Hi, I'm David Lawrence, and in this video I'm going to talk about the process of preparing the residual limb for a future prosthetic device. (music) Alright, when we're dealing with residual limb management, the process is trying to control the edema that's going to be in that residual limb. And there's a couple of different ways that we can do that. There's rigid compression and there's soft compression. Rigid dressings work very well. Sometimes they're put in post or put on post-operatively. They can work well but they demand constant follow-up because it's easy for the patient to start swelling and end up getting a wound. Much more common place today is people using soft compression. Soft compression can come in multiple different ways. One and the traditional, is an ACE wrap. For a below-knee amputee, a double length 4-inch ACE wrap is perfect. Much more common today though is now the shrinker. The shrinker is just more simple to use. There's really a number of different styles of shrinker. Compressogrip is probably the most common. However, if you need a firmer, thicker, more compression, Tru-Form is a thicker shrinker that does exist. And then a Juzo shrinker is a very light-weight, very soft. You chose that based on your patient's needs, and discomfort. If the limb is very sensitive, with not a lot of swelling, a soft shrinker is fine. A limb that has a great deal of swelling, large 'dog-ears', or something along that line, that needs more compression and the patient isn't hyper-sensitive, the Tru-Form is best. In the middle is the Compressogrip and this is why you see this used most often. So, with compressogrip, donning a compressogrip, or any shrinker, it's very important that you don't drag it on. You don't pull it on the bottom and drag it up like a sock. That'll cause damage to the incision line, both in particular on the sides and the bottom related to either if there's glue, sutures, staples, tape, whatever there happens to be, you want to protect that. You're always going to take your compressogrip or any shrinker and roll it back. Right, so that you get more of the center of the compressogrip, and you're going to expand it much like you would put on a stocking cap. And you're basically going to set that over top of the end of the residual limb. Notice how I'm not now rubbing over the incision line. From that point I can bring the compressogrip up and just over top of itself and right up the thigh. And you want to roll it all the way up. Don't leave any wrinkles or rolled up spots. That'll create a tissue dam which will hold fluid in place. Many of these compressogrips come with a ring. If it does, you just fold it back over. If yours does not have a ring, it's not a problem, simply take and do a full turn in the compressogrip like that, and then pull it right over the end. Now at this point again, I'm stretching it out a little bit wider and then I can slowly bring the pressure up on the bottom of the residual limb. You don't want it super tight, but you don't want a gap there either. Once you're here, you pull it all the way out and you'll notice that we have two different lengths. The lower layer is longer, the outer layer is shorter. This is going to create a gradient pressure, pushing fluid back to the heart. If someone has more swelling and needs more compression, you can bring this second layer back down creating a third layer. So now we have three layers right around where we need the most compression. Less pressure as it's pushing fluid up the limb. Now, if that's, once you've got that and the patient is stable in the compression the next concern really is protection. Because the most common reason why patients go back into the hospital following an amputation is falls and damage to the residual limb. So, there a number of devices out there now, just like this, that are protection devices. And basically it's a velcro attachment, the patient slides right into it, pull the velcro over it. It's a very simple fit. Some people think this is a shrinker. It's not. You have to have a separate compression device and then a separate protection device. Alright, our next issue is the issue of range of motion. And we're going to find with many patients in a very comfortable position in the bed is put into this knee flexion, hip flexion, external rotation, and abducted position. The patient is very comfortable. The problem with this is we set up a contracture problem. And we talk about contractures, people think that's talking about tight muscles. Contractures really talk about the joint itself. And if a joint is not moved over a time period and kept into a limited extension range of motion, the capsule will tend to dry out from lack of movement of the synovial fluid and contract or be unable or difficult to get back into full extension. So, very simply with patients we want them to understand that we want you comfortable in that hospital bed but if at all possible, we want to reduce all of this support down to a much more minimal level. So, he still has support, in other words he can still have a little bit of elevation, but you'll notice what we've done is brought the pillows down too to get more of the residual limb into extension. The other thing I'm going to talk to the patient about is, simply bringing that residual limb over and keeping it more straight. Now he's got a little bit of flexion at the knee, a little bit of flexion at the hip, but no external rotation or abduction which means it's going to be much easier for him to get into a neutral standing position. Now the other thing that can be very helpful is our protective device that we put on earlier. It not only is going to protect the patient from falls, but it's going to also hold that residual limb into extension. It's very comfortable to the patient because it's soft on the inside and it's going to give them good support, but also attain good knee extension. So, at this point we have talked about positional concerns and making sure we keep that joint range as neutral as we can, but the next issue is how do we keep the joint healthy with movement? And what you want to do is get that joint, both the hip and knee moving as much as possible in a safe and comfortable range so that the oils within the joint are moving and maintains the joint's health and decreases capacity for contracture. So, to do that, you're going to have the patient roll to their side, their sound side, because that's the direction they're going to roll to to get out of bed. And I'm going to have the patient now roll to the sound side, and then stay on their sound side. There you go. Bend those knees slightly. If you were going to get up at this point, he'd bring his legs off the end and push up, but from here we're going to do a very simple exercise where I can come in, support the residual limb so it's comfortable. Have the