blow knee amputation manual

8/8/2019 Blow Knee Amputation Manual

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The Amputation

Amputations are caused by:

y Accidentsy D iseasey C ongenital D isorders

The accidents most likely to result in amputation aretraffic accidents, followed by farm and industrialaccidents.

Amputations in the case of disease are performed asa lifesaving measure. The diseases that cause the most amputations are peripheralvascular disease (poor circulation of the blood) and cancer.

C ongenital disorders or defective limbs present at birth are not amputations, but rather are a lack of part or all of a limb. A person with a limb deficiency can usually behelped by use of an artificial limb. Sometimes amputation of part of a deformed limbor some other type of surgery may be desirable before the application of an artificiallimb.

The distribution of amputations by cause is shown below:

There are slightly more than 1.5 amputees per 1000 persons in the United States and C anada. Therefore, the present total in the United States is approximately380,000.

There are more "below-knee" (trans-tibial) amputeesthan any other type as can be seen from the chart below.

Surgeons preserve the knee joint whenever it is practicalto do so and will fashion the stump at the lowest practicallevel. Very short stumps make fitting extremely difficultand very long below-knee stumps are prone to circulation

problems.



The Syme's amputation, which is essentially removal of the foot at the ankle, usuallyresults in a stump that will bear a substantial part of the body weight over the end.

The Immediate Postsurgical Period

Nearly every amputee feels quitedepressed immediately after thesurgery, except possibly those whohave suffered intense pain for a period

just prior to the amputation. This

depression is usually replaced early by a will to resume an active life.

The dressing applied by the surgeon iseither "rigid," usually made of plaster-of-Paris, or "soft," using ordinarycotton bandaging techniques.

When the rigid dressing is used it isleft in place for 10 to 14 days during

which time most of the healing takes place. Sometimes a simple aluminumtube, or "pylon", and an artificial footare attached to the rigid dressing sothat walking, or gait, training can

begin even before the healing periodis complete.

When the soft dressing is used, elastic bandages are used soon after surgery

to aid circulation. The bandages areremoved and reapplied throughout theday. (Instructions for application of elastic bandages are given in the next section.)

Regardless of the type of dressing used, exercises are extremely important to preventcontractures (tightening of the muscles) which, when present, prevent efficient use of a prosthesis.



Some " D on'ts" that will help prevent muscle tightening, or contractures, are shownabove.

It is most important that the prescribed exercises be carried out regularly, and the positions shown above be avoided if the greatest benefit is to be obtained from the prosthesis.

Preparation for Fitting the Prosthesis

In general the earlier a prosthesis is fitted the better it is for the amputee. One of themost difficult problems facing the amputee and the treatment team is edema, or swelling of the stump, owing to the accumulation of fluids. Edema will be present tosome extent in all cases, and it makes fitting of the prosthesis difficult, but certainmeasures can be taken to reduce the amount of edema.

The use of a rigid dressing seems to control edema. After the rigid dressing has beenremoved and when a prosthesis is not being worn, elastic bandages are used to keepedema from developing.

The patient is taught the proper technique for bandaging and is generally expected todo this for himself as shown on the next page.

For the average adult, one or two elastic bandages four inches wide are used. D uringthe course of the wrapping, tension is used to maintain about two-thirds of themaximum stretch.

The stump should be bandaged constantly, but the bandage should be changed everyfour to six hours. It must never be kept in place for more than 12 hours without re-

bandaging. If throbbing should occur, the bandage must be removed and rewrapped.

Special elastic "shrinker socks" are available for use instead of elastic bandages, andwhile not considered by some to be as effective as a properly applied bandage, a"shrinker sock" is better than a poorly applied elastic bandage.

Whether an elastic bandage or a shrinker sock is used, it should be removed at leastthree times daily and the stump should be massaged vigorously for 10-15 minutes.The bandage or sock must be reapplied immediately after the massage.



S pecial Note: Regardless of the functions provided by the most sophisticated mechanical devices,the most important factors in the usefulness of an artificial leg are fitting of the socketand alignment of the various parts with respect to the body and with respect to eachother. Fitting and alignment are difficult procedures that require a great deal of skillon the part of the prosthetist and a great deal of cooperation on the part of the patient.D uring fitting and alignment of the first prothesis, it is necessary for the prosthetist totrain the amputee in the basic principles of walking in order for the prosthetist toarrive at the best set of conditions for the amputee. Fitting affects alignment,alignment affects fitting, and both affect comfort and function. In addition, extensivetraining is carried out later by the physical therapist.

Bandaging Technique

1. Start with the bandage held in place on the inside of the thigh just above theknee and unroll the bandage so that it is laid diagonally down the outer side of the stump while maintaining about two-thirds of the maximum stretch in the

bandage.2. Bring the bandage over the inner end of the stump and diagonally up the outer

side of the stump.3. Bring the bandage under the back of the knee, continue over the upper part of

the kneecap and down under the back of the knee.

4.

Bring the bandage diagonally down the back of the stump and around over theend of the stump. C ontinue up the back of the stump to the starting point on theinside of the thigh and repeat the sequence in a manner so that the entire stumpis covered by the time the roll is used up. The end of the bandage is held in

place with the special clips that are provided. It is important that the tightest part of the bandage be at the end of the stump.



The Preparatory Prosthesis5.

