For the sake of time, I think we can go ahead and get started. So first off, thank you all so much for attending our National Grand Rounds this evening. Our topic is Dermatologic Complications in Amputee Patients Background Evaluation and Management. And this evening, we have Dr. Joseph Burris joining us as faculty, as well as Dr. Jeremy Roberts, who will be moderating this session. And just a few quick housekeeping notes before we get started. This activity is being recorded and it will be made available on the Academy's online learning portal. So for the best attendee experience during this activity, please be sure to just mute your microphone when you're not speaking. You are invited and encouraged to keep your camera on and to also select hide non-video participants. So this will ensure that speakers are prominent on your screen. And then to ask a question, we definitely encourage participation. Please feel free to use the raise your hand feature or unmute yourself. Additionally, please feel free to use that chat feature as well. We will have a Q&A at the end of the hour, but just take note that time may not permit the panel to field every question, but we will definitely do our best. And just a few quick notes about some of our Zoom features here. We have that mute and unmute as well as start and stop the video. You can see the participants here as well as that chat feature. And then any reactions, feel free to use those as well. And then here at the top, these three dots, you can also manage your video and mute button. Oh, and hide non-video participants as well. And just a bit about our agenda this evening. We're going to go ahead and start off with our introductions. And then move on to our presentation and then end with our question and answer. And I will go ahead and pass it over to Dr. Roberts. Hi, good evening all. My name is Jeremy Roberts. I'm a PGY-6 Peds Rehab Fellow, soon to be PGY-7 Sports Medicine Fellow. And tonight, I have the honor and privilege of introducing Dr. Joseph Barras. Dr. Joseph Barras is the Chair of the Department of Physical Medicine and Rehabilitation at the University of Missouri School of Medicine. Dr. Barras joined the University of Missouri's Department of Physical Medicine and Rehabilitation in July 2001, where he is Professor of Clinical Physical Medicine and Rehabilitation. He received his medical degree from the University of Kansas School of Medicine in 1997 and completed a residency in Physical Medicine and Rehabilitation at the University of Missouri in 2001. Dr. Barras serves as the Medical Director of Rusk Rehabilitation Hospital. He's the Director of the Amputee Program at the Rusk Rehabilitation Hospital and a member of the Missouri Stroke Program. He served as the Residency Program Director for the Department of Physical Medicine and Rehabilitation from 2007 to 2021. Dr. Barras is currently a member of the American Academy of Physical Medicine and Rehabilitation AAPMNR, the Association of Academic Physiatrists AAP, and the American Board of Physical Medicine and Rehabilitation ABPMNR. Dr. Barras is the Chair of the AAPMNR APP Committee, a member of the Tri-Organizational GME Committee with AAPMNR, AAP, and ABPMNR, and a member of the AAPMNR Medical Education Committee. He's also a member of the AAP Chair Council. Dr. Barras was awarded the AAPMNR Distinguished Member Award in 2020. His clinical and research interests are in prosthetics and orthotics, specificity management, stroke rehab, biomechanics, and rehabilitation systems of care. He has presented locally, regionally, and nationally, and has authored articles on stroke and amputation. So welcome, Dr. Barras. All right. Good evening, everybody. Just wanted to make sure real quick, are we okay with the presentation? I'm getting the primary screen up. I think we are. Right now, I'm seeing your presenter mode. So I think you have to swap them. I'm going to have to do a swap here. Hang with me. That looks good. That looks good? Yes, that's full screen. We'll roll with that. Okay. Well, thank you, everybody, for the opportunity to speak this evening on dermatologic complications in amputee patients. A little bit of background on me. So as Dr. Roberts said, I joined our faculty at University of Missouri in 2001 after some excellent experiences in residency that motivated me in part to initiate a practice in amputee rehab. It's been an amazing journey over the past 23 years to see the growth in an amputee program that we've had here at the University of Missouri. And this really has been the opportunity to see really thousands of patients at this point who have various types of amputation and to be able to perform rehabilitation management with them. In the midst of all that came about a lot of the dermatologic complications that patients would get with particularly the use of prosthetic devices, but also in post-operative management. And really, there's been a lot of what I would call OTJ, on-the-job learning with this. And not too many resources out there on specifically dermatologic complications in amputee patients. So happy to provide and share knowledge that I've gained through the years