Archives of Physical Medicine and Rehabilitation
Volume 87, Issue 3, Supplement , Pages 15-20, March 2006

Limb Deficiency and Prosthetic Management. 3. Complex Limb Deficiency

  • Mark E. Huang, MD

      Affiliations

    • Department of Physical Medicine and Rehabilitation, Rehabilitation Institute of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL
    • Corresponding Author InformationReprint requests to Mark E. Huang, MD, Rehabilitation Institute of Chicago, 345 E Superior St, Chicago, IL 60611
    • ,
  • Virginia S. Nelson, MD, MPH

      Affiliations

    • Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI
    • ,
  • Katherine M. Flood, MD

      Affiliations

    • Physical Medicine and Rehabilitation Program, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
    • ,
  • Toni L. Roberts, DO

      Affiliations

    • Physical Medicine and Rehabilitation Service, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT
    • ,
  • Phillip R. Bryant, DO

      Affiliations

    • Good Shepherd Rehabilitation Hospitals, Allentown, PA
    • ,
  • Paul F. Pasquina, MD

      Affiliations

    • Physical Medicine and Rehabilitation Service, Walter Reed Army Medical Center, Washington, DC

Article Outline

Abstract 

Huang ME, Nelson VS, Flood KM, Roberts TL, Bryant PR, Pasquina PF. Limb deficiency and prosthetic management. 3. Complex limb deficiency.

This self-directed learning module highlights rehabilitation and prosthetic issues associated with complex limb deficiencies. It is part of the chapter on acquired limb deficiencies in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses rehabilitation and prosthetic management of patients with amputations for complex limb deficiencies secondary to trauma. Mechanisms of injury, prosthetic issues, prosthetic components, and potential problems in prosthetic fitting will be discussed.

Overall Article Objective

To evaluate common problems associated with complex limb deficiency.

Key Words:  Amputation , Artificial limbs , Burns , Multiple trauma , Rehabilitation

 

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3.1 Clinical Activity: You have been consulted to evaluate a 38-year-old man for right transhumeral and left Syme’s amputation 3 days ago secondary to electrical injury. Anticipate the potential complications and rehabilitation needs of this patient 

ELECTRICAL INJURIES ACCOUNT for 3% to 6% of the admissions to major burn units annually, with about 1000 electricity-related deaths annually.1, 2 Victims tend to be young and male. Electrical injuries are a unique subset of burns because of the need for larger volumes of fluid replacement, more extensive soft-tissue damage, and the need for more complex reconstructive procedures. Amputation rates from electrical burns can vary from 24% to 44%.1, 2 When amputation is performed, it tends to be required because of more extensive tissue damage along the length of the limb, resulting in more proximal amputations and multiple limb losses. Surgical amputation techniques that have been tried to preserve residual length are osteocutaneous pedicle flaps, muscle transpositioning, and free flaps to cover open areas.3, 4 The physiatrist should play a role in determining the optimal level of amputation to maximize function.

