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The Use of a Rigid Removable Dressing in a Juvenile Amputee: A Case Report

The rigid removable dressing (RRD) provides rapid residual limb shrinkage, prevents edema, provides soft tissue immobilization, decreases wound pain, prevents trauma to the residual limb, and decreases length of hospitalization for adult amputees. Traditionally, immediate postoperative prostheses are used for juvenile amputees. This is a case describing the use of a RRD in a juvenile amputee. The RRD allows for frequent wound inspection and provides progressive compression both to shape the residual limb and to decrease postoperative edema. In addition, it protects the wound during ambulation, normal childhood playing and mat exercises. The RRD also helps to teach the child and his family the principles of sock management. The RRD is a beneficial technique when used in the preprosthetic management of the juvenile amputee.

Controversy exists in the literature regarding appropriate postoperative management of the lower limb amputee.3 The choices of postoperative dressings in juvenile amputees have included soft sterile noncompressive dressings, soft compressive dressings, or rigid nonremovable dressings such as the immediate postoperative prosthesis.2 This is a case report of the use of a rigid removable dressing in a juvenile amputee.

Case Report

A seven year old male sustained a crush injury to his left lower extremity in a motor vehicle accident. He underwent a left below knee amputation and required multiple skin grafts. His hospital course was complicated by poor wound healing. At the time of discharge, the patient's wound site was open. He resumed his childhood activities, even playing in the dirt with no protective dressing.

The patient was seen at our institution thirty five days after amputation. The distal residual limb was edematous and not yet closed. The largest of the lesions was approximately 3 by 3 cm involving the skin over the distal tibia. Two other lesions involved the edges of graft sites, measuring approximately 1.5 by 1.5 cm each. A rigid removable dressing was fabricated when the patient was seen on initial evaluation. It was worn continuously except for wound care and inspection. When removed, the rigid removable dressing was reapplied to the residual limb within fifteen minutes to avoid formation of distal edema. The rigid removable dressing provided protection for the residual limb during mat activities, gait training, and normal childhood play including skateboarding and riding an all terrain vehicle.

With volume decrease of the residual limb, socks were added to maintain total contact and adequate residual limb compression. He required up to fourteen ply socks. After 14 days, sufficient wound healing allowed casting of his residual limb for a provisional prosthesis. The child adapted well to this. His gait pattern was excellent, and he demonstrated a good understanding of sock management.

Fabrication of the Rigid Removable Dressing

The casting procedure for the rigid removable dressing is a modification of the technique described by Wu.8 Casting begins with two to three prosthetic socks (totaling approximately six ply) applied over the soft sterile surgical dressing. Using a six ply sock allows the sterile postoperative dressing, when changed, to vary in bulk while still maintaining the total contact of the rigid removable dressing.3 The socks are applied layer by layer to prevent wrinkles. Plastic wrap may be used over the surgical dressing and after each layer of sock to facilitate donning. The plastic wrap decreases shear forces, and therefore donning the socks is less painful. When the residual limb is bulbous, padding is added on the concave side to avoid proximal narrowing and ensure easy removal and reapplication of the cast. After the appropriate number of socks has been placed, the limb is covered first with plastic wrap and then by an additional prosthetic sock which will be incorporated into the rigid removable dressing. The cast is fabricated in two layers, the first is composed of elastic plaster, then a second layer of fiberglass is applied. The trimline of the below knee cast is midpatella anteriorly, and lower posteriorly to allow knee flexion. For above knee amputees, the trimline is below the ischial tuberosity posteriorly, and adequately distal anteriorly to allow hip flexion. After initial fabrication of the rigid removable dressing and before it is removed from the patient, a reference mark is made anteriorly so that the dressing is always properly aligned. The prosthetic sock which was incorporated into the dressing is pulled tightly down around the outside of the cast to round any sharp edges of the cast. Below knee suspension is provided by an additional sock over the rigid removable dressing held in place by a supracondylar Velcro (TM) strap, a compressive sock, or Neoprene (TM) sleeve. In above knee amputees, a Juzo (TM) shrinker sock or cotton webbing waist belt with adjustable garters may be used. As residual limb edema resolves and the patient increases to fifteen ply sock, fabrication of a new, smaller rigid dressing should be considered. 3,4,8

Discussion

In reviewing the postoperative dressings currently used in the juvenile amputee, none is ideal. The rigid removable dressing offers several advantages over the traditional wound care alternatives of soft, sterile noncompressive dressings, soft, sterile compressive dressings, and rigid nonremovable dressings.

Soft, sterile noncompressive dressings such as gauze bandages are easy to apply, and they allow access to the wound for inspection. These dressings, however, do little to shape, compress, or protect the residual limb.4 These dressings, therefore, are not ideal for use in the juvenile lower extremity amputee.