in looking at some of the scientific resources, but then also just evaluating and treating a lot of patients with these issues. So we'll go ahead and roll here. I'm going to start out just, this is the overview. And if you look at these bullet points that we have here, we'll be looking at mechanical pressure issues as one section, skin disorders that patients have, allergic or contact reactions that people have, infection issues, superficial issues that people have with the skin, circulatory disorders. And then my favorite category, unknown etiology, which is a pretty big category, I think, overall for this. So in no way am I a dermatologist and defer to them on expertise. But just to refresh everybody's memories, because you probably haven't seen this since you were a medical student or possibly even in the pre-med. But if we're looking at the structure of the skin, and I think everybody can follow with my arrow here, the major levels or layers of the skin that we have issues with would be divided into the stratum cornea, which is that most superficial layer. And then beneath that, the epidermis layer. And there are certainly many different subdivision layers of the epidermis. But I think for the purposes of this talk, we can just keep it as the epidermis. The papillary dermis is these areas where we have protrusion of the dermal areas up into the epidermal layer. And then deeper to that, the reticular dermis area. And then below that, in terms of the depth to the skin, we have the hypodermis area. When we look at the skin another way, I just want to go through this animation a little bit. Important factors that we have in the skin include the sweat glands. And there are two major types of sweat glands in the body, the eccrine sweat glands. And these have a direct path to the surface. And then we also have apocrine sweat glands, which will predominantly be in the groin and axillary regions. Become much more active at puberty. And contribute to sweat functions that occur in association with the hair follicle. And we can see a hair follicle here and an associated sebaceous gland. So secreting sebum, which is an oily-like substance that will coat the hair as it is exiting the skin. When we look at the layers of the skin, you can kind of see an epidermal stratum corneum. The superficial layer here, the epidermis. And then you've got the epidermal areas, the deeper epidermal areas. And then we get down into the subdermal areas. We also have the adipose cells, the adipocytes that are down here. And then the vascular supply, even that is deep to that. And some of that supplying nutrition to hair and could be associated, like if you see a patient with peripheral vascular disease and loss of hair distributions. So what kind of injuries are going to happen to the skin? A decent representation here, I thought, worth going over. When we have friction effects of mechanical injury to the skin, if that's in a repeated rubbing situation, we'll develop a thickening, particularly of that outer layer of the epidermis. And at that point, we would have a callus formation occur, a thickening of that outermost layer. If we have a situation, and they call it pounding here, so a direct trauma that would occur, you can see that we would get deep tissue injury. And so we'll have hemorrhage all the way down into the deeper layers, the epidermis and sub-epidermal layers that are present. I'm going to skip over vibration. It doesn't really apply here. But in a sudden trauma situation with friction, we may develop a blister down on these epidermal layers. And if we have some type of lesion that is going to have penetration and if we get down into this epidermal layer, endermal layer, we can actually have granulomas develop. And we'll really see that in association with the darkening of the skin that would occur in focal fashion there. There's one other point I wanted to make over here to the left side, and that is the lichenification is a thickening of all of these entire layers as well. So we're going to hopefully improve our ability to describe some of these lesions just a little bit tonight with a reminder of some of these definitions for dermatologic purposes. If we talk about a macule, that is a flat lesion, which is less than 1.5 centimeters in diameter by nature or by definition. A patch is also flat, but it is greater than 1.5 centimeters. A papule, and I always learned in medical school and carried it on, palpable papules, right? And this is less than 1.5 centimeters in diameter. And if it's larger than that, then it is a nodule. So a spherically enlarged papule. A vesicle would be a fluid-filled papule. And as a blister would be an example of this at less than or equal to 0.5 centimeters. A bulla is a singular lesion, and a bullae with an E added on the end would be multiple lesions that are greater than 0.5 centimeters in diameter. Then there's the term eczema, which is a general inflammatory skin response. It has vesicles. It also has a serious oozing that occurs from breaks in the epidermal layer. So let's look and see what some of these different lesions are. So here's an example of a macule. So if you were to