The Importance of Wound Care for Limb Loss Patients
Knowledge of proper treatment of wounds is essential for both health-care professionals and O&P patients.
Individuals who experience limb loss must undergo several stages of wound healing. During the process, these patients face the risk of their wounds worsening or becoming infected, which can lead to pain, fever, swelling, additional surgeries, and other complications. To ensure a more successful recovery and rehabilitation period, it’s important for both the health-care professionals assisting new amputees and the patients themselves to understand proper wound care techniques.
In the first part of this article, Nancy Payne, MSN, RN, CWCN, shares the most important aspects of wound care for limb loss patients. According to Payne, her roles as limb loss clinical nurse specialist and certified wound care nurse at Duke University Hospital go hand in hand. Her specialized training in wound care allows her to adequately address the issues she sees in her patients, train amputees and their caregivers on appropriate wound care protocols, and train other members of the health-care team to appropriately assess wound care needs in a timely manner. The hope is that this combination of clinical application and patient/health team education will increase patient compliance and successful healing, while reducing the likelihood of the need for return hospital visits due to infections.
“Not all members of a patient’s health-care team are adequately trained to treat wounds or are connected to wound care professions, but all should take responsibility for assessing the need for appropriate wound care,” says Payne.
The second part of this article focuses on the patient’s role in wound care, sourced from the Amputee Coalition’s First Step program.
The Role of Health-Care Professionals in Wound Care
By Nancy Payne, MSN, RN, CWCN
There are five “degrees” of wounds. The body can usually heal an acute wound in four major phases: hemostasis, inflammation, proliferation, and remodeling. The mechanics of the healing process are granulation tissue formation, contraction, and epithelialization.1
- Hemostasis is the process of the wound being closed by clotting. The first step of hemostasis is when blood vessels constrict to restrict the blood flow. Platelets stick together in order to seal the break in the wall of the blood vessel and coagulation occurs, which reinforces the platelet plug with threads of fibrin, which are like a molecular binding agent.
- Inflammation is the second stage of wound healing and begins right after the injury when the injured blood vessels leak transudate (made of water, salt, and protein), causing localized swelling. Inflammation both controls bleeding and prevents infection. The fluid engorgement allows healing. During the inflammatory phase, damaged cells, pathogens, and bacteria are removed from the wound area. These white blood cells, growth factors, nutrients, and enzymes create the swelling, heat, pain, and redness commonly seen during this stage of wound healing. Inflammation is a natural part of the wound healing process and only problematic if prolonged or excessive.
- The proliferative phase of wound healing is when the wound is rebuilt with new tissue. In the proliferative phase, the wound contracts as new tissues are built. In addition, a new network of blood vessels must be constructed so that the granulation tissue can be healthy and receive sufficient oxygen and nutrients.
- The remodeling stage of wound healing is when the wound fully closes. The cells that had been used to repair the wound are no longer needed and are removed by apoptosis, or programmed cell death. Generally, remodeling begins about 21 days after an injury and can continue for a year or more. As a note, healed wound areas continue to be weaker than uninjured skin, generally only having 80 percent of the tensile strength of unwounded skin.2
Delays in Wound Healing
There are several common causes for delays in wound healing. One of the most common is restriction in blood supply to tissues, ischemia, which causes a shortage of oxygen that is needed to keep the tissue alive. Individuals that have just received an amputation also are at risk of re-injury due to falls or bumping of the residual limb.
The use of steroids, specifically corticosteroids, can cause rupture of surgical incisions, increasing the risk of wound infection and delaying healing of open wounds. They produce these effects by interfering with inflammation, fibroblast proliferation, collagen synthesis and degradation, deposition of connective tissue ground substances, angiogenesis, wound contraction, and re-epithelialization.3
Malnutrition also is a determining factor in a patient’s ability to heal post-
amputation. Nutrition deficiencies impede the normal processes that allow progression through stages of wound healing.
Malnutrition also can cause a decrease in wound tensile strength. Malnutrition has been linked to increased rates of infections in patients.4
Planktonic bacterial growth also can cause significant delays in wound healing but can usually be eliminated by white blood cell activity or antibiotic therapy. Bacteria biofilm, on the other hand, is a major barrier to wound healing. It is complex, adherent, and protected against white blood cells, antimicrobial agents, and systemic antibiotics, preventing host defenses from clearing the infection.
Converting Chronic Wounds Into Acute Wounds
An estimated 67 million individuals worldwide suffer from chronic wounds, also known as long-term lesions. Limb loss patients are at an increased risk for the most common types of wounds, including pressure ulcers, venous wounds, arterial wounds, and lesions associated with diabetes.5
Acute wounds are defined as disruptions in the integrity of the skin and underlying tissues that heal uneventfully with time. These lesions go through stages of healing in a timely manner and generally have minimal to no complications. Complete healing is likely within four weeks.