Burned muscle tissue causes myoglobinuria, and acute management requires massive fluid replacement to prevent renal failure. Early and extensive débridement and fasciotomy are performed on the involved areas to determine viable tissue, provide pressure relief, and facilitate granulation. Burned areas are initially covered with biologic dressings, such as porcine and cadaveric grafts, or synthetic grafts, such as plastic membranes and nylon mesh combined with silicone. Open areas can be covered with topical antimicrobials such as sulfadiazine or triple antibiotic ointments as well as petrolatum gauzes. Autografting is performed once the wound is free of necrotic tissue or infection. Use of split-thickness skin grafts with Tanner mesh allows for greater coverage of open areas with donor skin.5 Unmeshed skin grafts are used over cosmetically important locations such as the face to minimize contracture formation. Outcomes after burns are improved with an interdisciplinary approach, and rehabilitation typically continues months beyond the initial injury. Common complications of burn patients include persistent open wounds, contractures, hypertrophic scar formation, heterotopic ossification, and neurologic sequelae. Wound care is an essential part of burn management. Open areas should be covered with gauze during the therapy sessions to prevent further tissue damage or contamination.5 Patients may require skin grafting during the rehabilitation process. Relative immobilization of newly grafted sites for about 5 days is necessary to prevent graft disruption. Regions with superficial partial and deep partial burns are at increased risk of hypertrophic scar formation 1 to 3 months after injury. Maturation of scar tissue may take up to 2 years. The use of custom-fit pressure garments exceeding 25mmHg and the selective use of orthoses remain the mainstay of hypertrophic scar treatment.5 Although pressure is generally considered to be the primary mechanism of scar prevention with garments, some studies suggest that temperature elevation associated with garment wear decreases the inflammatory cascade and may play a role in scar reduction.6, 7 Newer interventions include the use of hydrocolloid dressings and anti-inflammatory agents. Topical salicylic acid and nonsilicone (hydrogel) sheeting have been proposed as treatment techniques.6 Massage with lubricating agents is also an important means of mobilizing scar tissue without causing undue shear injury.

Contractures are common sequelae that can occur early or late in the healing process. Constant vigilance to minimize development of contractures is critical. Primary prevention is achieved through range of motion (ROM) exercises and proper positioning. Therapy should focus on ROM using slow sustained stretch and proper body positioning to prevent contracture formation. Passive ROM (PROM) may initially be required, but progression to active assist and active ROM should be done as soon as is clinically feasible. Administration of pain medication before stretching programs greatly increases patient tolerance of the activities. Continuous PROM machines can assist with maintaining joint mobility in addition to regular therapy sessions. With shoulder burns, proper static positioning consists of maintaining 90° of shoulder abduction to prevent adduction contractures. Care should be taken to maintain scapular mobility with upper-limb amputation and hip and knee mobility in lower-limb amputations. Properly placed pillows and foam wedges can aid in the positioning process. Splinting can be used to position limbs and protect newly grafted skin areas. Static orthoses are commonly used for the hand or ankle region to provide neutral positioning. Both static and dynamic splints should be considered for contracture prevention. Orthoses are usually custom molded to the patient because of the complexities of the burns. The materials used are thermoplastics, such as polyethylene, which allow easy modification and fabrication with low temperatures. With the aforementioned interventions, care must be taken to prevent further skin breakdown or disruption of healing areas.

Heterotopic ossification (HO) is a common complication of burns. This phenomenon is usually seen in patients with more than 20% of the total body surface area (TBSA) burned. Although the overall incidence of HO can be as low as 1% to 3%, it can rise to 35% in patients with a higher percentage of burns over their TBSA.8 It is also more likely to occur in patients with prolonged immobility and open wounds, The most common site of HO in patients with burns is the posterior elbow, although the site of ossification does not necessarily correlate with the location of burn. HO becomes significant when it causes pain, nerve entrapment, or inhibits ROM or prosthetic fitting. In some cases it may spontaneously resolve. The mainstay of treatment is mobilization of the affected limb. Indomethacin remains the classic pharmacologic treatment for HO8 and has been shown to inhibit the differentiation of mesenchymal cells into osteoblasts. Although the use of bisphosphonates was advocated in the past, their current use is controversial because of questionable efficacy.8

The most common neurologic complications of burn injuries are entrapment and peripheral neuropathies. Neurologic involvement in patients with electrical injuries may also include headache, seizures, spinal cord injury, anoxic encephalopathy, and spasticity.5 Some of these symptoms can have a delayed presentation as late as 2 years after injury. Initial assessment by the physiatrist should include a comprehensive neurologic examination to rule out concomitant spinal cord injury or cognitive deficits. Psychologic and speech evaluation should also be performed to assess cognition.

Psychologic adjustment issues are common in burn patients. It has been reported that burn patients have a higher incidence of premorbid psychiatric illnesses or substance abuse.5 Delirium, adjustment disorder, depression, and anxiety are commonly seen within the first few months and usually resolve after 6 months.5 Fukunishi9 found the incidence of posttraumatic stress disorder and major depression was 34% and 7%, respectively. Preinjury status is a strong predictor of long-term emotional adjustment after major burns. These patients will benefit from counseling, psychotherapy, and pharmacologic agents.