run your fingers across this, it would be flat, so not palpable. And that's less than 1.5 centimeters. But here is a case where we have a patch. So this is much larger, as we can see, encompassing an entire residual limb essentially, but also not having elevation specifically. A papule is going to be a situation such as this, such as an epidermoid cyst. And we'll talk about those here in a little bit. But we can see that that would be palpable. These examples of vesicles that have been unroofed. So you also have to think about the stages of recovery. So these were fluid filled, but they've lost that outermost epidermal layer, and they have been unroofed. And so we're seeing this at a different stage. So recognizing that is important, and it's actually in a healing stage at that point. When we look at a blister, a classic example of a distal residual limb blister here, this fluid-filled sac. Now, these can have hemorrhage within them, or they can have a clear serous fluid inside of them, either one. And here's an example of hemorrhage inside. In a post-op patient here, and a very large bulla lesion. But as we can see, multiple bulla that are surrounding the primary incision line of this residual limb. On to the definition of a nodule. So here happens to be a rheumatoid nodule that was on a patient with a baloney amputation. So we talked about this eczema. And it's sort of various phases of opening of the skin. There may be oozing. We may have sloughing areas of the skin. So all of this combination that's occurring in these various stages in one example. So we're going to break down now and look at mechanical injury first. And we'll look at tissue destruction, and then examples of tissue proliferation with mechanical injury. So I think, you know, when we talk about destruction, we have that sudden onset of friction, and we can get blister formation from that. Trauma, abrasions and erosions, ulcerations that can occur related to this. I want to bring into the picture maceration, or moisture-associated skin disorder and injury. It's moisture and friction cause a loss of that top keratin layer that we have at the outermost aspect of the skin. It'll have that whitish appearance associated with it. Intertrigo, I'll show an example of that here in a little bit. It's where the skin that is in opposition in an invaginated area becomes reddened. And then we can also have atrophy of the tissue as well. When we look at pressure sores, these are the classic stages. I'm not going to take the time to stop and review exactly what these definitions are. Stage 1, 2, 3 and 4. Those that are very difficult to stage are unstageable, and then your deep tissue pressure injuries as well. When we look at patients in the early postoperative situation, obviously a significant barrier to healing and a barrier toward moving on to prosthetic fitting and subsequent training and use is going to be the presence of limb edema. A couple of good examples here with what is classically called the dog ear with the closure of a below knee amputation. A good looking primary incision line though here. One that's closed with staples here also looks pretty good, but some significant edema that we've got on the distal residual limb. So one of our goals postoperative is to try to slowly reduce this edema and begin the shaping of the residual limb from a bulbous shape to at least a cylindrical shape knowing that eventually the distal residual limb is going to assume really a conical shape as it goes through maturation. So ways that we do that are important because in rehab we're trying to reshape these limbs or shape these limbs such that they can be ready for prosthetic devices and to promote healing. And how do we go about that? And I'm just going to present a couple of ways. When I can present a couple of ways and there are many more that would mean that there is no universally accepted management method for residual limb edema. And we need to keep that in mind. I think that there are factors that would go into your specific facility, your institution, your health system, and how you can manage patients that might sway how you manage postoperative limb shaping. But it is a common goal that we have for the patients. We can see an example here and there are many online resources for how to properly, as is the example in this mannequin here, how to properly place a figure of eight ACE wrap. And the keys there are to use this crisscrossing pattern and also if possible at all to go above the knee, proximal to the knee, and also to keep the pressures low on this and create a pressure gradient from distal to proximal such that we can slowly move fluid in that direction. What happens if you have a problem? Now here's an example of a mechanical injury. We've got the primary incision line here, but this is a patient that had the ACE wrap on too tight. It is crossing the patellar tendon area, which is generally pretty forgiving, but this was a discovery on morning rounds one day and demonstrates mechanical injury for that. Another common method of managing the residual limbs in below knee amputation listed here or shown here is a two-layer BKA