Soft compressive dressings such as elastic bandages and shrinker socks allow access to the wound, and are relatively inexpensive. Using elastic bandages has several disadvantages. Residual limb wrapping is a fine motor technique which is difficult to master.5 To maintain adequate compression, the elastic bandage must be reapplied every four hours.3 Improperly applied bandages can slip off or produce a tourniquet effect causing increased distal edema, ischemia, and the potential for skin breakdown.3 In addition, soft compressive dressings do little to protect the residual limb from trauma.4

Rigid nonremovable dressings have been used postoperatively for juvenile lower extremity amputees since the early 1950's when they were introduced by Berlemont.1 These dressings are advantageous in that they decrease postoperative edema, protect the residual limb from trauma, and allow early ambulation.3 There are several disadvantages in using the immediate postoperative prosthesis. The cast must be cut to allow access to the wound, therefore monitoring the skin is difficult. As residual limb volume decreases, effective compression may last only two to four days.7,8 Unless the loosened cast is changed at frequent time intervals, it will not provide adequate compression for further shaping. A poorly fitting cast may cause pistoning of the residual limb in the cast during ambulation. Pistoning can contribute to skin breakdown.7,8 To correct the problems of ineffective compression, the cast must be removed and refabricated at frequent time intervals. This process is labor intensive and requires that a skilled prosthetist be on call to remove or replace the cast at any time. Although the immediate postoperative prosthesis allows for early ambulation, the gait pattern promoted is abnormal with the knee held in extension.2

The rigid removable dressing is superior to the soft noncompressive, soft compressive and rigid nonremovable dressings. It provides total contact to shape the residual limb and limit edema.3 The rigid removable dressing also provides soft tissue immobilization which may promote wound healing, decrease wound pain, and protect the residual limb from trauma during a variety of activities.5 A study by Wu and Keagy6 compared the postoperative use of the rigid removable dressing and elastic bandages. From amputation to ambulatory discharge, the average rehabilitation stay was 191.4 days in the elastic bandage group compared to 101.8 days in the rigid removable dressing group. This suggests that using the rigid removable dressing contributes to decreased length of stay.

Complications in using the rigid removable dressing may occur with improper donning. If the incorrect number of socks is used or the cast is improperly aligned, there is a potential for distal edema or breakdown over bony prominences. This problem can be obviated by proper patient and family education.

Conclusion

The rigid removable dressing can be used effectively in managing a juvenile lower extremity amputee. When compared to traditional wound care alternatives, the rigid removable dressing offers significant advantages. It allows easy access to the wound for inspection; provides residual limb shaping; protects the wound from trauma; and instructs the patient and family in the principles of sock management. A child with delayed wound healing may derive psychological benefit from safely participating in a wide variety of activities using the rigid removable dressing. The rigid removable dressing should be considered in the preprosthetic management of all juvenile lower extremity amputees.

UMDNJ/New Jersey Medical School-Kessler Institute for Rehabilitation, Pleasant Valley Way, West Orange, N.J. 07102

References:

  1. Burgess EM, Romano RL: The Management of Lower Extremity Amputees Using Immediate Post-Surgical Prostheses. Clin Orthopedics 57:137-46, 1968.
  2. Friedman LW: The Indication for and Modern Management of Conventional Amputation. Vasc Surg 5:36-41, 1971.
  3. Leonard JA, Andrews KL: Rigid Removable Dressing, Immediate Postoperative Prostheses, and Rehabilitation of the Amputee, Ernst and Stanley (editors), Current Therapy in Vascular Surgery, Philadelphia, BC Decker, 1990.
  4. Leonard JA, Meier RH: Prosthetics, DeLisa JA (editor), Rehabilitation Medicine Principles and Practice, Philadelphia, JB Lippincott, 1988.
  5. Mueller MJ: Comparison of Removable Dressings and Elastic Bandages in Preprosthetic Management of Patients with Below Knee Amputations. Physical Therapy 62:1438-41, 1982.
  6. Wu Y, Keagy RD et al: An Innovative Rigid Dressing Technique for Below the Knee Amputation. J Bone and Joint Surg 61A:724-29, 1979.
  7. Wu Y, Krick HJ et als: Postoperative and Prosthetic Management of Below Knee Amputees with Removable Rigid Dressing and Scotchcast Preparatory Prosthesis, Proceeding of the 8th Annual Conference of Rehabilitation Engineering Society of North America, 370-372, 1985.
  8. Wu Y, Krick H: Removable Rigid Dressing for Below Knee Amputees. Clin Prosthet and Orthotics 11:33-44, 1987.