Amputation as a consequence of burn injury presents unique challenges to the rehabilitation team. Although early mobilization is optimal, it may be difficult to initiate in the patient with multiple amputations. This patient may initially not be able to tolerate ambulation on his residual limb, even when fitted with a Syme’s prosthesis, because of limb tenderness and ongoing wound healing. The patient would likely use his left arm to handle assistive devices to help with eventual ambulation. A single-arm-drive wheelchair may be helpful for basic propulsion. A sliding board can be useful with transfers, although care must be taken to avoid shear on any open areas in contact with it. A tilt table and standing frame can assist this patient in tolerating an upright position. He will need to master 1-handed skills initially for basic self care but also focus on strengthening bilateral shoulder girdle muscles in anticipation of using a transhumeral prosthesis. Early involvement of a psychologist can help address emotional adjustment to burns and amputation. The psychologist can also assess for cognitive impairment given the high incidence of neurologic sequelae.

Prosthetic fitting will most likely occur in a delayed fashion if there are extensive open areas in the residual limb. Fitting should not be done until skin areas are healed over pressure-sensitive areas. Mobility skills can be advanced once the patient’s skin is healed enough for prosthetic fitting. It is anticipated that this patient will require periods of immobilization of the burned areas because of slowly healing or reopened skin areas. As this patient becomes more proficient with his prosthesis, a vocational rehabilitation assessment would be appropriate for possible reintegration into the workforce.

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3.2 Educational Activity: To differentiate how limb loss due to burn injury in this patient differs from other mechanisms of traumatic amputation and its impact on rehabilitation management 

Dillingham et al10 reported that only 16% of all amputations in the United States are the result of trauma. This deduction was based on data from nationwide hospitals from 1988 to 1996. Sixty-eight percent of traumatic amputations involved the upper limb, with over 63% involving the thumb and finger and 14% involving the toes. Traumatic amputation commonly occurs in a workplace setting but can also be seen in residential and combat settings. The male-to-female ratio of amputation in the workplace is 5:1.11 In a combat setting, the major causes of amputation are bullets and explosive devices,12 with traumatic amputation accounting for 29% of injuries in recent combat settings.13

The mechanism of injury in amputation can significantly affect the time for wound healing and prosthetic fitting. The major factors that affect the extent of injury in traumatic amputation are the type of object involved in the injury; its direction, magnitude, and speed-of-energy vector; and type of tissues involved.14

The type of object causing direct trauma can affect the amputation. If the object was moving at high speed and is relatively sharp, such as a power saw, the actual amputation site will generally have sharp margins and minimal associated trauma. Objects that are more blunt, such as a lawnmower blade, will produce greater tissue trauma at the amputation base. In cases of mangling of an extremity, such as occurs when limbs are caught in heavy machinery, the involved site will have irregular margins and significant accompanying tissue trauma. Low-energy injuries result from accidental knife wounds, closed fractures, and small-caliber gunshot wounds. Low-energy wounds usually have damage localized to the areas of injury, which results in crushing and laceration locally. The focal nature of the wound allows for more rapid wound healing and primary closure.12 Reimplantation may warrant consideration for amputations with clean wound margins and minimal associated trauma in the residual limb but is less successful in injuries with large amounts of tissue trauma.15, 16

Medium-energy wounds have moderate associated tissue damage. Examples include avulsion, degloving injuries, open fractures, or dislocations. Avulsion injuries more commonly involve digits as opposed to the long bones of the extremities. High-energy wounds typically result from high-speed missiles such as bullets or shrapnel. High-energy trauma is usually associated with significant adjacent tissue damage. This damage depends on the type of tissue involved. As an example, low-velocity bullets (<300m/s [<1000ft/s]) produce shock waves that may be tolerated by muscle and bone but not by gas-containing viscera. High-velocity bullets (traveling >300m/s) produce temporary cavitation and shock waves in addition to local damage.12 This can be especially destructive to vessels and nerves, producing traction injuries and rupture. Bone does not absorb energy as well as soft tissue and has a tendency to fracture in response to a high energy load.14 Explosive blasts cause amputation by an initial shock wave, resulting in limb fracture and subsequent avulsion through the fracture site.17