shrinker. Again, I like to actually write on my orders low tension because we want to keep the pressures low on the residual limb when it's bulbous in nature in particular. And an example of an above knee shrinker that is here. Problems that can develop, this is an example of a patient with a below knee shrinker and removing it on rounds one day and the patient has a pressure area over the patella here. And so another management method may be a removable rigid dressing. It has some really excellent points in managing a residual limb. It's a fiberglass casted cap that goes on the below knee segment. What I like about it is the protection from direct trauma. If a patient falls on it, it's going to give excellent protection over what is here, a trauma associated very difficult closure in a below knee amputation. The patient can learn how to use sock ply to adjust as their limb volume decreases. They can add ply beneath the RRD and this teaches them, starts to teach them the concepts of sock management with a BKA socket. We just see examples here of supplies, the RRD, and I like to use a knee immobilizer over that to remind keeping the patient in full extension. Several other commercially available and otherwise devices that are out there for residual limb management as well. Again, it's not the focus of the talk so we move through that a little more quickly. An example here though with the RRD is bow stringing of the hamstrings and it caught the patient's hamstrings of the proximal aspect of that RRD. Here's an example where it caused pressure on the patella. You do have to be careful in particular with dysvascular patients which is going to be the majority of patients that you're going to see in most rehab settings are of a dysvascular nature rather than of a traumatic etiology. I kind of put this slide in here just to remind me and us of the fitting procedure. When we feel the patient is ready for that prosthetic device they're going to go to the prosthetist's office. They may perform some final limb shaping with the patient of various natures. They're going to do this procedure called casting which back in the day was physically casting a patient. Now often involves using volumetric CAD CAM measurements of a residual limb and developing a diagnostic test socket from this. Then the patient will undergo final fitting when they return. First the diagnostic test socket, final adjustments made to the diagnostic test socket and then presenting back and undergoing the final socket fitting usually in somewhere in a three to six week timeline for all of that to happen usually. This is an opportunity to come in and talk about what's going to happen when we put the below knee amputation patient in pressure tolerant and pressure sensitive areas. We're going to have intolerant areas that are common and these are the places where patients will get pressure sores, mechanical injuries along what is called the tibial blade commonly along the fibular head area. In the patellar tendon area or patellar ligament area it is generally pretty tolerant but the tibial tuberosity in the patella can be problem areas. The femoral condyle areas can be problem areas as well. Good pressure loading areas like the medial tibial flare and I'm sorry the femoral condyle areas are actually good areas to typically do loading. The medial and lateral tibial flare above the fibular head is a good place to put pressure. Then the posterior aspect we've got a lot of opportunity back in the gastroc area popliteal area but even more distal into the gastroc area for pressure tolerance and being very mindful of just as in that example with the RRD the bow stringing of the hamstring tendons as they cross the knee and when the patient has flexion of the knee so being very careful to look for pressure areas there because the first thing that happens when the patient gets up on their prosthetic device after that really nice fitting is they put pressure on the residual limb and it begins to decrease in volume and then we add SOCPLY. I've got one of my former residents here I don't know if he's on tonight but if so hi Lou and he's holding essentially what was a large helmet of prosthetic socks this was over 20 ply where patient came in with that so completely out of fit. We see examples here a nice one visually to pick up is where we might put pads in order to be able to help shape a maturing limb as it goes from cylindrical to more conical shape. It's not uncommon also to use lambswool and the distal aspect of the socket and this is the soft insert that goes inside of a hard socket. It's my preference in the first socket that we use this and possibly even subsequent sockets such that we reduce some of the mechanical pressures. An example of above knee here don't want to leave that out but putting it in this case inside of a flex liner inside of a socket but oftentimes we place pads between the flex liner and the hard socket as well. So to look at some examples of pressure so this is pressure over bony prominences we've got the fibular head here we've got the lateral knee joint line here we can see a tibial tuberosity pressure a little bit on the patellar