Chronic wounds, however, fail to complete the cycle of healing within two to four weeks despite interventions. This can be due to patient comorbidities or the characteristics of the wound itself. Healing will plateau, causing a chronic wound to remain in a state of inflammation. Chronic wounds can have persistent or recurrent infection and develop drug-resistant biofilms.
Because fibroblast, endothelial cells, and keratinocytes are unable to produce new vessels, long-term wound care is needed. Chronic wounds can sometimes necessitate a revision surgery, which can include revision to a higher level of amputation.
The most common method used to convert a chronic wound into an acute wound is the use of sharp, surgical debridement, which induces acute tissue injury bleeding and results in hemostasis, activating regulatory processes that normally control repair and encouraging the progression of healing.
Another method used to convert chronic wounds to acute wounds is the use of ultrasonic wound care, in which a low-frequency ultrasound (20-40 KHz) is transmitted through a saline medium. Mechanism of action is production, vibration, and movement of micron-sized bubbles in the saline and wound tissue. This method increases wound perfusion, allows for debridement of necrotic tissue and bacterial effect, and disrupts biofilm and reduces wound pain.
- Doughty DB, Moore KN. Wound, Ostomy, and Continence Nurses Society Core Curriculum. 2016; Philadelphia: Wolters Kluwer.
- The Four Stages of Wound Healing. March 17, 2017. Retrieved July 10, 2018, from https://www.woundsource.com/blog/four-stages-wound-healing
- Anstead GM. Steroids, Retinoids, and Wound Healing. October 1998. Retrieved July 10, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/10326344
- Stechmiller JK. Understanding the Role of Nutrition and Wound Healing. Feb. 3, 2010. Retrieved July 10, 2018, from https://onlinelibrary.wiley.com/doi/full/10.1177/0884533609358997
- Mercandetti M. Wound Healing and Repair: Overview, Types of Wound Healing, Categories of Wound Healing. Retrieved July 10, 2018, from https://emedicine.medscape.com/article/1298129-overview
Dabiri G, Damstetter E, Phillips T. Choosing a Wound Dressing Based on Common Wound Characteristics. Jan. 1, 2016. Retrieved July 10, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4717498/#B5
Degrees of Wounds
- Primary— Heals without open areas, infection, or wound complications.
- Secondary— Small open areas that can be managed, and ultimately heal with dressing strategies and wound care.
- Requires minor surgical revision—Skin and subcutaneous tissue (no muscle, no bone involved).
- Requires major surgical revision—Involves muscle or bone, but heals at initial amputation “level.”
- Requires revision to a higher amputation level— For example, a transtibial amputation that must be revised to either a knee disarticulation or a transfemoral amputation.
The Patient’s Role in Wound Care
The following information was sourced from the Amputee Coalition’s First Step and can be requested in pamphlet form by calling 888/267-5669 or in the Amputee Coalition store at www.amputee-coalition.org/amputee-coalition-store/.
With thousands of questions posed to the Amputee Coalition every year, one of the most common topics is wound care, according to Karen Lundquist, chief communications officer, Amputee Coalition. “It’s a serious topic, and one that merits close attention by people with limb difference and limb loss in partnership with their clinicians and caregivers,” she says. “With vascular conditions leading the causes of amputation, it is especially critical to begin with the basics: Check your feet regularly.”
Depending on the reason for a patient’s amputation, and the state of the limb at the time of surgery, definitive closure of the wound may take place immediately or it may be delayed. Wound care involves multiple phases. The Amputee Coalition has provided the following information to be shared with patients regarding the importance of wound care and the patient’s role in managing their surgical wounds and the skin of their residual limbs.
Postamputation: Two Phases of Recovery
Phase 1: The first phase of recovery is preclosure of the residual limb. The goal of wound management during this phase is to promote healing of the underlying soft tissue and to treat or reduce the risk of infections. In some instances, a drainage tube is inserted to remove fluids and aid in tissue repair. A member of the surgical team will do the dressing changes. The following information should be shared with patients regarding their role in wound management during this first phase:
- Notify your nurse if your dressing becomes soiled or you notice any leakage of drainage.
- Wash your hands if you come in contact with drainage. Hand soap and hand sanitizers are available in your room.
- Make sure everyone who comes in contact with your wound wears gloves and washes his or her hands before and after a dressing change.
- In some instances, visitors may need to take special precautions to reduce the likelihood of transmitting an infection to others. In such cases, the nurses will review with you any special precautions for visitors. We are counting on you to see that these precautions are followed.
