WOUNDS AND SCARS IN AMPUTEES AN OVERVIEW SANZIDA HOQUE SENIOR INPATIENT REHABILITATION PHYSIOTHERAPIST NEPEAN HOSPITAL
Mar 29, 2015
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