WOUNDS AND SCARS IN
AMPUTEES
AN 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

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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


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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

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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:


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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

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
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:


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
70% poor healing/ infection
20% poorly fashioned stump
10% phantom limb pain
Types of complications include:

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Infection
Tissue necrosis
Pain
Dehiscence
Surrounding skin problems
Bone erosion/ osteomyelitis
Haematoma
oedema
WOUND HEALING
COMPLICATIONS contd

INFECTION

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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

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Caused by poor tissue
perfusion
Dusky, purple,
gangrene, sloughy
tissue, cold and painful
RX: Debridement (larval
therapy vs. surgery)
WOUND HEALING
COMPLICATIONS contd

PAIN

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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

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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


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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


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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

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Common due to vascular insufficiency and fluid
retention
RX: Elevate, stump supports, VAC, elastic
stump socks, plaster casts (RD/ RRD)
WOUND MANAGEMENT


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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

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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

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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

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Air splint
Paste (zinc oxide and calamine)

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Thermoplastic

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E.g. polyethylene (figure above)
ADVANTAGES

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e.g. Unna Boot
Better volume control than soft dressings
Can be used with pylon and foot for early mobilisation
(IPOP and EPOP)
DISADVANTAGES

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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

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Provides compression
Smooths scar
Can allow early prosthetic use with the liner
DISADVANTAGES

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Sweat
Needs to be washed daily
Minimal protection against trauma
WOUND MANAGEMENT contd

SOFT DRESSINGS
WOUND MANAGEMENT contd
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SOFT DRESSINGS
SHRINKERS, ELASTIC BANDAGES
ADVANTAGES

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Low cost
Washable
Easy to don/ doff
Easy to monitor wound
DISADVANTAGES

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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

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Only RCT/ CT on silicone and corticosteroids
Not specific to the amputee population
Other recommendations are low level expert
advice
SCAR MANAGEMENT

SURGICAL

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CORTICOSTEROID INJECTION


Ultrasound, hot packs, wax, to increases tissue extensibility
SILICONE GEL SHEETING


Stretches tight collagen, results inconclusive, used in burns
HEAT THERAPY


Liquid nitrogen to affect cell microvasculature, flattens scars in 51- 74% of cases
COMPRESSION


Flattening of scars seen in 57- 83% of cases
CRYOTHERAPY


Inhibits protein synthesis, diminishes tissue deposition and softens scars
LASER THERAPY


Tension releasing or excision, has a high risk of reoccurrence when not used in
conjunction with corticosteroid and silicon gel sheeting
Good evidence with 8 RCTs
PHARMACOLOGICAL

NSAIDs, Antihistamines, Interferons
SCAR MANAGEMENT contd

MASSAGE

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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
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“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
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“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-skincare.html
“Scar management” Naude L. (2006) Wound Care