Friday, December 2, 2022

Responses: BK amputee with blister

Thank you for your responses! These blisters ended up going away as some
of you had predicted.
Original post:

Hi all,

I have a BK amputee wearing a 3s system (Alpha liner). He is a dialysis
pt with a normal size 6″ residual limb. He has been getting water
blisters

at the distal end of his residual limb. I have ensured he is not end
bearing and have a liner-liner sock under the Alpha liner. He still gets
these
water blisters. He is only wearing the prosthesis for 30 minutes per day
for now. I will be removing the pin and use a suspension sleeve next.
Has
anyone had a similar problem with distal water blisters? He even got them
from wearing a stump shrinker prior to wearing a prosthesis.

Thank You,
David Falk, LPO, CPO
Falk P & O

Responses:
I have had similar patients and it was almost always either the conical
shape of the liner is to tight and it is trying to slide off or when he is
putting it on, he is not FULLY putting it on with total contact, therefore
creating a void between his stump and the liner so it suck on the end.

David, I too have had this problem with a couple of new amputees. I have
never been able to figure out the cause but they go away after a bit of
wearing the prosthesis and never come back. I told the pt. not to pop the
blisters and just leave them alone and they just dried up and not to return to
become a problem.I checked for total contact , fit, and alignment all checked
out ok. I don’t know what the cause is other than fluid working it’s way
out of the distal aspect or heat blisters? Most of my problem was directly
on the incision area and a little on the vary distal. Let me know what you
find from others please> Thanks David good luck

The problem you are having may have to do with ensuring he is not end
bearing. Distal contact is a must in order to avoid this problem

Yes I have experienced this many times over the past thirty years.
Obviously the patient in question is also a Type 2 diabetic. There are
also obvious fluctuations in volume of the residuum due to dialysis. In my
experience I have found that folks who do not control their fluid intake
between treatments tend to have more volume fluctuations. The day following
dialysis their residuum is rather large and after donning the prosthesis the
fluid wants to escape quickly. If there are thin areas of skin the fluid will
escape thru the least path of resistance creating tiny water blisters.
Sometimes one or two and other times ten or twelve.
I have also seen this with non dialysis patients. Funny thing is there’re
all diabetics.
It can be very frustrating and in the past I always blamed myself for this
reaction. After the years I have just learned to deal with it as it
happens and always let my diabetic/dialysis patients to be aware of this
phenomenon. It does always subside in time however.
I have toyed in the past to try to do a study on this but as usual have
not had the time. Sounds like a good project for a new resident or an Academy
Fellow looking to publish to take on this project.
I know this isn’t really helpful, but I have a pt who get’s blisters from
everything except for the Alpha liner. Her water blisters were caused by
an allergic reaction to all other liners. She’s good hygenically, so that
wasn’t the issue. She even had a reaction to the Alps liner…which to
me, seems identical to the Alpha….but it was consistent. Whenever she went
back to the Alps or otto bock liners, she’d have the reaction. Does he
have any allergies that you know of?
1. Water blisters are not caused by Force. They are caused by friction
and moisture.
2.End bearing or distal end contact shouldn’t cause a blister.
3. If the patient is lacking distal contact with a pin system, then
under non weight bearing conditions the weight of the prosthesis can
pull on the pin causing a “plunger” effect b/w the liner and distal end
of the residual limb. Basically, pulling fluid distally with the
potential of causing water blisters
4. If the patient suffered water blisters with just wearing a shrinker,
then the problem could be intrinsic in nature. May be they are not
pulling enough fluid off during dialysis. What is his normal dry weight
compared to his current dry weight? Are they able to get him to his dry
weight? Does he have CHF? Is he on fluid pills and does he take them
appropriately.
Put him into suction socket.
Let him wear a thin sheath between his residuum and liner.
Blisters are coming from air pockets trapped between skin and liner,
prolly poor donning technique, that start working as vacuum chambers
during ambulation. Pin suspension “milks” distal end, aggravating this.
Are these blisters along the suture line? I often see this,
especially if the suture site is invaginated. My experience has been
that a lack of contact is the culprit, not too much pressure
I had a very similar situation with a late fifties female who had several
other concomitant health issues, but was not on dialysis. The distal third
of her residual limb presented with skin that was blotchy, slightly raised
and red in appearance that was present prior to amputation. It was the
first case of this I had seen, and she was never given a name of what it was,
but was ensured it would not affect her prosthetics care and was given
clearance to begin. I started her in a 3S system as well and immediately
developed the same watery blisters (sometimes with a bloody hue to them). I too
ensured good total contact globally, avoidance of excessive distal
inferior end pressure and even switched liners, all to no avail. I then removed
the pin and added the sleeve, and the blisters ceased immediately. We came
to the conclusion the fragile nature of the distal skin could not tolerate
the negative pressure created by the distal draw of the pin. Hope
this helps!
I experienced something similar with a TEC liner on a “fairly regular”
established BK patient. He had only worn the leg a couple of days. At
the time I struggled to come up with an idea why it happened and
understandably he refused to wear the liner further so I could not
investigate it. It did not look like distal congestion and I considered
the socket a good fit. So, I will be keen to see what feedback you get.
Sounds like either negative pressure or air trapped when donning liner.
Make sure he dons it completely against the distal end of the limb.
I have seen this presented a number of times. Often the blisters occur at
the scar sites where adhesions can occur. Often continued gentile
manipulation of scar tissue can help the situation. Even if you don’t
change
anything, they will often resolve themselves. Infection is an issue. Have
them keep the sites clean. Liner-liner socks with silver help. You may need