Massive crush injuries result in multiple fractures of the affected limb along with large areas of soft-tissue damage. Ischemic changes in the involved limb from injured blood vessels limits potential tissue salvage. Limbs may not initially be severed in the crush injury but may subsequently require amputation because of poor tissue viability. Concomitant systemic shock secondary to massive injuries contributes to ischemia of the involved limb. These factors may adversely affect amputation levels because of lack of viable tissue for flap creation. Thus, these patients have higher amputation levels than their counterparts with low-energy injuries. Reimplantation is usually not an option because of the condition of the amputated limb.

Electrical injuries cause massive direct trauma, particularly to nerves, vessels, and soft tissue. Electrical injuries are categorized into low-tension (<1000V) and high-tension (>1000V) injuries. In electrical injuries, electricity passes through tissue, producing thermal injury. The damage depends on the current, voltage, resistance, and duration of contact. Typically, higher current, higher voltage, lower tissue resistance, and increased duration result in greater tissue damage. Nerves and blood vessels have the least resistance and suffer the most damage, whereas bone has the greatest resistance and has the least amount of damage. The high resistance of bones results in marked heat production and subsequent destruction of surrounding soft tissue. Electrical injuries can appear relatively minor on visual inspection; however, damage is usually greatest in deeper soft-tissue structures. There are entrance and exit sites that correspond to the path of the current, with more extensive tissue involvement occurring at the exit site.5

Initial damage progresses over time in electrical injury. There is initial vascular occlusion, which can cause tissue and limb ischemia.18 Further tissue necrosis can be seen days to weeks after the initial injury.1 This delayed response may be caused by direct cell damage, related release of inflammatory mediators, progressive arterial thrombosis, and bacterial infection. Electrical injuries can result in large open areas that may require subsequent surgical revisions. In addition to the deep-tissue injury, electrical injuries also typically cause marked superficial soft-tissue injury, which require wound care and, often, skin grafting.

Meningococcemia and toxic epidermal necrolysis cause similar skin and tissue involvement, resulting in limb loss. Both conditions can cause significant tissue damage by severe, widespread ischemia associated with bacteria-induced thrombosis, concomitant use of pressors, and, in the case of meningococcemia, endotoxin release.19 The ischemia often results in multiple limb amputations. Sequelae from meningococcemia have been discussed in a previous Study Guide.20

In general, amputations as a result of low-energy trauma, especially those with clean margins, are the most amenable to early prosthetic fitting, because primary wound closure is usually possible. In cases of extensive tissue damage with significant skin involvement, prosthetic fitting is often delayed so as not to compromise wound healing. Skin grafting or amputation revision will further delay prosthetic fitting. Preservation of residual limb length is important in maximizing functional outcome. Limb-lengthening procedures for short residual limbs may also enhance functional use of a prosthesis.21 Rehabilitation should focus on early mobilization to prevent contractures and deconditioning and on facilitation of wound healing in preparation for prosthetic fitting.

Areas that are covered by skin graft and burned skin are relatively intolerant to shear and pressure, which frequently delays prosthetic fitting and training.22 A significant negative effect on rehabilitation is delayed prosthetic fitting caused by open wounds. Patients with open wounds require careful prosthetic fitting and may need repeated adjustments and time off the prosthesis to allow healing of these wounds.