area and the distal anterior tibial end is where it's most notorious for skin breakdowns even particularly if there is adherency or not much soft tissue coverage over the distal anterior tibial area and poor skin mobility. An example here of just other kinds of trauma if the patient is not meticulous at putting on their socks we can get a fold situation and the patient can get a sock wrinkle associated pressure injury here. When they're coming into the amputee clinic you want to be looking at their equipment. This is obviously very advanced cases but actual cases where people have come in they're a little overdue to get back for their follow-up appointments and we're seeing examples of excessive pressures that are occurring here. Just more examples of excessive pressure this is more of a chronic pressure some moisture associated injury some thickening lichenification that's occurring around the patellar tendon area which is usually pretty pretty forgivable and pretty pressure tolerant with that. Other examples distal tibial pressure here I talked about the distal anterior tibial end more acute and more in a chronic situation here other examples where even keratinization has occurred. Interestingly a hair growth in here which would be more unusual but a keratinizing that's occurred in that area. The converse of positive pressure negative pressure occurring at the distal end and blisters here with one open and bleeding. There's another term for really what's starting to happen with this patient I'll go over that here in just a little bit. Examples of negative pressure you really have to watch along primary incision lines and vaginated areas are suspect for causing negative pressure. You might have a good socket contact out here and back here but you might not have good socket contact where this invagination occurs and it can pull some negative pressure as the patient is ambulating in stance phase and swing phase during their gait. This is an interesting situation that develops particularly in prosthetic patients intertrigo which is this reddened tissue destruction that occurs again in an invaginated area. This is where the skin is held in apposition from one side to the other and moisture is often a culprit down in here as well but you'll see this very reddened nature and the best thing to do with these situations is to actually try to open it back up in some fashion such that it doesn't have those tissues touching each other. We talked about moisture a little bit earlier example here of distal moisture that's occurred in an invaginated area and we see that also over here. We've also got a positive pressure on this patient here as well. Tissue proliferation some of the terms that are used with this and I'll show you pictures as a lichenification where the skin is thick and leathery would be the description. Hyperkeratosis that keratin layer thickening with a callus. Corn is in particular he has an apex that moves inward. I showed you that invasion earlier from the outermost to the more inner layers and it is a very cornified type of the outer layer that hyperkeratosis develops and in a focal nature. I'll show you some pictures of that. Follicular hyperkeratosis coiled hairs there are examples of that. I don't know that I've got any great ones of coiled hairs to show you tonight but then Verrucas hyperplasia is a specific situation that I want to share with you. So this is examples of lichenification some thickening in a little more of a slightly acute phase here. This is never super acute it's going to be over the course of really more months situation at the least several weeks. This is a case here on the right of some very chronic tissue lichenification that's occurred. Again just examples moving along there's going to be a lot of pictures tonight by the way. This is while the the presentation just goes with dermatologic issues. Pressure at the patellar tendon area and over time a thickening has occurred over the patellar tendon specifically. We talked about hyperkeratosis just a couple of slides back there. A specific example here and you can see that on this very challenging patient of mine who was one of the first patients I ever saw coming out of my training had a traumatic amputation. Very significant heterotopic ossification spurs that developed at the tibia and the fibula was very long in this patient creating some special challenges to say the least. A little cartoon here given to me by one of my mentors who recently passed away but I will give credit to him for learning a lot of dermatologic complications and amputees. This is that case where we talk about the keratin plug that outermost layer of tissue getting down into the dermal layers. Then we can have a separation from the epidermis and a cyst developing. It's keratinized. You get an inflammatory reaction associated with that that can lead to tissue destruction. Now we've got a keratinized layer down deep and a wall back out to the skin surface that can actually just shed layers of keratin associated with them. This is some hyperkeratosis focal areas, patellar tendon area that happened with the patient from chronic pressures. Here