- Exercise caution when moving in bed or getting in and out of bed so that you do not dislodge any dressings or drainage tubes. Notify the nursing staff if dressings become loose or dislodged.
- Eat a healthy, well-balanced diet of foods rich in nutrients and vitamins. Tissues cannot heal if they are not provided with the necessary nutrition. Dietary supplements are often provided in addition to your meals to ensure that sufficient calories and protein are available to facilitate the healing process.
- Inform members of your rehabilitation team if you experience pain during the care of your wound. By working together, you and your rehab team can establish a medication schedule that will minimize your discomfort during dressing changes.
Injuries that lead to amputation also may result in skeletal injuries to remaining limbs. As a result, patients may have skeletal pins and/or an external fixator device applied to maintain bone alignment and promote healing of fractures. Patients who have one of these devices may want to take the following steps in caring for the device and their skin:
- Wash your hands with soap and water.
- Mix small amounts of sterile normal saline and hydrogen peroxide in a sterile container.
- Saturate a sterile cotton swab applicator in the solution.
- Using a circular, rolling motion of the cotton swab, cleanse the pin sites from the insertion site outward.
- Avoid going over previously cleaned areas with a used swab.
- Gently push down on the skin with the swab to prevent skin from adhering to the pin.
- Leave the pin sites open to the air unless drainage is present. If drainage is present, pin sites can be covered with sterile gauze.
- Notify a member of the rehabilitation team if you notice swelling, redness, pain, tenderness, or a change in drainage from any of your pin sites.
Phase 2: The second phase of recovery is definitive closure of the residual limb. The goal of wound management during this phase is to prepare the residual limb for prosthetic fitting. Initially, the patient will have sutures in place to close his or her surgical wound. These are usually removed in approximately 14 to 21 days. The sutures will be covered with petroleum-impregnated gauze, and initially, bulky gauze dressings will be applied to provide additional protection. These dressings are typically changed twice daily, or more frequently if necessary. Once the sutures are removed, adhesive strips are applied as the final stage of wound closure takes place. These strips will fall off naturally in about five to seven days.
Throughout this stage of the wound healing process, compression dressings also will be applied to reduce swelling and begin shaping the residual limb for prosthetic fitting. There are two types of compression dressings: rigid and soft. Rigid compression dressings are made from casting material and will be changed as the swelling in the residual limb decreases. Soft compression dressings are initially elastic bandages applied in a specific way to reduce the swelling at the lower portion of the residual limb. These bandages will need to be reapplied several times during the day to maintain proper compression. Members of the rehabilitation team will instruct patients in the proper application of these bandages.
The patient’s role in wound management now includes all of the previously listed items, plus these additional responsibilities for rigid or soft dressings:
Rigid Compression Dressing
- Keep the cast dry. Getting the cast material wet can weaken the cast, and damp padding can irritate the skin.
- Avoid getting dirt or powder inside the cast.
- Never stick objects inside the cast to scratch your skin. If itching persists, let your nurse know so other measures can be taken.
- Notify a member of your rehabilitation team if you feel increased pain or numbness that may be caused by swelling or a cast that is too tight.
Elastic Bandage Compression Dressing
- Do not pull at your sutures, even if the skin around the sutures itches.
- Notify a member of your rehabilitation team if you notice any tearing or separation of the sutures.
- Notify a member of the rehabilitation team if you notice that the skin around the sutures is red or swollen or if you notice any pus draining from the suture area.
- Rewrap your residual limb several times during the day (usually at least four or five times) to maintain proper compression. This not only reduces the swelling and increases circulation and healing, but also reduces pain.
- Obtain new elastic bandages if the ones you are using become soiled or lose elasticity.
Directions for Wrapping With an Elastic Bandage
Below-Knee, Below-Elbow, and Above-Elbow Amputations
- Using a four-inch-wide elastic bandage, go over the end of the limb, slightly stretching the bandage.
- Relax the stretch and secure the bandage by going around the limb once.
- Increase the stretch and go to one side of the center.
- Decreasing the stretch, go around back. Go up the other side of the center as you increase the stretch again.
- Repeat this figure-eight pattern until the end is securely bandaged, and then secure the bandage with Velcro or tape. (Do not secure bandages with pins.)
- If the length below the knee or elbow is very short, you will need to make a similar figure-eight pattern above and below the joint and then secure the bandage.
- Use two six-inch-wide elastic bandages. (Bandages can be sewn together.)
- Wrap around the waist twice.
- Wrap around the end of the limb.
- Wrap back around the waist.
- Wrap around the end of the limb.
- Wrap around the waist and secure. (This is the anchor for the next bandage.)
