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WOUNDS AND SCARS IN AMPUTEES AN OVERVIEW

WOUNDS AND SCARS IN AMPUTEES AN OVERVIEW. SANZIDA HOQUE SENIOR INPATIENT REHABILITATION PHYSIOTHERAPIST NEPEAN HOSPITAL. AIM. Improve understanding of wound healing and scar formation

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WOUNDS AND SCARS IN AMPUTEES AN OVERVIEW

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  1. WOUNDS AND SCARS IN AMPUTEESAN OVERVIEW SANZIDA HOQUE SENIOR INPATIENT REHABILITATION PHYSIOTHERAPIST NEPEAN HOSPITAL

  2. 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

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

  4. 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

  5. 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

  6. WOUND HEALING contd • 3 = Remodelling phase • 3 weeks to 2 years • Collagen remodels to better resist strain • Reduction in vascularisation with the cicatrix whitening

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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)

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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)

  20. 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

  21. WOUND MANAGEMENT contd • Non adhesive • Silver coated • Alginate • Hydro fibre

  22. WOUND MANAGEMENT contd • OVERVIEW OF EACH TYPE OF DRESSING • RD/ RRD

  23. 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

  24. WOUND MANAGEMENT contd • SEMI-RIGID DRESSINGS

  25. 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

  26. WOUND MANAGEMENT contd • SILICONE LINERS

  27. 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

  28. WOUND MANAGEMENT contd • SOFT DRESSINGS

  29. 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

  30. WOUND MANAGEMENT contd

  31. 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

  32. 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

  33. 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)

  34. 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” O’Brien 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

  35. 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/wound-skin-care.html • “Scar management” Naude L. (2006) Wound Care

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