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Oct 29

Management of Persistent Skin Conditions on a Transtibial Stump

Hi guys,

This is an interesting case that I’m having difficulty with. This lady had a traumatic TT amputation a few years back now. Currently is having trouble with a “rash” on the base of the stump which has been there for a while now. Pays for her own liners and walks heaps on her prosthesis normally but now is having to keep it off to allow the rash to clear up – as soon as the liner goes back on it comes back. Has tried all manner of lotions and potions which don’t seem to work. The base of stump looks a bit Verrucous hyperplasia like to me but again not sure (haven’t seen it face to stump yet). Will let you know when I see her in person but my initial thoughts are to check distal contact, check the liner fits properly. She is talking about further surgery to clean up the stump for fitting not cosmetic reasons. Maybe a custom liner might be required. Any other ideas welcome.

Skin condition 10 Oct 2013

Skin condition 10 Oct 2013

Skin condition 10 Oct 2013

Skin condition 10 Oct 2013

Skin condition 10 Oct 2013

Skin condition 10 Oct 2013

Skin condition 17 Oct 2013

Skin condition 17 Oct 2013

4 comments

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  1. Tony

    You probably are on the right track, but my thoughts would be:

    1) Fit of liner / distal contact – is it too loose distally, or too tight distally which causes some constriction or pushes the soft tissue into a cone shape, bunching the soft tissue and then causing localised increased negative pressure when that tissue elongates in swing. I was led to believe that a wrongly sized liner causes uneven suction pressures, which can lead to increased distal suction. Might also be worth asking about oedema fluctuations as the fit may vary.

    2) Fit of socket – pistoning, or not enough proximal suspension which then puts the suspension of the prosthesis totally reliant on suction distally (ie is the liner creating a correct seal proximally or is it biased to distal stump). If there’s not a correct seal there can be an increased pulling effect distally (especially if the liner also has a locking pin). I know it’s not strictly correct depending on the TSB socket type, but I have seen prosthetists use socks and gel pads to selectively pack sockets and improve suction seals proximally and mid-stump, so all the hydrostatic pressure changes through stance to swing are more even and not so much distally.

    3) Check the liner materials she has used – it might be worth trying different material (urethane, silicon, copolymers).

    4) Obviously check cleanliness of the liner, and how often she doffs/dries her stump. There may be a low level infection that clears up 99%, but returns when she starts getting around and the stump goes back to it’s sweaty environment. Also some greasy lotions actually can make things worse as they affect the skin/liner interface.

    5) I also knew one guy who put the old cotton daw sheaths against his skin, under the liner, to help with sweating issues – I don’t think this is recommended but it worked for him so couldn’t talk him out of it. He also didn’t have to rely on pure suction between skin/liner for suspension, if I recall, so it didn’t matter so much.

    Maybe check out the site if there’s anything there:
    http://www.austpar.com/portals/prosthetics/transtibial_sockets.php and look at the TSB and liner sections.

  2. Sandeep Gupta

    We had a patient who had verrucous hyperplasia. He had fluid issues and his stump was too big for the socket. Once we were able to get his stump oedema back to “normal” the issues settled.

    So along with distal contact, a liner that’s too big and socket issues, check the patient’s weight and whether their stump has changed in dimension. The patient may require a smaller liner and/or a new socket.

    If the patient has a newish socket and liner, then maybe try a half sock to improve distal contact.

    If it is some sort of rash – ie dermatitis, then stump and liner hygiene often help. Or if she has issues with sweating then using cotton between the skin and liner (which Tony mentioned). If stump and liner hygiene are good, then as Tony mentioned, she may need to change to a different type of liner.

    Is she using moisturising lotion? When is she applying the lotion at night or in the morning? Night is better as the moisturising lotion will have been absorbed into the skin. Morning application will result in more movement between the liner and skin.

    Sandeep Gupta
    Level 4 Musculoskeletal/Amputee Physiotherapist
    Royal Prince Alfred Hospital

  3. Marnie Jones

    You have received great advice. I agree with the fit, hygiene, wearing time and what she does at non-prosthesis time. The waxy appearance of the verrucous hyperplasia would indicate a whole new prosthesis, weight management, but less time off the prosthesis. We have seen steady improvement with the correct fit/contact. Way out on left field, I have had a patient with scabies who needed extended time without the prosthesis and the special treatment for that. I don’t think a surgical revision is necessary.

    Wishing you the best,

    Marnie Jones

  4. lynette Wakefield

    Hi Craig

    The advice you have had already is quite extensive and I believe on the right track. Check the fit of both the socket and the liner. Make sure it is not too tight proximally as this will cause the venous problems and any tight areas presure dn perhaps friction, in which case you may need to look at socket adjustment or replacement of socket and/or liner.

    I’d be interested to see if the problem happens just with sitting wearing the socket and how quikcly as
    the material the liner is made of may also be an issue as well as what it is washed with. Both can be a source of allergies. Even very innert materails can cause problems. (for example l had a transtib patient allergic to the glue used in the moulding of her pelite liner on her first lprosthesis. Her stump blistered and with later applications went bright red as well around the distal stump where most of the glue is concentrated. Teh team chased other causes both prosthetic aand medical before I realsied waht the problem was).

    Given the skin fold isues I would also look for suspension methods that minimise traction and friction on the distal end of the stump as both of these will be a furrther point of irritation in this area. I’d peronally suggest a ring suction liner with the concentration of rings proximal to this area.

    Hygeine is also an isue that you may need to look into. Don’t forget to look at what soaps and moisturisers they are using, allergies again, and ensuring moisturisers are used when the prosthesis is not going to be worn immediately i.e best at night rather than in the am.

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