is keratotic plugs and this has occurred a little more on the popliteal area for a patient but you can see this plug that's occurred right there for that patient. The key is get the pressure off. It's going to take a long time for these keratotic plugs to heal. I'll throw in there that you might want to consider the use of a topical urea cream but have the patient be diligent about diligent about applying this twice daily for what could be months actually. All right, moving on to different issues. Here's a just a hair follicle irritation. It's got that conical almost a volcano type appearance with a center plug associated with that. Some of it is you're going to see a lot of hair follicle involvements with pressure in the popliteal region. This was much more common in the PTB design than in the more total contact total surface bearing designs that are more favored today. As we've been able to get better at doing fabrication and be more contoured in socket development but cases of a lot of pressure in the popliteal area here. Want to take a second and talk about, this is a negative pressure situation. In the early on, it is referred to as choke syndrome. And what'll happen is you'll have a patient wear the prosthetic device. They may feel snug up in the proximal aspects, but they may feel like they are having some bell clapping down in the distal aspect, and they might take off the prosthesis. And you'll see this dark purple circle that's down in there. And this early on would be called the choke syndrome. Now, it may or may not go away in a short period of time. If it's very brief, it can be reversible. And we know that we need to add something in the socket to increase positive pressure there. For instance, Lambswool, a distal end pad. And notice that a lot of these treatments are mechanical for these situations, is to either increase or decrease the mechanical pressure on areas based upon what patients are presenting with. In the long-term, choke syndrome causes a tissue proliferation and a baruchus hyperplasia. And here's an example of that. This patient happened to be in an open-ended socket, which was an older design. This was a common complication back in those days. I want to talk for a second about epidermoid cysts. And I think a picture is worth a lot of words here. It's very confounding when you see this. I think it can strike fear into the physiatrist as well as the patient. It will be a cystic area that they're often going to present. It's going to be open and draining. But if you look very closely here, you can distinguish this from common pustular drainage. This sort of has a brown, waxy appearance. And what is really happening is that sebum is going to be leaving. I'm getting some marks on the screen here. Hopefully they're not being seen by everybody. But this is a sebaceous drainage that's occurring in these epidermoid cysts, where we have the hair follicle that is pinched off at the surface and therefore secreting, secreting, secreting until it hits a bursting point. Very common in the popliteal fossa area. I had an unfortunate patient that had these, and they had even attempted to do a skin graft for the patient back in the popliteal area, which, needless to say, was not a good idea and resulted in other complications for the patient. Going to switch gears and go to a different area now. Contact dermatitis is our next topic. Primary irritant, we've got skin reactions on the first exposure, then a refractory period, sensitization. Then they re-expose and have other, a more pressing, fulminant reaction to that. It's characterized by erythema, itching and burning, an eczema's reaction and inflammation. They may vesiculate. They may have oozing and crusting over of lesions in various stages that occur with this. So let's get a look at some pictures. And here's where we see those various stages. I showed this earlier, eczema's dermatitis, and it's of an allergic nature. So we'll talk about treatment here in a second. With that, right there, find the offending agent. If you've got contact dermatitis that's occurring, there may be some agent that is contributing to this. The common ones, here's an example. We used to use wool socks a lot more. This patient became sensitized to wool. They presented here with these vesicles unroofed 10 days later. So common ones are the foam rubbers that may be used against the skin. Peelite inserts, sometimes if cowhide is put on there, it doesn't have to be right next to the skin. If it oozes through other materials, for instance, textiles, it can get closer to the skin and cause these reactions. Various cements that are used. If you have wool socks, patients cleaning their residual limbs with scented soaps. In particular, they travel somewhere, they use somebody else's soap, and then they have a reaction that occurs. Maybe in a hotel room or something like that. Topical medications that they might be using for other reasons. And then they may just autosensitize to something they've been using for years, but just subsequently have a reaction to that. Can't go into the details of that as it would take a little bit too much time for treatment. Infections