patient bend that knee and pull the hip forward to comfort. Now if it's like, "Ah, it hurts..." then don't pull that much. Just a slight amount of knee flexion and hip flexion. And then, really importantly, reaching back, extending that knee as much as possible. And I can help them guide that motion. And extend that hip as much as possible to get some stretch. Then the patient goes back and forth and just bends that knee into some compression and discomfort and slowly comes back out and reaches back trying to get that hip as extended and knee as extended as possible. And then just repeat that motion. So I talk to patients every time you're going to get up, or at least every hour, slowly and gently take that hip and knee through whatever range you can get without pain. You're not trying to get pain at this point. This is early on in the process, it's just about gentle, controlled movement. So, our last concern is that issue of incision line management. Is how well is that going to heal? Remember, two concerns are: Is it mobile? Number three is has it got good tensile strength? In an incision like this that's about two weeks out we want to be very careful with that incision line but we realize that we're well past the inflammatory phase and we're into the phase of neovascularization, where he's forming a good scar underneath but haven't reached the 21 day mark where we should have a solid wound / scar, even though it's not strong yet. So, at this point in time, what do we want to work on? A couple issues that are really important is coming down to that patient on an incision line like this and putting say your thumbs, two fingers whatever you want, I like thumbs, on both sides of the incision line. You're going to approximate the incision line a little bit and then just gently move your thumbs together. Now, what are you doing? They're moving together because we're moving the skin over top of the underlying tissue. Anytime you have an incision like this, it's cut obviously deep through multiple layers. And if we're not careful we can end up with an area of invagination. That means that wound has scarred down to the tissue underneath. So early on I don't want to put any strain on the incision line, but I just gently want to move that incision line around so it's free and that the skin stays free to slide and shear inside that prosthetic in the future and not have adhesions. Once the patient has progressed and we've gone past that three week mark and we have about a 60% attainable tensile strength. We want to get the rest of that tensile strength and that's done by mobilization. So, now instead of approximating and moving the thumbs together, I can allow those thumbs to move separate from each other and create some shear across that incision line. Many times what you'll see in dry skin that's healing is you'll see flaking off of the skin. That's actually a good sign. It means you're getting the good healthy skin from underneath growing and you're flaking off some of the dead skin on the top. The progression from that is to progressive into putting your thumb or finger right on the incision line and doing circular motions. Again, just loosening up the shearing of the wound so it can move and freely move inside the socket. Now how do you know when you can stop? I usually tell people you want to mobilize for at least 6 weeks or so. But one way to know is that that line, that epithelial line or that lump that you feel under the incision line. You can keep mobilizing until that lump is gone and you feel like the skin is flush with the skin around it. Then there's really no need. This is the time also when you want to start getting the patient involved. Because once you've got a good stable wound and it's not still bandaged and it's solid, the patient can be taught to start mobilizing that themselves. Really it's going to be very helpful in multiple ways. One is so that they get more mobilization on a regular basis and better movement of the incision line. Second of all, so they interact with their residual limb more. That helps with some of our phantom limb concerns and to keep them to be interactive with the residual limb versus the idea of feeling fearful of it. One thing that can be helpful is some sort of skin lotion or some people use cocoa butter. It works really well on a very heavy-scarred, very thick skin area. But you do want to be careful that none of these things are anti-septic. So, do not rub this on anything with an open wound. But if we have a wound that's an incision line that closed, you're just trying to improve tensile strength or decrease the scabby-ness, this stuff can work great. Anything where there's a potential opening, no kind of lotion, no kind of lubricant, because none of these things are anti-septic. Our last concern that we talked about with the patient is being concerned about their opposite or contralateral limb. One of the things that is really prevalent in patients because they're spending a lot of time in bed is the back of their heel and stasis ulcers. If they already have some peripheral neuropathy where they don't feel very well in their foot and they're putting all the weight of the back of their leg on that heel for a long time in the bed, you can develop a pressure sore in the back of the heel. Very simple little trick is to have the patient pick that leg up, bring it down and just let the heel come right off the end of a pillow. So it doesn't have to be a big thick pillow, just enough so you can see I'm loading or unloading the heel here and protects it. The last issue is to be looking at that patient if they're getting a lot of peripheral edema. Now, when they're in the bed like this in a neutral position if they have venous insufficiency, the leg swelling will come down and look great. But if they get up and they start moving around or in the wheelchair more and you're finding that their ankle swells a lot that means they're getting blood flow into the foot but they're having a hard time getting it out. Compression garments can be very helpful: knee high, ted-hose, anything along that line. One thing that's really important about donning and doffing though is very much like a shrinker. You don't drag them on from the bottom. You simply roll them half-way out, donn the foot first, and then roll the ted-hose all the way up. Makes it much easier to utilize. Thanks for watching and we hope that you found this helpful. This video is part of a series on prosthetic interventions, ranging from managing the residual limb after amputation to running with a prosthesis. We encourage you to view our other videos in this series and to share them as well. You can find them on our YouTube channel at YouTube.com/MissionGait. To stay up to date on our latest content, click the link in the corner to subscribe and be sure to like and share this video!