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STUMP BANDAGING
Of the LowerExtremity Amputee
BELLA J. MAY, B.A.
IN MANY REHABILITATION centers proper positioning in bed immediately after sur
and hopsitals throughout the country, the phys gery; walking, exercise, and stump bandaging are
ical therapist must wait for the amputee to be usually started a few days after surgery. Early
referred for treatment. Often the surgeon will preprosthetic treatment and prosthetic fitting lead
not refer the elderly patient or the one suffering to better adjustment and rehabilitation of the
with a vascular impairment until the sutures are amputee. The application of this rationale of
removed and healing is complete. treatment toward the geriatric amputee, particu
Early referral of the young, traumatic amputee larly one suffering from some form of vascular
for proper preprosthetic treatment is well accepted. disease, however, leads to much controversy.
Such treatment has three main purposes: Delayed referral may mean a lapse of several
1. To prepare the stump for a prosthesis. weeks or perhaps months before the patient is
2. To maintain general physical condition. started on the proper program to prepare him for
3. To aid the patient's psychological adjustment an artificial limb. Too often this delay results in
to his disability. contractures, muscle weakness, and edematous,
These aims are achieved through a program of flabby stumps that require many extra weeks of
exercise, proper body positioning to prevent con prosthetic treatment.
tractures, crutch training, and stump bandaging. According to many surgeons, early walking and
In the young amputee this training is begun exercise are contraindicated for the geriatric
as early as the patient's general physical condition amputee because such exercise may lead to in
will allow. The amputee is encouraged to assume creased edema, sloughing of tissue, and slowing of
the healing process as a result of additional stress
placed on the already compromised circulation of
The author is Supervisor of Rehabilitation, Jackson the stump. Proper bandaging is necessary to con
Memorial Hospital, Miami, Florida. trol this edema, but, since this requires consider
808 JOURNAL OF THE AMERICAN PHYSICAL THERAPY ASSOCIATION
able skill and frequent reapplication, it is im this is merely to help keep the bandage on and
practical.1 Too often the patient is unable to must not be tight.
bandage himself in the early days after surgery The Pattern of Wrapping the Stump. The band
and qualified personnel are not available to re age is started just above the lateral tibial condyle;
bandage the stump as often as necessary. Im
proper stump bandaging can cause irreversible it is brought diagonally across the anterior aspect
damage. On the other hand, proper stump of the stump to the medial distal corner (Fig. 1 A).
bandaging, resulting in shrinking and shaping the It is then brought back diagonally across the stump
stump, is a major key to successful prosthetic posteriorly, swung across the beginning of the
fitting. bandage and anchored with a circular turn above
While working with over 200 geriatric and vas the patella (Fig. IB). After a single anchoring turn
cular amputees in the Rehabilitation Department above the knee, the bandage is brought back down
of Jackson Memorial Hospital, the advantages of around the medial tibial condyle (Fig. 1C), and Downloaded from https://academic.oup.com/ptj/article/44/9/808/4629233 by guest on 15 September 2022
early preprosthetic treatment became evident. across the posterior aspect of the stump to the
lateral distal corner as seen in Figure ID. Figure
THE BELOWKNEE AMPUTEE IE shows how the figureofeight pattern is con
tinued for the rest of the bandage, taking care
When belowknee amputee patients were started to cross the crest of the tibia in an angular manner.
on the usual routine of exercise, walking, and If semicircular turns are necessary to bring the
stump bandaging, several patients showed increased bandage in proper position, they must always be on
drainage, sloughing of tissue, and delayed healing the posterior aspect of the stump in order to com
within a few days of the treatment. In all cases the press soft tissue without hampering circulation. As
trouble was traced to improper bandaging. Great the figure of eights are made, they should partially
care always was taken during the treatment period overlap so that the whole stump is covered, with
to bandage the stump properly and carefully and to the greatest amount of pressure on the distal end.
teach the patient the proper techniques. In the In an extremely short stump, it may be necessary
interval between treatment sessions, however, the to bring the bandage above the knee several times
patient often attempted to reapply the bandage, to avoid circular turns below the patella. The
usually replacing it improperly and causing figureofeight pattern is from the proximal to
damage to the stump. Occasionally, the patient distal and proximal again, starting at the condyles
would leave the bandage untouched for twenty and covering the stump to include both condyles
four hours, causing wrinkles and binding which as well as the patella tendon. Only the patella, it
were equally damaging. self, is left free so as not to interfere with knee
motion and allow free circulation in the popliteal
Method area (Fig. IF).