Fitting as soon after surgery as possible also helps to

combat edema. A preparatory prosthesis is frequently usedfor several weeks or months until the stump has stabilized

before the "permanent", or definitive, prosthesis is provided.The socket of the preparatory prosthesis may be made of either plaster-of-Paris or a plastic material, and is usuallyattached to an artificial foot by an aluminum tube oftencalled a "pylon". The aluminum pylons are usuallydesigned so that the position, or alignment, of the foot withrespect to the socket can be changed when necessary.

Although a variety of shoes may be worn with artificial limbs, the patientshould consult with the prosthetist before selecting the shoes to be used becauseheel height is a major factor in alignment of the artificial leg. A belt about thewaist is usually used to help keep the prosthesis in its proper place on thestump. At least one prosthetic sock is worn between the socket and the body to

provide for ventilation and to protect the skin from rubbing. Most prostheticsocks are woven of virgin wool, but socks of synthetic yarns are also used.Three thicknesses are available: 3 ply, 5 ply, and 6 ply. Additional socks can beused to compensate for stump shrinkage if the amount of shrinkage is not toogreat. The prosthetist and therapist can suggest the sock or socks to be used, butonly the patient can determine the proper selection. (A chart to guide inselection of sock thickness is shown in C are of the Stump .)

Prosthetic socks must be changed daily to reduce the chance of irritation of the skinand dermatitis.

Prosthetic socks require special care in laundering. Instructions are provided by themanufacturers.

A specially woven nylon sock known as a prosthetic sheath is used by many amputees

between the skin and the regular prosthetic sock to provide additional protection fromabrasion. The sheath also allows perspiration to escape to the prosthetic sock and thusto the atmosphere.



Fabrication of a Below-Knee Prosthesis

Whether the prosthesis is to be crustacean or endoskeletal (often called "modular") type, the

prosthetist usually begins by wrapping the stumpwith plaster-of-Paris bandages to obtain a negativemold. A positive model is made by filling thenegative mold with a mixture of plaster-of-Paris andwater, and allowing it to harden.

After modification of the model to provide the proper

characteristics to the finished socket, a plastic socketis formed over it. The first one is usually a test, or check, socket made of a transparent plastic to determine if further modifications areneeded.

A new method being used by many prosthetists for obtaining a modified model of thestump involves use of a computer and automatic machinery. Known a C AD/C AM(C omputer-Aided- D esign /C omputer-Aided-Manufacturing), this method permits

prosthetists to modify the model more easily since it does not require making andcarving an actual plaster model.

The socket is mounted on an adjustable leg for walking trials, and when both the prosthetist and the amputee are satisfied, the limb is ready for the finishing procedures. The exoskeletal shank may be of plastic-covered wood or all plastic. Theendoskeletal type uses carved foam rubber over the supporting pylon and the entire

prosthesis is encased in a either a latex or fabric stocking.

Steps in the fabrication of a plastic prosthesis for a below-knee (trans-tibial) amputee:



A. A negative mold of the stump is made by wrapping it with a wet plaster-of-Paris bandage.

B. A positive model of the stump is made by filling the cast with a mixture of

plaster of Paris and water.C . After modifications have been made to the model by the prosthetist to

make sure that the pressures m the socket will be correct, a test, or check socket, is made by forming a heated sheet of clear plastic over the model.

D . The clear plastic socket is tried on to make sure that it fits properly.E. A new positive model is made by filling the clear socket with a mixture of

plaster of Paris and water.F. The socket to be used on the definitive prosthesis is formed over the model

by using either a mixture of plastic resin and cloth or by forming a heatedsheet of plastic over the model.

G. The definitive socket is attached to a pylon that can be adjusted foralignment and walking trials can be made.

H. The finished prosthesis maybe either exoskeletal or endoskeletal.



Care of the S tump

The stump must be washed daily to avoid irritations and infection. Mild soapand warm water are recommended.The interior of plastic sockets also must be kept clean by washing daily withwarm water and a mild soap. Use of detergents should be avoided at all times.Some amputees have found a hair dryer to be useful in drying the stump and

preparing the socket for donning.Prosthetic socks must be applied carefully to avoid wrinkles, and should be

replaced daily with newly laundered ones; more often in warm, humid weather.They should be washed in warm water with a mild soap. Manufacturersrecommend that socks be rotated on at least a three- or four-day schedule toallow the fibers to retain their original position.Reductions in the size of the stump can be accommodated by adding one or more prosthetic socks.Prosthetic socks are woven especially for their intended use and are availableinthree thicknesses and a variety of sizes.The thicknesses generally available are designated 3-ply, 5-ply, and 6-ply. Withthis combination, various thicknesses can be obtained as follows:

One 3-ply = 3 pliesOne 5-ply = 5 pliesTwo 3-ply = 6 plies;One 3-ply + one 5-ply = 8 pliesOne 6-ply sock can be used instead of two 3-ply socks.Some amputees have found that use of a one-ply cotton filler sock provides asatisfactory way to obtain a still finer adjustment in thickness. If the amputeehas trouble in obtaining comfort by a combination of prosthetic socks, heshould consult his prosthetist immediately.Frequent adjustments are often required in the first year. When the prosthesis

does not feel comfortable during standing and walking, it should be removedand reapplied. If discomfort persists, the prosthetist should be consulted.

blow knee amputation manual

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