National Cancer Centre - Cancer Update

Amputation is the removal of a body part and it occurs due to many reasons:

Trauma: for e.g., motor vehicle accidents, work related injuries
Diseases: poor circulation, diabetes, cancer
Conditions that is present at birth

There are many factors that determine how much of the limb is amputated. Generally, the longer the remaining limb and the more joints that are kept in tact, the easier it is to fit and use prosthesis.

Foot Amputations
Amputation of any part of the foot. This includes mid tarsal amputations, Lisfranc amputation, Boyds amputation, and Symes amputation
Transtibial Amputations (below the knee)
Amputation occurs at any level from the knee to the ankle
Knee Disarticulation
Amputation occurs at the level of the knee joint
Transfemoral Amputations (above knee ):
Amputation occurs at any level from the hip to knee joint
Hip Disarticulation:
Amputation is at the hip joint with the entire thigh portion being removed.

Nursing management of patient with amputation

Pain Management
Managing pain is important. It is important to serve analgesia strictly. Assess patients’ response towards pain medication. Psychological support
Patients undergoing amputation will be under tremendous stress. Anxiety level will be escalated. It is important that patient understands the reasons for surgery and how to deal with it postoperatively. Consistent support and encouragement from family members and healthcare workers are important towards patients’ recovery.
Rehabilitation
Rehabilitation plays an important role towards patients’ recovery. Exercise should be initiated early. Patients will be seen by a Physiotherapist postoperatively and is responsible to teach some range of motion (ROM) exercises, muscle strengthening, stump exercises, balancing exercises etc to patient. The Occupational Therapist will be teaching patient wheelchair transfer, safe transferring techniques and conduct activities of daily (ADL) assessment.

The Immediate Post surgical Period
Nearly every amputee feels depressed immediately after the surgery, except possibly those who have suffered intense pain for a period just prior to the amputation. This depression is usually replaced early by a will to resume an active life.

The dressing applied by the surgeon is "soft," using ordinary cotton bandaging techniques. Elastic bandages are used soon after surgery to aid circulation. The bandages are removed and reapplied throughout the day.

Regardless of the type of dressing used, exercises are very important to prevent contractures (tightening of the muscles) which, when present, prevent efficient use of a prosthesis.

Dos and Don’ts to prevent muscle tightening, or contractures.
Coronal T2-weighted scan of the prostate show seminal vesicle invasion (arrow) on the right.

Prescribed exercises should be done regularly, and the positions shown be avoided if the greatest benefit is to be obtained from the prosthesis.

Preparation for Fitting the Prosthesis
In general, the earlier a prosthesis is fitted, the better it is for the amputee. One of the most difficult problems facing the amputee and the treatment team is edema, or swelling of the stump, owing to the accumulation of fluids. Edema is present to some extent in all cases, and it makes fitting of the prosthesis difficult, but measures can be taken to reduce edema.

Elastic bandages are used to keep edema from developing. The patient is taught the proper technique for bandaging and is generally expected to do this for himself. The stump should be bandaged constantly, but the bandage should be changed every four to six hours. It must never be kept in place for more than 12 hours without re-bandaging. If throbbing should occur, the bandage must be removed and rewrapped.

Special elastic "shrinker socks" are available for use instead of elastic bandages, and while not considered by some to be as effective as a properly applied bandage, "shrinker socks" is better than a poorly applied elastic bandage.Whether an elastic bandage or shrinker socks is used, it should be removed at least three times daily and the stump should be massaged vigorously for 10-15 minutes. The bandage or socks must be reapplied immediately after the massage.The Preparatory Prosthesis
After surgery, fitting as soon as possible also helps to combat edema. A preparatory prosthesis is frequently used for several weeks or months until the stump has stabilized before the "permanent", or definitive, prosthesis is provided.