of the skin is the next area. Common issues, impetigo, folliculitis, furuncles, otherwise known as boils, cellulitis, abscesses. We would try to do culture-based treatment for that, but it's often very difficult to obtain clean cultures and often we're left to empiric treatment and we should use guidelines associated with that. Decisions on whether oral IV or topical antibiotics would be appropriate depending upon the severity of the nature of these. Fungal infections are also very common because we put people a lot in gel liners these days. They keep moisture inside. The patients wear them all day. When we get into the summertime and the environments get hot, we're going to see they may pull it off and have these red scaling plaques. The go-to treatment for this is topical antifungals, all of the azole meds. The key is to treat for a sufficient period of time, which is well beyond an observed, complete healing appearance of the skin. I tell patients to continue for five to seven days beyond that time. I also tell them to wash, for instance, gel liners. I tell them to clean them with isopropyl alcohol with spray bottles that helps directly kill bacteria and fungus and is an excellent way for them to reduce the loads of bacteria and fungus that can get on these gel liners. You can consider the use of Diflucan. Of course, we need medication interactions and watching liver function tests can be complications with that in sometimes very sick patients. Non-blistering lesions, don't forget the common things. You can get insect bites. We talked about the fungal infections. People also get scabies as well. They get pediculosis. Those are things that can happen. Insect bites, HSV can happen. There are more rare Stevens-Johnson and erythema multiforme that can occur. Bullous pymphagoid can occur. So these are skin blistering lesions that you can see as well. An example here of folliculitis and lichenification that's occurred. A very old picture taken from one of my mentors had a phylacer here, but at the distal aspect of it, thickening where it was riding down, some folliculitis that was occurring back in the popliteal fossa. I'll show you some closeups of that here. Here we've got some evidence of folliculitis in this aspect of it. I'm gonna skip down and there's an abrasion that's going across here. And then there are some epidermoid cysts that are down here a little more distal. So, and then some thickening that you can see right here, right here that is occurring as well. So all associated, you know, maybe with fit, maybe with infection. I might elect to treat the patient like this with something like a topical clindamycin solution. If I really don't feel that they need a systemic oral antibiotic and an IV wouldn't be indicated in this situation. Something that I like to do, and I wanna stop and point this out for a minute is sometimes I'll get out my phone and I will take a picture and then blow it up significantly. And you can get down and see very close up actually a little vesicle associated with a hair follicle. And that's gonna be an easy way to see lesions that are associated with hair follicles is to get down there very close or you take a picture and blow it up with your phone, a practical way to use your phone for that. A case here of cellulitis distally, some satellite lesions that have started. So this patient is gonna present, they're probably gonna be clinically at least somewhat sick, not feeling well. This is going to be red. It's going to be warm to the touch very commonly. Patient may or may not have an elevated white blood cell count on laboratories. This is an example of a stitch abscess. Very common to get abscesses here. I did not have a good picture of pustular drainage, but I think people are pretty well familiar with pustular drainage and what that looks like. Distinguishing that from some of that sebum drainage that we saw on the earlier slide is not unusual. You might see this in the primary incision line and it might've been one of those absorbable sutures that didn't. Moving into the fungal area here, this is a classic ringworm lesion, an excellent example of that. And it has got that circular nature to it. It's got some scaling that's occurring in the middle of it. So a really good example of that. This is sort of a different appearance where it is extended onto the entire residual limb. Now, as a practical point, you can't have a microscope and do a fungal prep on your patients when they are going around into the rehab clinics. So a lot of times you're going to have to make an educated guess as to what you think this is and try something and then follow up with the patient and have good communication with them. I use a lot of the portals and have the patients send pictures back and forth so I can look at evolution of change when I initiate treatments for patients. I wanna talk about circular disorders next and vascular insufficiency and congestion. This is a great example of a severe vascular insufficiency. Wound margin necrosis is occurring and this patient would be at severe risk of non-healing. They may develop further complications where the wound is just gonna