WOUNDS AND SCARS IN

AMPUTEESAN OVERVIEW

SANZIDA HOQUE

SENIOR INPATIENT REHABILITATION PHYSIOTHERAPIST NEPEAN HOSPITAL

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

OVERVIEW Pathophysiology of wound healing and

scar formation Complications with wound healing Wound management in amputees Scar management in the amputee

population

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

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

WOUND HEALING contd 3 = Remodelling phase

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

whitening

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

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

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

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

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

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

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

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)

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

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

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

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

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)

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

WOUND MANAGEMENT contd Non adhesive Silver coated Alginate Hydro fibre

WOUND MANAGEMENT contd OVERVIEW OF EACH

TYPE OF DRESSING RD/ RRD

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

WOUND MANAGEMENT contd SEMI-RIGID

DRESSINGS

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

WOUND MANAGEMENT contd SILICONE LINERS

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

WOUND MANAGEMENT contd SOFT DRESSINGS

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

WOUND MANAGEMENT contd

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

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

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)

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

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