to change liners to help with the “pulling on the skin”. Another thought is

that a vacuum system is sometimes a good choice. You must ensure total
contact so not to place too much pressure on any one place.
Initial thoughts are that he is getting a distal distraction of the
liner/pin while in swing phase which will pull the liner away from skin causing
the water blisters. You may try adding the sleeve while still using the pin.
In my experience, water blisters are caused by lack of contact. Hope you
get it figured out!

This is a common problem when the socket is not fitting in some degree of
“Total-Surface-Bearing”. Blisters terminally usually indicates insufficient
terminal/distal compression, especially combined with proximal
constriction/tightness, which restricts venous and lymphatic return flow
superiorly. Make sure there is not excessive proximal compression,
especially posteriorly over the popliteal region, which is where major
vessels are close to skin, especially vein can be constricted if there is
excessive popliteal compression. Secondarily, place a terminal pad to
increase terminal/distal compression. Seek medical monitoring. Reduced
prosthesis wear, using Bioclusive over blisters, or, per medical advice, no
prosthesis until blisters reduce

just had a pt come in yesterday with a similar symtom. In his case, I
suspect but cannot confirm that he did not don his liner correctly and had an
air bubble trapped at the distal end of his liner. I would be curious to
see the other responses/solutions you receive

I had a patient once that was in a Dermo Cushion liner that developed water
blisters. Typically water blisters will form in a suction system when you
don’t have any distal contact. The axial loading causes excessive skin
tension without distal contact and can actually augment the shear forces that
occur to the patients residuum. However, in this case we did a clay ball
test and confirmed that he was getting distal contact. So the only other thing
that could possibly cause water blisters to form was a compromise in skin
integrity. The “skin friendly” material used in the dermo liners actually
softened the skin too much allowing the skin layers to shear more easily. I
would ask the patient if he is using any lotions on the limb that are
causing the skin to be “softened”. This may be the root of your problem. Hope it
helps

I have a patient who is not on dialysis but has renal failure issues and
major swelling at times. He also is having these water blisters showing up
at times. He was having these problems before even getting a shrinker, and
the doctor and I both felt that maybe wearing a shrinker would help get
the fluid to leave his limb (bk amputee) and help reduce the swelling and
pressure inside his limb. That seemed to improve for the most part for a few
weeks when he was wearing the shrinker. But now that he has a prosthetic
leg, he has a suction fit with an Iceros liner. The first few weeks of
wearing the leg, he had no issues or problems. Then for a few days, he had
blister issues come back, and then went away on their own. There was no
changing in what he was doing with the prosthetic leg, he just kept doing exactly
the same as he was before the blisters showed up, and he has not had any
issues since that time either.
Fortunately they did heal up and went away rather quickly, and didn’t end
up infected or with other problems.
But we have all ruled out anything relating the prosthesis or shrinker as
causing these blisters or having really any affect on that situation. They
might return at some point, but we hope to not see that again.
The one that they he MIGHT think contributed to the blisters and skin
irritation could be the type of soap that he was using at that time. That is
always one of the very first questions that I ask any patient that shows up
with skin problems. When he had to think about the soap issue, he recalled
changing soaps sometime in that time period. He will stick to the plain
Dial gold bar soap, and see if that makes any difference.

It has been my experience that shear force is always the culprit.The skin
gets pulled tight when he puts his leg down in the socket causing the
blisters. You can use a piece of clay in the bottom of the socket to see how much
room he has in the distal ens when weight bearing. That will tell you if
he is getting distal contact.Make sure he is getting distal contact and it
will clear up. Hope this helps

It’s from a lack of contact….Add a skived round distal end pad made out
of
1/4″ plastazote to inside of the liner

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