  multiplication of fibroblasts even after the
  wound is closed

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WOUND HEALING COMPLICATIONS

• Factors that influence wound healing in amputees
  are nutrition, age, smoking, old grafts, co
  morbidities (diabetes, anaemia, renal failure),
  inappropriate level selection, inadequate post op
  management, infection and the technical precision
  of the surgeon

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WOUND HEALING COMPLICATIONS contd

• Common complications include
• 70 poor healing/ infection
• 20 poorly fashioned stump
• 10 phantom limb pain
• Types of complications include
• Infection
• Tissue necrosis
• Pain
• Dehiscence
• Surrounding skin problems
• Bone erosion/ osteomyelitis
• Haematoma
• oedema

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WOUND HEALING COMPLICATIONS contd

• INFECTION
• MRSA
• Cellulitis
• Increases amount of exudate ? breakdown of suture
  line ? wound dehiscence and tissue necrosis
• RX antibiotic, control BSL, debridement, wound
  cleansing, frequent dressing changes, silver/
  iodine dressings

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WOUND HEALING COMPLICATIONS contd

• TISSUE NECROSIS
• Caused by poor tissue perfusion
• Dusky, purple, gangrene, sloughy tissue, cold and
  painful
• RX Debridement (larval therapy vs. surgery)

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WOUND HEALING COMPLICATIONS contd

• PAIN
• Incisional stump pain vs. phantom pain
• Can be caused by infection, depression, increased
  pressure in cast, necrosis
• RX opiates, NSAIDs, local anaesthetics,
  anticonvulsants, tricyclic antidepressants, TENS,
  massage/ touch

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WOUND HEALING COMPLICATIONS contd

• DEHISCENCE
• Can be caused by trauma, too early removal of
  sutures, stump swelling increasing tension on
  wound
• RX VAC system, absorbent hydro fibre/ alginate
  dressings, surgery to explore, excise and close
  wound

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WOUND HEALING COMPLICATIONS contd

• SURROUNDING SKIN PROBLEMS
• Blistering is caused by reduced elasticity in
  dressing and increased oedema
• dermatitis
• RX Use non adhesive/ low adhesive dressing, do
  not use tape

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WOUND HEALING COMPLICATIONS contd

• BONE EROSION/ OSTEOMYELITIS
• Bone erosion can occur if the mm retracts over
  the stump or if wound is dehisced and increases
  the risk of osteomyelitis
• Infected sinuses
• RX Surgical intervention, antibiotics, alginate/
  hydro fibre dressings

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WOUND HEALING COMPLICATIONS contd

• HAEMATOMA
• Collection of blood increases tension in wounds
• RX Surgical debridement, often automatic
  drainage
• STUMP OEDEMA
• Common due to vascular insufficiency and fluid
  retention
• RX Elevate, stump supports, VAC, elastic stump
  socks, plaster casts (RD/ RRD)

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WOUND MANAGEMENT

• No overall consensus about wound dressing to
  optimise healing
• Primary goal should be to protect the wound,
  promote healing and reduce complications (eg.
  Infection)
• Wounds does not mean NWB. WB can help control
  oedema and facilitate healing
• Repeated inspection and modification of treatment
  is important and decisions should be made based
  on the progression/ lack of progression/
  worsening of the wound
• Type of dressing influences wound healing.
  Dressings with better pain management, oedema
  control improves healing

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WOUND MANAGEMENT contd

• Non adhesive
• Silver coated
• Alginate
• Hydro fibre

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WOUND MANAGEMENT contd

• OVERVIEW OF EACH TYPE OF DRESSING
• RD/ RRD

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WOUND MANAGEMENT contd

• RD/ RRD
• ADVANTAGES
• Limits/ reduces oedema
• May attach a foot/ pylon allowing early WB and
  gait training
• Earlier time to prosthetic fitting with better
  wound healing and volume control
• Wound inspection possible with RRD
• Knee flexion contracture prevention in RD
• Stump protection from trauma (falls)
• DISADVANTAGES
• Specialist skill/ therapist required for
  application
• Close monitoring required and often not possible
  with RD
• Can be heavy and affect bed mobility

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WOUND MANAGEMENT contd

• SEMI-RIGID DRESSINGS

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WOUND MANAGEMENT contd

• SEMI RIGID DRESSINGS
• Air splint
• Paste (zinc oxide and calamine)
• e.g. Unna Boot
• Thermoplastic
• E.g. polyethylene (figure above)
• ADVANTAGES
• Better volume control than soft dressings
• Can be used with pylon and foot for early
  mobilisation (IPOP and EPOP)
• DISADVANTAGES
• Off the shelf, may become loose
• does not protect from trauma as not rigid
• Air splint does not completely conform like RDs