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3.3 Clinical Activity: To evaluate this patient for prosthetic fitting 2 months after amputation 

Time to prosthetic fitting is a challenge in people with electrical burns. Although surgeons may differ in practice regarding timing of fitting, the current standard of practice is to attempt fitting of upper-extremity amputees within 30 days of amputation23 because of the increased acceptance and success rate associated with early fitting. This may not be feasible in patients with extensive or severe burns with open skin areas that may hamper prosthetic socket fit or suspension. During this time, application of orthoses may be attempted on the residual limb to facilitate functional use before preparatory prosthetic fitting. In these cases, ingenuity on the part of the rehabilitation team is essential for creating a functional orthosis. Patients with transradial amputations can be fitted with universal cuffs to allow attachment of utensils. A clamshell design can facilitate donning and doffing and can accommodate wound dressings. This clamshell can be used as an attachment for utensils or other assistive devices to allow the patient to perform functional activities.24 For this patient, a clamshell orthosis around his transhumeral amputation with an attachment distally would accommodate feeding utensils or writing instruments. Orthoses can also facilitate use of ambulatory aids such as crutches or a custom socket to assist with transfers (fig 1). Shear and pressure on the involved skin may be minimized with use of customized padding within the orthosis. Skin areas in contact with the orthosis should be monitored for skin and tissue breakdown to ensure tolerance of the orthosis.

Prosthetic fitting may begin when most of the skin over pressure-sensitive areas is healed. The use of pressure garments for scar prevention helps reduce edema and facilitates prosthetic fitting.25 Skin-grafted sites have the potential for breakdown even if well healed, because this tissue is never as durable as the original skin. Consideration should be given to skin grafting of open areas of the residual limb before prosthesis fitting. Immediate postoperative prosthesis (IPOP) fitting is preferred in cases of primary closure to improve acceptance and facilitate early functional prosthetic use. The IPOPs should be functional in design and not cause further harm to the residual limb.

Associated soft-tissue, nerve, or bony injuries may impede use of cable-driven prostheses.22 For upper-limb amputees, scarring in the axillary and shoulder region may limit shoulder flexion and abduction, as well as scapular protraction. The patient may have difficulty using the prosthesis for midline activities and for operating a terminal device. Wrist flexion units may compensate for impaired ROM in the residual limb.

The socket interface is critical to maintaining skin integrity. In this case, the use of an elastomeric liner may help reduce shear forces on friable skin.22, 26 Occasionally, the liner with interlocking pin can create shear at the terminal aspect of the residual limb around the base of the pin interface with the liner. A custom-molded urethane base liner (Otto Bock)a may also be considered. Another option would be prosthetic socks impregnated with silicone in combination with a soft liner. However, silicone-impregnated socks are not as durable and may require frequent replacement.

A reasonable prosthetic prescription for this patient’s trans-humeral amputation would be the following:

1.Suspension: an elastomeric liner with interlocking pin can be used for suspension. The liner may help prevent skin breakdown in the residual limb with usage.

2.External power: a body-powered prosthesis is recommended as the initial device.

3.Harness: a figure-of-8 harness with extra padding over the harness and torso regions is needed to prevent skin breakdown across burn areas in contact with the prosthesis. The harness can serve as accessory suspension.

4.Cable system: a dual-control system is used for operating the elbow and terminal device.27

5.Elbow: the optimum elbow is body powered with manual lock.

6.Terminal device: the recommended type has a voluntary opening hook.

Circumstances exist under which initial fitting with an externally powered prosthesis (eg, a Utah armb) or a hybrid system may also be appropriate, such as when skin shear or nerve injuries impair use of a body-powered prosthesis. However, funding limitations may inhibit prescription of these devices. An upper-limb prosthetic prescription guide was provided in a previous Study Guide.20

The Syme’s amputation is a disarticulation at the talocrural joint. The heel fatpad is preserved and anchored to the distal tibia to allow for end-weight bearing. Non–weight-bearing casts are applied immediately, or a few days postoperatively, to allow for wound and tissue healing. This casting technique helps to minimize the chance of fat pad migration.28 After 4 to 5 weeks, a walking cast may be applied with proximal off-loading and a pattern bottom component (a pad applied to the bottom of the cast to allow weight bearing). These casts are changed every 10 to 14 days until leg volume is stabilized and the wound is sufficiently healed, at which point the patient is ready for preparatory prosthetic fitting.