The socket of the preparatory prosthesis may be made of either plaster-of-Paris or a plastic material, and is usually attached to an artificial foot by an aluminium tube often called a "pylon". The aluminium pylons are usually designed so that the position, or alignment, of the foot with respect to the socket can be changed when necessary. Although a variety of shoes may be worn with artificial limbs, the patient should consult with the prosthetist before selecting the shoes because heel height is a major factor in alignment of the artificial leg.A belt about the waist is usually used to help keep the prosthesis in its proper place on the stump. At least one prosthetic sock is worn between the socket and the body to provide for ventilation and to protect the skin from rubbing. Most prosthetic socks are made of woven virgin wool, but socks of synthetic yarns are also used. Three thicknesses are available: 3 ply, 5 ply, and 6 ply.Additional socks can be used to compensate for stump shrinkage if the amount of shrinkage is not too great. The prosthetist and therapist can suggest the sock or socks to be used, but only the patient can determine the proper selection. Prosthetic socks must be changed daily to reduce the chance of irritation of the skin and dermatitis.Additional socks can be used to compensate for stump shrinkage if the amount of shrinkage is not too great. The prosthetist and therapist can suggest the sock or socks to be used, but only the patient can determine the proper selection. Prosthetic socks must be changed daily to reduce the chance of irritation of the skin and dermatitis.

Prosthetic socks require special care in laundering. The manufacturers provide instructions. A specially woven nylon sock known as a prosthetic sheath is used by many amputees between the skin and the regular prosthetic sock to provide additional protection from abrasion. The sheath also allows perspiration to escape to the prosthetic sock and thus to the atmosphere.

Donning Your Prosthesis and Socks

Be sure the prosthesis and socks have been cleaned and thoroughly dried before donning. Wear a fresh sock everyday. Your residual limb should be clean and dry as well. Before donning the prosthesis, inspect the leg with a mirror for any areas of redness, breakdown or tender to the touch Place a sock over the end of your residual limb before donning prosthesis. The socks protect your skin from injury and sores. Apply each sock one at a time. Place all seams facing out and away from bony areas. Wear enough socks to hold your socks properly down in the prosthesis, and to prevent movement up and down inside the prosthesis. Be sure that your socks fit closely, without any folds or wrinkles. Folds and wrinkles cause increased pressure on the skin that can lead to skin irritation and breakdown and decrease circulation.
Do not put band-aids or tape on your leg before wearing your prosthesis. Once the socks are on, the prosthesis may be donned slowly and gently.

Care of Your Remaining Leg

Inspection skin frequently especially your feet for signs of redness, skin breakdowns and areas tender to touch Do not wear socks with holes or darns Changes socks daily Break in new shoes slowly Do not cut on corns or calluses Have a podiatrist cut your nails Wash feet in warm water, not hot, and pat dry with a soft towel Avoid walking barefoot
Wear only well fitting shoes

Care of Your Residual Limb

Wash your residual limb every evening with lukewarm water and a mild soap. Bathing may cause the residual limb to swell, which could affect the fit of the prosthesis. Therefore, evening bathing is recommended.To eliminate bacteria growth, thoroughly clean skin folds using cotton swabs. Completely rinse and towel dry. Inspect your residual limb after wearing your prosthesis; carefully watch for such skin changes as redness, breakdown or areas tender to the touch. This can be accomplished with the use of a long-handled mirror.Gently massage your residual limb daily. This will help decrease sensitivity and increase pressure tolerance. Do not apply oils, creams or alcohol to your residual limb because your skin must toughen for you to wear your prosthesis. Creams cause your skin to soften, and alcohol causes your skin to become dry. Avoid prolonged dependent positioning of residual limb
Avoid prolonged pressure to the stump site to avoid skin breakdown

Sock Hygiene

Wash all residual limb covering materials (ace wrap, shrinker, socks) daily in lukewarm water and a mild soap or Woolite Gently squeeze the soap through your socks. Do not twist or rub. Rinse thoroughly.
To dry, roll your socks in a towel and place on a flat surface or over an empty bleach bottle that has holes poked in it.

