Surgical Wounds and Acute Amputees

pre-operative treatment includes

nutrition, pressure relief, treatment of infection, fluid/blood replacement, need for colostomy, local ulcer care

clean surgical wound

nontraumatic, no break in sterile technique (no rip in skin, elective procedures)

clean-contaminated surgical wound

involving GI or respiratory

contaminated surgical wound

major break in sterile technique, with gross spillage from GI tract

dirty or infected surgical wound

acute bacterial inflammation, pus and devitalized tissue found

post-operative period care

fluids/warmth/O2, pain management, glucose control, early mobilization, edema control, pulmonary hygiene, stress, appropriate wound care

hemostasis in surgical wound healing

acute wound created under sterile conditions

surgical dressing in hemostasis for surgical wounds

dressing on for 24-48hr, prudent to protect incision from harm, majority of primary dressings are gauze

surgical wound inflammatory phase

typically limited in acute surgical wounds

inflammation stage of surgical wound healing

epithelial resurfacing 2-3 days, cover for comfort and protection, inflammatory signs within 4 days (may not see these with immunocompromised), check incision sites

generally, sutures/staples are removed

7-10 days post-op (situational)

risk factors for dhiscence

DM, high dose steroids and high bacterial levels, mechanical stress

dehiscence

swelling/redness involved and sutures start to pull apart from eachother

once dehiscence occurs

manage as you would any other open wound, focus on nutritional and circulatory support, topical therapy

topical therapy for dehiscence to

eliminate necrotic tissue, control bioburden and maintain moist wound environment

proliferation phase of surgical wound healing

begins approximately on post-op day 4 and lasts 2-3 weeks

granulation

new blood vessels formed to replace those damaged or destroyed by surgery and collagen is synthesized to connect tissue layers together

healing ridge

firmness to tissues caused by new collagen to area - can usually be palpated between post-op days 5 and 9 if no risk of dehiscence

dehiscence can occur

after or during proliferative phase - concern if cant palpate healing ridge (assess factors affecting wound healing)

incision drainage characteristics

initially bloody, tinged blood, clear/yellow, then none by day 5-9

remodeling phase of surgical wound healing

granulation tissue is remodeled and tensile strength increases, new tissue 70-80% as strong as original tissue, full remodeling can take 1-2 years

skin grafts

can be composed of 1 or more types of tissue, does not have its own blood supply - need to utilize donor sites

split thickness graft

epidermis and part of dermis

full thickness grafts

epidermis and entire dermis (preferred in areas where significant scarring/contracture could occur leading to aesthetic or functional consequences)

indications for grafts

clean and vascularized wound bed, wounds that could close on their own but consideration of contractures/fractures

contraindications for grafts

inadequate blood supply, or inadequately debrided

reasons for graft failure

shear, inadequate debridement, infections

flaps

composed of 1 or more tissues, has its own intrinsic blood supply

causes of skin flap failure

compromised vasculature (poor flap design, infection, trauma/sheer, iatrogenic injury like cutting vessel)

flaps indications

tissue deficit, exposed critical structures, functional benefits, ability to treat cause of wound

contraindications for flaps

patient to ill to tolerate, inability to resolve underlying condition causing wound, inadequate tissue perfusion to support healing

reasons for ampuations

disease (60-85%), trauma (15-35%), tumor (5%), congenital (3%)

levels of LE amputations

anywhere from toe to hemicorpectomy

BKA

below knee amputation/transtibial

AKA

above knee amputation/transfemoral

transtibial BKA want to

preserve limb length as much as possible to max control, WB through residual limb - if too long doesnt leave room for prosthesis - 5-7in is ideal

transfermal AKA want to

conserve length for level control, WB through soft tissue

surgical considerations for LE amputations

need to remove nonviable tissue while allowing for closure and appropriate shape of residual limb

too short residual limb length

hard to keep prosthesis on, decreased WB surface

too long residual limb length

joint doesnt line up with contralateral limb

bone ends of amputations are

rounded off and nerves are pulled and cut so they retract (phantom pain)

skin flaps in amputations

common to see combo of myoplasty (muscle to muscle) and myofascial closure for stabilization and minimizing sliding over end of bone (or myodesis)

postoperative dressings include

rigid, semi rigid or soft

postoperative goals for amputees

control edema, shape limb for appropriate prosthetic fitting, protect, prevent contracture (no pillow under knee), provide patient education on care for residual limb, desensitization,

ideal limb shape for fitting into prosthetic

cylindrical shape

rigid dressing

prevents knee flexion contracture, manages edema, protects surgical site, typically need second rigid dressing 7-10 days after - common for BKA

removable rigid dressing

ability to remove dressing and monitor surgical site, use prosthetic socks of increasing thickness to maintain fit as edema decreases

compression therapy for amputes

can be used alone if no other protocol is appropriate, use compressive wrap/shrinker to control edema

gel liner

rolls onto limb - commonly used to help fit residual limb into prosthetic

phantom limb sensation/pain

normal and almost universal, early on may be triggered by edema, balance and safety implications - try desensitization techniques

transtibial positions to avoid

hanging residual limb over bed, sitting in WC with residual limb flexed, pillow under knee or hip, crossing legs

most common contracture for transtibial amputation

knee flexion

transfemoral positions to avoid

pillow under back, curving spine, pillow under hip, prolonged abduction

most common contracture with transfemoral amputation

hip flexion or abduction

mobility issues for acute amputee

condition of remaining limn, premorbid status, strength, endurance, balance, bed mobility, transfers