The Syme’s amputation is amenable to several prosthesis socket designs: posterior opening, medial opening, stovepipe, and expandable wall. The posterior opening design, also referred to as the Canadian Syme prosthesis, allows for the bulbous end of the limb to clear the narrow ankle portion of the prosthesis during donning. The opening is then covered with a rigid panel secured by a strap. This enables a narrower cross-section to be made at the ankle. However, the posterior opening greatly weakens the structure of the prosthesis. The medial-opening prosthesis has the opening on the medial aspect. This greatly reduces forces around the opening of the prosthesis and provides greater prosthetic durability.29 As a result, the medial-opening device tends to be the preferred prosthetic approach. The stovepipe, or sleeve, prosthesis is named for the cylindric shape of the prosthesis and liner. A flexible inner liner with filler material around the areas proximal to the bulbous end is donned over the residual limb. The liner is then placed in the cylindric prosthesis. This design is hampered by the bulky appearance around the ankle. The expandable wall prosthesis is another option, with slightly less bulk. Its walls are flexible to allow passage of the residual limb during donning and doffing. The Rancho Syme prosthesis is a current example of this design. Its flexible inner socket is supported by a frame of laminated thermoset plastic. However, expandable wall variants still tend to be slightly bulkier than their medial- or posterior-opening counterparts.

A significant issue for Syme’s amputation is the need to equalize leg length when adding foot components because of the long residual limb. Feet used for more proximal amputations, such as those at the transtibial level or higher, tend to result in a longer prosthesis and thus unequal leg lengths. Low-profile foot components specifically designed for Syme’s amputations, such as the Flex Foot,c can minimize lengthening of the prosthetic limb relative to the sound limb. In most cases the ankle is fixed, although the keel may have a dynamic-response component. The fixed ankle results in an increased knee flexion moment. Placing the foot in slight plantarflexion may reduce the knee flexion moment. A lift in the contralateral shoe may be needed to correct leg-length discrepancy. Contractures can occur at the hip, knee, or ankle. Prosthetic accommodations for contracture formation should be considered. For example, a plumb line adjustment to the ground reaction force for a hip abduction contracture can provide better alignment and improved functional use of the prosthesis.

A reasonable prosthetic prescription for this patient’s Syme’s amputation would include the following 4 features:

(1)An exoskeletal structure.

(2)A stovepipe or expandable wall prosthesis with elastomeric liner are the most feasible socket designs. The liner may help minimize shear across fragile skin areas.

(3)No ankle, to minimize additional leg length.

(4)A low-profile dynamic response foot (recommended for active patients).

With proper prosthetic management, this patient should become a functional user with both his transhumeral and Syme’s prostheses.

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3.4 Clinical Activity: To re-evaluate this patient, who reports skin breakdown over his residual limbs after receiving his prosthesis 

Common skin problems have been discussed in a previous Study Guide.26 As described above, skin breakdown is a constant issue in patients with burns. Frequent socket adjustment and replacements are required for these patients. Often, skin breakdown occurs after a period of excessive prosthetic use. The first step in evaluation is inspection of the residual limb to determine the areas of skin breakdown. With skin breakdown over bony prominences, the liner or socket can be adjusted to provide pressure relief. Skin breakdown from shear or pressure can be present over any portion of the residual limb that is in contact with the socket interface or suspension system. In these cases, assessing the socket for proper fit will determine whether shear or direct pressure is the source of the problem. A total contact socket is preferred to distribute pressure over the entire residual limb. Change in residual limb volume associated with limb maturation, weight gain, and edema can alter socket dynamics and create increased shear. Pistoning of the socket during functional use may also be observed with lack of total contact. In this case accommodation with additional padding or suspension can alleviate this problem.

