Phase 1: Preclosure of the Residual
The goal of wound management during this
phase is to promote healing of the underlying
soft tissue and to treat or reduce the risk of
infections. In some instances, a drainage tube
is inserted to remove fluids and aid in tissue
repair. A member of your surgical team will do
the dressing changes.
Your role in wound management during this
stage includes the following:
- Keep your wound clean and dry. Notify your
nurse if your dressing becomes soiled or you
notice any leakage of drainage.
- Wash your hands if you come in contact with
drainage. Hand soap and hand sanitizers are
available in your room.
- Make sure everyone who comes in contact
with your wound wears gloves and washes
his or her hands before and after a dressing
- In some instances, visitors may need to take
special precautions to reduce the likelihood
of transmitting an infection to others. In
such cases, the nurses will review with you
any special precautions for visitors. We are
counting on you to see that these precautions
- Exercise caution when moving in bed or
getting in and out of bed so that you do not
dislodge any dressings or drainage tubes.
Notify the nursing staff if dressings become
loose or dislodged.
- Eat a good diet. Tissues cannot heal if they
are not provided with the necessary nutrition.
Dietary supplements are often provided
in addition to your meals to ensure that
sufficient calories and protein are available to
facilitate the healing process.
- Inform members of your rehabilitation team
if you experience pain during the care of
your wound. By working together, you and
your rehab team can establish a medication
schedule that will minimize your discomfort
during dressing changes.
Blast injuries that lead to amputation often
result in skeletal injuries to remaining limbs.
Often, the amputee will have skeletal pins and
an external fixator device applied to maintain
bone alignment and promote healing of
fractures. If you have one of these devices,
your role in taking care of it and your skin will
also include the following:
- Wash your hands with soap and water.
- Mix small amounts of sterile normal saline and
hydrogen peroxide in a sterile container.
- Saturate a sterile cotton swab applicator in the
- Using a circular, rolling motion of the cotton
swab, cleanse the pin sites from the insertion
- Avoid going over previously cleaned areas
with a used swab.
- Gently push down on the skin with the swab
to prevent skin from adhering to the pin.
- Leave the pin sites open to the air unless
drainage is present. If drainage is present, pin
sites can be covered with sterile gauze.
- Notify a member of your rehabilitation
team if you notice swelling, redness, pain,
tenderness, or a change in drainage from any
of your pin sites.
Phase 2: Definitive Closure of the
The goal of wound management during this
phase is to prepare your residual limb for
prosthetic fitting. Initially, you will have sutures
in place to close your surgical wound. These
are usually removed in approximately 14-
21 days. Your sutures will be covered with
petroleum-impregnated gauze, and bulky
gauze dressings will be applied to provide
additional protection. These dressings are
typically changed twice daily. Once your
sutures are removed, adhesive strips are
applied as the final stage of your wound
closure takes place. These strips will fall off
naturally in about 5-7 days.
Throughout this stage in your woundhealing
process, compression dressings will
also be applied to reduce swelling and begin
shaping your residual limb for prosthetic
fitting. There are two types of compression
dressings: rigid and soft. Rigid compression
dressings are made from casting material
and will be changed as the swelling in your
residual limb decreases. Soft compression
dressings are initially elastic bandages applied
in a specific way to reduce the swelling at
the lower portion of your residual limb. These
bandages will need to be reapplied several
times during the day to maintain proper
compression. Members of the rehabilitation
team will instruct you in the proper application
of these bandages.
Your role in wound management now
includes all of the previously listed items plus
these additional responsibilities for rigid or
Rigid Compression Dressing
- Keep the cast dry. Getting the cast material wet can weaken the cast,
and damp padding can irritate your skin.
- Avoid getting dirt or powder inside the cast.
- Never stick objects inside the cast to scratch your skin. If itching
persists, let your nurse know so other measures can be taken.
- Notify a member of your rehabilitation team if you feel increased pain or
numbness that may be caused by swelling or a cast that is too tight.
Elastic Bandage Compression Dressing
- Do not pull at your sutures even if the skin around the sutures itches.
- Notify a member of your rehabilitation team if you notice any tearing or
separation of the sutures.
- Notify a member of your rehabilitation team if you notice that the skin
around the sutures is red or swollen or if you notice any pus draining
from the suture area.
- Rewrap your residual limb several times during the day (usually at least
4-5 times) to maintain proper compression.
- Obtain new elastic bandages if the ones you are using become soiled or
Directions for Wrapping with an Elastic Bandage
(Below-knee, below-elbow and above-elbow amputations)
- Using a 4-inch wide elastic bandage, go over the end of the limb slightly
stretching the bandage.
- Relax the stretch and secure the bandage by going around the limb
- Increase the stretch and go to one side of the center.
- Decreasing the stretch, go around back.
- Go up the other side of the center as you increase the stretch again.
- Repeat this figure eight pattern until the end is securely bandaged and then secure the bandage with Velcro or tape. (Do not
secure bandages with pins).
- If the length below the knee or elbow is very short, you will need to make a similar figure eight pattern above and below the
joint and then secure the bandage.
- Use two 6-inch wide elastic bandages. (Bandages can be sewn together.)
- Wrap around the waist twice.
- Wrap around the end of the limb.
- Wrap back around the waist.
- Wrap around the end of the limb.
- Wrap around the waist and secure. (This is the anchor for the next bandage.)
- Take another 6-inch wide elastic bandage and, similar to the technique used for below-knee amputations, go over the end of the limb slightly stretching the bandage.