It is necessary for an amputee, or some member The Second Bandage. In the average length
of the family, to learn how to bandage the stump stump, two 4inch elastic bandages are necessary
as early as possible. Therefore, simple, easyto to properly shrink and shape the stump. Some
learn techniques were devised that reduce the times in the early postoperative days only one
hazards of early preprosthetic treatment and meet bandage is used if the stump can adequately be cov
the particular requirements of the patella tendon ered. In long or especially large stumps, three
bearing prothesis. bandages are necessary for proper shrinkage. With
Under the old method, the amputee was taught practice, it has been found that a 4inch bandage
to make two or more recurrent turns and anchor is the best width for all adult belowknee stumps.
them with one or more circular turns around While it might increase shrinkage to use more than
the proximal portion of the stump before going two bandages for the average stump, it has been
into the figureofeight pattern. Many patients found that most patients cannot tolerate this.
would continue to make circular turns after the The second bandage is wrapped like the first
recurrents, carrying the bandage from the proxi with the following exceptions. It is started above
mal end of the stump to the distal end, or they the medial tibial condyle and brought across the
would make several tight circular turns around the anterior aspect of the stump to the lateral distal
proximal end of the stump to anchor the recurrents corner (Fig. 1G). It will be noted that with the
before making a few figureofeight turns to catch first bandage, the line of stress is from proximal
the corners. These circular turns would choke the lateral to distal medial, pulling the medial distal
stump, cutting off or radically slowing circulation. tissue posteriorly and the lateral distal tissue
This obviously led to edema, sloughing, poor anteriorly. In order to create uniform pressure
shrinkage, and bulbous stumps. for proper shaping of the stump, the second band
In the new method of bandaging, the patient is age is started medially, thus pulling the lateral
taught only angular turns in a figureofeight distal tissue posteriorly and the medial distal
pattern. The only circular turn is an anchor above tissue anteriorly.
the knee and the patient is repeatedly advised that In a long stump, 6 inches or more, it is not
September 1964 Volume 44 Number 9 809
t
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FIG. 1. Steps in bandaging the belowknee amputee are shown.
(A) The first bandage is started immediately above the lateral
tibial condyle, brought diagonally across the anterior portion of
the stump, swung around, and (B) brought diagonally across the
posterior aspect of the stump and anchored above the knee.
(Continued on page 811.)
necessary to anchor the second bandage above throughout the preprosthetic period. The amputee
the knee, but it can be anchored with a semi is taught to wash his bandages frequently and re
circular turn across the patella tendon. With both place them as soon as they start to lose their
bandages an effort is made to bring the angular elasticity. As the pressure is increased, the am
turns across each other rather than in the same putee must be warned against pulling the bandage
direction in order for the weave of the bandage, to the fullest extent of its elasticity as this causes
itself, to assist in exerting a uniform pressure on wrinkles, undue and uneven pressure on the stump.
the stump. Often in the last days of preprosthetic training,
Bandage Pressure the amputee will still have some excess tissue at the
distal posterior end of the stump. In these cases
In the early postoperative days, the bandage is extra pressure can be brought to bear in these areas
wrapped very loosely with minimal pressure by bringing the bandage from one corner directly
distally and no pressure proximally. One or to the other over the posterior aspect of the stump
more sterile gauze pads are placed between the before bringing it proximally (Fig. 1H). Several
incision and the bandage to absorb any drainage. of these posterior semicircular turns can be in
If necessary the elastic bandage can be rewrapped corporated in the bandaging but a regular figureof
without disturbing this sterile dressing. After eight turn should separate them. When the am
drainage has ceased, a single gauze pad is main putee is taught this change in the method of
tained between the sutures and the bandage so as bandaging, it must be carefully explained that
to prevent pulling on the sutures. This pad is dis these turns should only be used at the distal end
continued as soon as the sutures are removed un of the stump.
less the stump has not yet healed primarily. Occa
sionally, primary healing is slowed by the vascular THE ABOVEKNEE AMPUTEE
condition of the stump and there may be an open
area along the incision after the sutures are re In the aboveknee amputee, an improperly
moved. In these cases, sterile dry dressings are bandaged stump may create such problems as
continued under the bandaging until the incision is adductor rolls which result in the need for many
completely healed. Contrary to opinion, bandag prosthetic adjustments as the stump shrinks within
ing even in these cases does not compromise heal its socket. Many geriatric amputees have dif
ing if done properly. Actually, bandaging and ficulty adjusting to a prosthesis; these added
walking aid healing even with difficult cases, as problems may make successful wearing impossi
they are deterrents to dependent edema and venous ble.
stasis. Proper bandaging will reduce the excessive
As healing takes place and the sutures are re adipose tissue and will lessen the tendency of
moved, the pressure of the bandage is increased development of an adduction roll. In addition,
to the tolerance of the patient. Care must be taken bandaging supports the soft tissues in the early
to provide the amputee with good elastic bandages healing phase following amputation. It is dur
and to insure an adequate supply of these bandages ing this phase that the efficiency of the vascular
810 JOURNAL OF THE AMERICAN PHYSICAL THERAPY ASSOCIATION
FIG. 1 (continued). (C) The bandage
then is brought around the medial
tibial condyle, (D) across the posterior
aspect of the stump, (E) continued
across the crest of the tibia at an
angle, (F) with the patella left un
covered. The second bandage (G) is
started in a similar manner, above the
medial tibial condyle and brought di
agonally across the anterior aspect of
the stump to the lateral distal corner.
(H) Extra pressure is brought on ex
cess tissue by a semicircular turn pos
teriorly.
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September 1964 Y Volume 44 Number 9 811
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