Prosthetic Care

Wipe out the prosthetic socket daily with a damp cloth and a mild soap or alcohol. Dry the socket thoroughly with a clean towel.
The prosthesis should be placed on its side on the floor when not in use so that it does not fall over and crack.

Bandage Care

Wash elastic bandages with mild soap and warm water. Rinse thoroughly
Do not hang up to dry – this may spoil the elastic. Lay out on a flat surface. Keep away from heat and sunlight, which may also harm the elastic.

Equipment Training

Amputee should be trained for use of following equipment which should be procured for ease in activities of daily living. Bath-seat shower hosenon-skid mat or strips long bath spongetoilet rails
other - commode, sliding board

Transfers (with PT)

Walk with appropriate assisting device into bathroom
transfer on/off toilet
transfer in/out tub and/or shower using equipment

Bathing Training

Patient is able to reach all body parts
patient is using adaptive equipment appropriately
patient can stand to bathe buttocks and perineum safely

Mobility in the Kitchen and Home

Open and close refrigerator door
take out and return item to refrigerator
turn on/off stove and/or oven
turn faucet in sink on/off
carry filled pot to the stove
remove hot pan from stove and/or oven
remove and return items from cupboards and/or drawers at all levels
pick up something from the floor
set table
other, i.e. vacuuming, cleaning tub

Education

Body mechanics Nutrition Safety
Energy conservation/ work simplification

Upper Body Exercise Program

Wheelchair pushups Push-up blocks Wall pulleys bilateral sander Ergometer Theraband Dowel exercises Hand grippers free arm exercises with weights
Un-supported sitting with ball toss, balloon volley, beanbags

Stump Bandaging

Un-supported sitting with ball toss, balloon volley, beanbags Bring the bandage over the inner end of the stump and diagonally up the outer side of the stump. Bring the bandage under the back of the knee, continue over the upper part of the kneecap and down under the back of the knee.
Bring the bandage diagonally down the back of the stump and around over the end of the stump. Continue up the back of the stump to the starting point on the inside of the thigh and repeat the sequence in a manner so that the entire stump is covered by the time the roll is used up. The end of the bandage is held in place with the special clips that are provided. It is important that the tightest part of the bandage be at the end of the stump.

3 general rules if skin disorders develop:

See your physician for treatment. A minor disorder may become disabling if incorrect treatment is used. See your prosthetist . Adjusting the prosthesis may do away with the cause of the skin disorder.

Never use strong disinfectants, such as iodine, on the skin of the stump.

Abrasions
The skin is sometimes abraded (rubbed raw) by the socket.

Gently wash skin with liquid or cake cleanser and warm water. Cover with a mild antiseptic, such as backtracking ointment and sterile gauze Make sure prosthesis is dry before it is put on If abrasions occur often, see your prosthetist
If an abrasion shows any sign of infection: see your physician

Blisters
If a blister is small and does not hurt:

Wash it with antiseptic cleanser and leave it alone. Opening a blister without proper precautions and sterile instruments may cause infection
If it is large, painful and recurs often, see your physician

Bacterial Infections
May become serious and should be treated without delay.
Hair-root infection is a common minor bacterial infection. To treat:

Clean area daily with liquid antiseptic cleanser Keep dry at other times
Allow air to circulate freely over infected area

Boils and Abscess are two more serious types of bacterial infection.
If they occur, see your physician.
Until then:

Rest as much as possible, with prosthesis off and stump raised.
Apply hot compresses (cloth soaked in hot water) for 30 minutes every 3-4 hours

Fungus infections
Are usually not serious but may be annoying.
For prevention:

Follow rules of stump hygiene Leave area of infection exposed to air as much as possible
Keep skin dry

Maria Abdullah
Nurse Clinician
Dept of Orthopaedics
Singapore General Hospital

Paurnima Uday
Prosthetist & Orthotist
Trufit Limbs Centre