Wound Care, Preventing Contractures
September 2008 Issue
Fostering wound healing and preventing muscle contractures are important aspects of postoperative therapy.
"After amputation surgery, the first order of business is fostering wound healing," says Joan Edelstein, PT, MA, FISPO, adjunct faculty member of Columbia University, New York, and former associate professor of clinical physical therapy and director of the Columbia Program in Physical Therapy.
Edelstein outlines three principal types of wound dressings: elastic bandage, rigid dressing, and semi-rigid dressing. ( Editors note: For more information on wound care and types of dressings and their advantages/disadvantages, see the report on the American Academy of Orthotists and Prosthetists (the Academy) Clinical Standards of Practice report on "Postoperative Management of the Lower Extremity" .)
Edelstein favors the Unna boot, a semi-rigid dressing with calamine, glycerin, and gelatin. "Its easy to apply and removeall you need is bandage scissors," Edelstein says. "Its also somewhat sticky, so it will adhere to the skin and the patient thus will not need a waist belt or shoulder harness. Patients appreciate this because they dont want any more apparatus than is absolutely necessary. We did a comparison study with elastic bandages; the Unna was far, far more successful, especially for people with transfemoral amputationsand its about 150 years old!"
The study, titled "Unna and Elastic Postoperative Dressings: Comparison of Their Effects on Function of Adults with Amputation and Vascular Disease," by C.K. Wong and Edelstein, was published in the Archives of Physical Medicine and Rehabilitation, September 2000.
Contractures are easy to prevent but difficult to correct, observes the National Institutes of Health (NIH). The NIH provides these guidelines for persons with lower-limb amputations:
- The amputee must not lie on an overly soft mattress, use a pillow under the back or thigh, or have the head of the bed elevated. Standing with the transfemoral residual limb resting on a crutch should be avoided. All these practices can lead to hip flexion contractures.
- The amputee must not place a pillow between the legs, since this creates a hip abduction contracture.
- A transtibial amputee must not lie with the residual limb hanging over the edge of the bed, with a pillow placed under the knee, or with the knees flexed, and must not sit for a long period of time in order to avoid knee flexion contractures. The transtibial amputee should sit with the knee extended on a board under the wheelchair cushion with a towel wrapped over the board.
- Amputees should lie prone for 15 minutes three times a day to prevent hip flexion contractures. The amputee who cannot lie prone should lie supine and actively extend the residual limb while flexing the contralateral leg.
Read the related article "Preprosthetic Therapy: Is It Needed? Does It Help" in the October 2008 issue of The O&P EDGE.