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WOUND MANAGEMENT contd

• SILICONE LINERS

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WOUND MANAGEMENT contd

• SILICONE LINERS
• ADVANTAGES
• Provides compression
• Smooths scar
• Can allow early prosthetic use with the liner
• DISADVANTAGES
• Sweat
• Needs to be washed daily
• Minimal protection against trauma

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WOUND MANAGEMENT contd

• SOFT DRESSINGS

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WOUND MANAGEMENT contd

• SOFT DRESSINGS
• SHRINKERS, ELASTIC BANDAGES
• ADVANTAGES
• Low cost
• Washable
• Easy to don/ doff
• Easy to monitor wound
• DISADVANTAGES
• May slip off
• Slower healing, longer hospital stay
• Elastic bandage can be inconsistent with
  application causing pressure problems

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WOUND MANAGEMENT contd
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SCAR MANAGAMENT

• Prevention is better than treatment
• Limited literature
• Only RCT/ CT on silicone and corticosteroids
• Not specific to the amputee population
• Other recommendations are low level expert advice

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SCAR MANAGEMENT

• SURGICAL
• Tension releasing or excision, has a high risk of
  reoccurrence when not used in conjunction with
  corticosteroid and silicon gel sheeting
• CORTICOSTEROID INJECTION
• Inhibits protein synthesis, diminishes tissue
  deposition and softens scars
• LASER THERAPY
• Flattening of scars seen in 57- 83 of cases
• CRYOTHERAPY
• Liquid nitrogen to affect cell microvasculature,
  flattens scars in 51- 74 of cases
• COMPRESSION
• Stretches tight collagen, results inconclusive,
  used in burns
• HEAT THERAPY
• Ultrasound, hot packs, wax, to increases tissue
  extensibility
• SILICONE GEL SHEETING
• Good evidence with 8 RCTs
• PHARMACOLOGICAL
• NSAIDs, Antihistamines, Interferons

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SCAR MANAGEMENT contd

• MASSAGE
• Commonly used with amputees no RCT/ CT found
• Recommended 5- 10 min 3-4 times/ day
• Decreases oedema
• Breaks down scar tissue blocks
• Increases capillary proliferation and healing
• Assists desensitisation
• Re hydrates scar tissue (use of vitamin E cream
  is mentioned but no evidence)

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REFERENCES

• Wound healing complications associated with
  lower limb amputation Harker J. (2006)
• Phases of wound healing Fishman T. D. (1995)
• Stump management after trans-tibial amputation
  A systematic review Nawijn et al. (2005)
  Prosthetics and orthotics international
• Early treatment of trans-tibial amputees
  Retrospective analysis of early fitting and
  elastic bandaging Van Velzen et al. (2005)
  Prosthetics and orthotics international
• Silicon gel sheeting for preventing and treating
  hypertrophic and keloid scars OBrien L. and
  Pandit A. (2007) Cochrane database of systematic
  reviews
• Musculoskeletal complications in amputees Their
  prevention and management Bovvker et al. chapter
  25, Atlas of limb prosthetics surgical,
  prosthetic, and rehabilitation principles
• A clinical evaluation of stumps in lower limb
  amputees Pohjolainen T. (1991) Prosthetics and
  orthotics international

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REFERENCES contd

• Adherent cicatrix after below-knee amputation
  Lilja M and Johansson T. (1993) Journal of
  prosthetics and orthotics
• The use of silicone liners in early prosthetic
  rehabilitation. A pilot trial Anandan P. (2003)
  orthotic and prosthetic services Tasmania
• Stump ulcers and continued prosthetic limb use
  Salawu et al. (2006) Prosthetics and orthotics
  international
• A primer on ace wrapping and other compressive
  and protective dressings for the amputated
  residual limb Highsmith J.
• Healing of open stump wounds after vascular
  below-knee amputation plaster cast socket with
  silicone sleeve vs. elastic compression Vigier
  et al. (1999) American congress of rehabilitation
  medicine.
• International clinical recommendations on scar
  management Mustoe et al. (2001)
• http//www.amputee-coalition.org/military-instep/w
  ound-skin-care.html
• Scar management Naude L. (2006) Wound Care