- Take another six-inch-wide elastic bandage and, similar to the technique used for below-knee amputations, go over the end of the limb, slightly stretching the bandage.
- Relax the stretch and secure the bandage by going around the limb once, then increase the stretch and go to one side of the center.
- Decreasing the stretch, go around back, and then go up the other side of the center as you increase the stretch again. Repeat this figure-eight pattern until the end is securely bandaged, making sure to bandage all of the way up into the groin area. Secure the bandage with Velcro or tape. (Do not secure bandages with pins.)
Remember: For best results, you must reapply the elastic bandages whenever they loosen.
Wearing an Elastic Shrinker Sock
Using an elastic shrinker sock is another way to reduce swelling. These shrinker socks can be used alone or in combination with elastic bandages. If the limb is still very sensitive, it will be more comfortable to stretch the shrinker as it is being put on, either by using two pairs of hands or an appropriate-size ring made of a stiff material such as PVC.
- With two people using all four of their hands (two can be the patient’s), put all of the fingers down to the bottom of the shrinker, thumbs on the outside, spare material scrunched down, and stretch out until the bottom of the shrinker is completely flat and stretched out.
- Place the flat, inside part of the shrinker against the end of the amputated limb.
- In one swift motion, keeping the stretch and letting the material slide from between the thumb and fingers, pull the shrinker up the limb.
- There should be no gap between the end of the residual limb and the shrinker.
- If this is for an above-knee amputee, make sure the long side is around the hip and the short side is all of the way into the groin.
Using a Ring
- Make sure the chosen ring will slide easily all of the way to where the shrinker will end on the limb.
- Stretch the shrinker over the ring until the end is flat.
- Place the flat, inside part of the shrinker over the end of the limb and feed the shrinker up the limb until it is as high as needed.
- Remove the ring.
Preparing for Prosthetic Training and Desensitizing the Residual Limb
At this point in the rehabilitation process, there are four techniques that can be used to prepare the residual limb for prosthetic training: massage, tapping, desensitization, and scar mobilization.
Early massage and tapping of the residual limb will help the patient develop a tolerance in the residual limb to both touch and pressure. Both of these techniques can be performed through soft compression dressings and when the soft compression dressing is off. Additionally, these techniques may help decrease sensation of phantom pain.
- Using one or two hands, massage your residual limb using a soft, gentle kneading motion. Initially, be especially cautious when massaging over your sutured area.
- Massage the entire residual limb.
- Over time and once your sutures are removed, you can increase the pressure to massage the deeper soft tissues and muscles in your residual limb.
- This should be done for at least five minutes, three or four times daily. It can be done more often if it is found to be helpful in reducing phantom pain.
- Tap your residual limb with your fingertips, being careful not to tap with your fingernails. Gentle tapping over the suture line is generally allowed even before your sutures are removed.
- Over time and once your sutures are removed, you can increase to a slapping motion, using one or two hands.
- Tapping should be done for one to two minutes, three or four times daily. It can be done more often if it is found to be helpful in reducing phantom pain.
Desensitization is the process of making the residual limb less sensitive. If a patient starts with a soft material and progresses to rougher materials, desensitization can help increase tolerance to touch in the residual limb.
- This technique is done when you are not wearing your soft compression dressing. It should be done for two to three minutes twice daily and is usually done during bathing times.
- Initially, start with a cotton ball and gently rub the skin of your residual limb, using a circular motion.
- When you are able to tolerate it, progress to a rougher material such as a paper towel.
- Finally, advance to a terry cloth towel.
- This technique should be done until you can tolerate gentle friction from a terry cloth.
This technique is done to keep the skin and scar tissue on the residual limb loose. Scar adherence to underlying tissue can be a source of pain when using a prosthesis and also may cause blistering. It is best performed when the patient is not wearing compression dressing.
- Place two fingers over a bony portion of your residual limb.
- Press firmly and, keeping your fingertips in the same place on the skin, move your fingers in a circular fashion across the bone for about one minute. Continue this procedure on all of the skin and underlying tissue around the bone of your residual limb.
- Once your incision is healed, use this procedure over your scar, moving your fingers in a circular fashion to loosen the scar tissue directly.
- This technique should be done daily when you bathe.
Inspection of Your Residual Limb
- Regular inspection of your residual limb, using a long-handled mirror, will help you identify skin problems early.
- Initially, inspections should be done whenever you change your compression dressing. Later on, most amputees find daily inspection sufficient for the early identification of skin problems.
- Inspect all areas of your residual limb. Remember to inspect the back and all skin creases and bony areas.
- Report any unusual skin problems to a member of your rehabilitation team.