- Relax the stretch and secure the bandage by going around the limb once, then increase the stretch and go to one side of
- Decreasing the stretch, go around back, and then go up the other side of the center as you increase the stretch again.
Repeat this figure eight pattern until the end is securely bandaged, making sure to bandage all of the way up into the groin
area. Secure the bandage with Velcro or tape. (Do not secure bandages with pins.)
Remember: For best results, you must reapply the elastic bandages whenever they loosen.
Wearing an Elastic Shrinker Sock
Using an elastic shrinker sock is another way to reduce swelling.
These shrinker socks can be used alone or in combination with elastic
bandages. If the limb is still very sensitive, it will be more comfortable
to stretch the shrinker as it is being put on either by using two pairs of
hands or an appropriate-size ring made of a stiff material such as PVC.
||1. With two people using all four of their hands (two can be the patient’s),
put all of the fingers down to the bottom of the shrinker, thumbs on
the outside, spare material scrunched down, and stretch out until the
bottom of the shrinker is completely flat and stretched out.
||2. Place the flat, inside part of the shrinker against the end of the
||3. In one swift motion, keeping the stretch and
letting the material slide from between the
thumb and fingers, pull the shrinker up the
4. There should be no gap between the end of
the residual limb and the shrinker.
5. If this is for an above-knee amputee, make
sure the long side is around the hip and the
short side is all of the way into the groin.
Using a Ring
- Make sure the chosen ring will slide easily all of the way to where the shrinker will end on the limb.
- Stretch the shrinker over the ring until the end is flat.
- Place the flat, inside part of the shrinker over the end of the limb and feed the shrinker up the limb until it is as high as
- Remove the ring.
Preparing for Prosthetic Training
At this point in your rehabilitation, there are four techniques you can use to prepare your residual limb for prosthetic
training: massage, tapping, desensitization and scar mobilization.
Massage and Tapping
Early massage and tapping of your residual limb will help you develop
a tolerance in your residual limb to both touch and pressure. Both of
these techniques can be performed through your soft compression
dressings and when the soft compression dressing is off. Additionally,
these techniques may help decrease your sensation of phantom pain.
- Using one or two hands, massage your residual limb using a gentle
kneading motion. Initially, be especially cautious when massaging over
your sutured area.
- Massage the entire residual limb.
- Over time and once your sutures are removed, you can increase the
pressure to massage the deeper soft tissues and muscles in your
- This should be done for at least 5 minutes 3-4 times daily. It can be done
more often if it is found to be helpful in reducing phantom pain.
- Tap your residual limb with your fingertips,
being careful not to tap with your fingernails.
Gentle tapping over the suture line is generally
allowed even before your sutures are
- Over time and once your sutures are removed,
you can increase to a slapping motion using
one or two hands.
- Tapping should be done for 1-2 minutes 3-4
times daily. It can be done more often if it is
found to be helpful in reducing phantom pain.
Desensitization is the process of making your residual limb less sensitive. If you start with a soft material and progress to
rougher materials, desensitization can help you increase your tolerance to touch in your residual limb.
- This technique is done when you are not wearing your soft compression dressing. It should be done for 2-3 minutes twice
daily and is usually done during bathing times.
- Initially, start with a cotton ball and gently rub the skin of your residual limb using a circular motion.
- When you are able to tolerate it, progress to a rougher material such as a paper towel.
- Finally, advance to a terry cloth towel.
- This technique should be done until you can tolerate gentle friction from a terry cloth.
This technique is done to keep the skin and scar tissue on your residual limb loose. Scar adherence to underlying tissue
can be a source of pain when using your prosthesis and can also cause blistering. This technique is best performed
when you are not wearing your compression dressing.
- Place two fingers over a bony portion of your residual limb.
- Press firmly and, without moving your fingertips, move your fingers in a circular fashion across the bone for about 1 minute. Continue this procedure on all of the skin around the bone of your residual limb.
- Once your incision is healed, use this procedure over your scar moving your fingers in a circular fashion to loosen the scar
- This technique should be done daily when you bathe.
Inspection of Your Residual Limb
- Regular inspection of your residual limb using a long-handled mirror will
help you identify skin problems early.
- Initially, inspections should be done whenever you change your
compression dressing. Later on, most amputees find daily inspection
sufficient for the early identification of skin problems.
- Inspect all areas of your residual limb. Remember to inspect the back of
your residual limb and all skin creases and bony areas.
- Report any unusual skin problems to a member of your rehabilitation
Daily Foot Care
For lower-extremity amputees, it is important to maintain the health of
your remaining foot. This is especially important if you have diabetes or
if you have decreased circulation or sensation in your lower extremities.
Your daily routine should include the following:
- Wash and dry your foot properly: Use a mild soap, rinse thoroughly, and
dry your skin by blotting or patting, making sure to dry between your
- Inspect your foot daily: Check for blisters, cuts and cracking.
- Protect your foot from injury: Wear shoes or slippers at all times, and
check your shoes every time you put them on for tears, rough edges or
Permission to resume showering is based on a
number of factors and is highly individualized.
Your safety and other factors, such as the
condition of other wounds and injuries, must
all be considered. When you feel ready to
resume showering, the best thing to do would
be to discuss the specifics of your situation
with a member of your rehabilitation team or
peer visitor. You need to ask questions about
home adaptation, shower chairs and any help
to get family members trained on any assisted
bathing or cleaning care.
Some of the most embarrassing moments for
our service members can occur while getting
to or going to the toilet. Discuss with your
nurse your options and limitations or use
your peer visitor for advice and alternatives.
Be patient as your new routine will be
comfortable again soon.
—by Paddy Rossbach, RN, President/CEO,