Treatment begins by determining whether the open areas are small enough to allow continued prosthetic use. If areas enlarge, then time off the prosthesis will be necessary to permit healing before more adjustments can be made. If the area is small (≤1cm), immediate adjustments can be made: changing the number of sock ply worn over the liner, changing elastomeric liner thickness, and adjusting of the prosthetic socket to relieve pressure over open areas. In some cases, switching from an interlocking pin suspension to more of a suction fit with the elastomeric liner can address distal residual limb skin breakdown. Regrafting of skin with additional split-thickness skin grafts may be necessary, but the risk for future skin breakdown persists. Prosthetic wear time should be incrementally increased to prevent recurrence of skin breakdown.

Bony overgrowth in the residual limb may also lead to skin breakdown. Although this is usually seen in the pediatric population, it can also be seen in adults with traumatic amputation.30 Bone spur formation at the distal end of the amputated limb can occur after electrical injury and may be induced by the actual reaction to the electrical injury, by trauma, or because of surgical technique.31 The incidence of bone spurs is reported to be as high as 82% in long bones.32 The bone spur areas may be quite tender and have spur protrusion through the epidermis. Evaluation can begin with plain film radiography to confirm bone spur formation. The first step in treatment is socket adjustment and additional padding around the bone spur area. Off-loading of the distal residual limb will help in most cases to prevent further skin breakdown. The socket can be adjusted so that pressure is transmitted to more tolerant areas such as the patellar tendon. A distal pad made from elastomeric materials may be used as additional padding for this area. If the bone spur continues to cause skin breakdown despite adjustments, then resection may be necessary. HO, which is seen commonly in burn and blast patients, can also create new pressure-sensitive areas.30 The HO can present as warmth, swelling, pain, and reduced ROM. In areas with little soft-tissue coverage, new hard irregular surfaces may be palpated on the residual limb. Patients suspected of having HO can be evaluated by plain films of the residual limb to determine exact location. Early HO may not be apparent by plain radiographs but may be identified on a triple-phase bone scan. The prosthetic socket can be changed to accommodate areas that are now pressure sensitive from the bone formation. Fitting may also be complicated if the ossification is impairing ROM and decreasing functional use of the prosthesis. Treatment of HO has been discussed in section 3.2 of this Study Guide. Joint arthrodesis from HO can result in limitations of prosthetic use and may require attempts at excision to regain ROM. In some cases, function of the extremity may be limited until definitive HO excision is performed. These patients will obviously require significant rehabilitation after excision to help prevent recurrence and to facilitate movement of the involved joints.

Proper hygiene of the residual limb is essential. Prosthetic sockets and liners tend to retain moisture, which can lead to harboring of bacteria and fungi.33 The moisture and bacteria can rapidly accelerate skin breakdown and cause subsequent infection. Daily washing of liners or socks with soap and water, with adequate drying time between washings, will minimize infection. Proper skin care should also extend to the residual limb, with attention to proper washing and adequate drying. Issuing the patient multiple socks and liners will allow the patient to rotate socks as 1 is being worn and the others cleaned. Antiperspirants and powders can be used in cases of excessive perspiration.

There is little in the literature other than case reports discussing the long-term prognosis for patients with amputations after burns. In general, these patients can be successful prosthetic users despite being more prone to skin problems than the usual patient with acquired limb deficiency. Careful attention to proper prosthetic fit and hygiene are essential to maximizing outcome.

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References 

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    ⁎

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References 

    • a Otto Bock, 2 Carlson Pkwy N, Ste 100, Minneapolis, MN 55447.
    • b Motion Control Inc, 115 N Wright Brothers Dr, Salt Lake City, UT 84116.
    • c Ossur North America, 27412 Aliso Viejo Pkwy, Aliso Viejo, CA 92656.
    • ⁎ Key reference.

 No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated.

PII: S0003-9993(05)01458-9

doi:10.1016/j.apmr.2005.11.024

Archives of Physical Medicine and Rehabilitation
Volume 87, Issue 3, Supplement , Pages 15-20, March 2006

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