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Stump board (for below-knee amputees sitting out in wheelchair)

Pillows

Hoists and appropriate amputee and rehabilitation slings or sliding sheets may be required if the patient presents as a manual handling risk

Preprocedure

Action Rationale

1 Explain and discuss the procedure with the patient. To ensure that the patient understands the procedure and gives their valid consent (NMC 2008, C).

2 Wash hands thoroughly or use an alcohol-based handrub. To reduce the risk of contamination and cross-infection (Fraise and Bradley 2009, E).

3 Ensure that the bed is at the optimum height for the patient and handlers. If two handlers are required try to match handlers’ heights as far as possible. To minimize the risk of injury to the practitioner and patient (Smith 2005, C).

Procedure

Upper limb amputee

4 Ensure patient is maintaining full range of motion of all remaining joints of the upper limb. To prevent contractures in case of possible prosthetic rehabilitation and functional use. E

Below-knee amputee

5 Maintain knee extension.

In bed: do not place a towel or pillow under the knee unless it is supporting the whole of the stump; that is, do not encourage the knee to be maintained in a flexed position.

To prevent knee flexion contracture. E

To assist stump oedema management. E

To promote healing. E

In chair: use a stump board on the wheelchair if one has been issued. If the patient is sitting out in the chair then support the amputation with a footstool and pillows.

To support knee joint. E

To prevent excessive knee flexion. E

To aid stump oedema management (White 1992, R4, E).

To protect the residual limb. E

Above-knee amputee

6 Maintain hip in a neutral position. To maintain hip extension. E

In bed: ensure the patient is periodically lying supine.

Or:

To prevent hip flexion contracture. E

Consider prone-lying or side-lying with the hip in neutral position.

To avoid shortening of hip flexors and abductors. E

In sitting: ensure that the patient does not place a towel or pillow under stump.

To prevent excessive hip flexion. E

Problem-solving table 7.5 Prevention and resolution (Procedure guideline 7.11)

Complications

1 Limb contracture can occur due to:

— immobility

— alteration in muscle balance around the joints

— pain

— habit.

In order to help prevent limb contracture, the patient will require adequate analgesia to control pain. It is also important to remind them if they are tending to adopt positions of their stump which could lead to limb contracture. The physiotherapist may recommend that the patient adopt certain positions for periods during the day to help prevent contractures such as prone-lying for above-knee amputees (Figure 7.20).

2 Ongoing phantom limb pain. This can be a persistent problem and will need referral to the pain team for appropriate management.

3 Wound infection or delayed healing. Review by medical team for appropriate management.

Figure 7.20 The correct position for prone lying (t/t denotes transtibial).

Reproduced from Engstrom and van de Ven (1999).

Websites

http://spinal.co.uk

www.asia-spinalinjury.org

http://guidance.nice.org.uk/CG75

References

ACPIN (1998) Clinical Practice Guidelines on Splinting Adults with Neurological Dysfunction. Association of Chartered Physiotherapists Interested in Neurology, Chartered Society of Physiotherapy, London.

ACPRC (1996) Physiotherapy Management of the Spontaneously Breathing, Acutely Breathless, Adult Patient: A Problem Solving Approach. Chartered Society of Physiotherapy, London.

Ada, L., Goddard, E., McCully, J. et al. (2005) Thirty minutes of positioning reduces the development of shoulder external rotation contracture after stroke: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 86 (2), 230–234.

Adam, S. and Forrest, S. (1999) ABC of intensive care: other supportive care. British Medical Journal, 319 (7203), 175–178.

Aggarwal, R. and Hunter, A. (2007) How exactly does the chest wall work? Student BMJ, 15.

BACPAR (2006) Clinical Guidelines for the