break down internally and open up. And so at this point, it's really recommend that you have regular follow-ups back with the surgeon and their monitoring as to whether this would heal or not to be determined. Just serial evaluations are gonna be important. Ischemia on the residual limb, this is that blanching venous type of congestion that you have and you can see they got a prolonged pallor that occurs with a patient with significant vascular disease and ischemia. Venous congestion and edema here causing a stasis dermatitis. There's some eczema associated with this. So patient could benefit from having, at this point, a topical steroid may be helpful in reducing some of the inflammation. We have to watch for bacterial and fungal infections that occur with that. So, all right, we're gonna do just a little bit of quiz time. I'm gonna take a couple more minutes and just show a few more pictures cause it's fun. And then we will skip out and go on to some questions. Again, showed this one earlier, but this is that patellar pressure sore from a shrinker. What do we have here? We got pressure at the distal anterior tibial end of a chronic nature with lichenification that's occurred. Maceration and a skin fissure has occurred here. So complex wounds. You're not gonna fix them overnight. None of these look like they have infections. So the key is to reduce the focal pressures in these areas. Probably need to have really good discussions with your prosthetist about making modifications to reduce focal pressures. I spend an inordinate amount of time in amputee clinic figuring out how to shift pressures from one pressure sensitive area to a more pressure tolerant area. It doesn't always mean socket replacement. It generally means socket modification, stocking up or stocking down. Both situations, pads placed in key strategic areas of pressure tolerance to increase pressure in those areas and reduce the non-pressure sensitive areas. Cases here, poor ACE raft, also significant vascular insufficiency with this patient. Just a pressure situation with this patient that's gone on subacutely. Now this is wound necrosis from vascular insufficiency. That will never heal. This is more wound margin necrosis. I know this patient became an above knee amputee with that. Common to have limb edema. We've got some insufficiency here. And so the key is going to be to try to gently without injuring this very sensitive skin, begin the journey of low pressure ACE wrap in order to start reshaping this limb such that you can move on with healing and fitting the prosthetic device. Interesting case here, a patient with Berger's disease. So a very significant discoloration of the residual limb and the flap ended up having that color. So it puzzled me for a little while. A good example here of Bullis lesions, very significant shaping issues associated with this patient's residual limb, vague dog ears. Examples of folliculitis, a patient, and again, blowing it up and seeing those hair follicles with the lesions up close. Versus a contact I would, in the summertime, you can get a sweaty associated skin disorder, but it's called prickly heat would be the common name of that, but it will resolve with cooling off and usually the patient removing the prosthetic device for a little while. Gonna skip over a couple here in the name of, for the sake of time, a fungal infection there though in treatment. And a couple more here that we're gonna skip over. A good example of a distal fungal infection here. This would be an advanced fungal infection here with some fissuring of the skin that's occurred and a patient in very significant trouble at this point. Evidence of some macules and some papules. These will be good for people who want to go back and review pictures later. An example of wound margin necrosis here at the distal end and then pressure over the patellar area for that. So we'll skip over this one. A big blister that is unroofed here and then a follow-up picture that is after that. And so we had good healing occur with this patient, just took some time. The use of a zero flow dressing was helpful. A patient in prosthetic training had some choke syndrome here with blistering and then the blisters coalesced a little bit more. So the key here is get positive pressure back on that and they will resolve typically pretty quickly, pretty superficial. Another example of a blister here. The choke syndrome in a patient here that I had demonstrated earlier. All right, I'm going to skip over a couple more here. An interesting situation here when you're looking at your AKA shrinkers, always make sure you check the proximal line. This patient had a severe deficit on arrival from the acute hospital to the rehab hospital. So, all right, well, I'm going to go ahead and break there and ask if anybody has any questions. Feel free to put your questions in the chat box as well. No, thank you. I appreciate it. As I said in the beginning, this was one where you're going to see a lot of pictures. I think it's a good one to go back and take a look at later because it's just an accumulated patient vignettes and what the diagnosis, whether we knew that ahead of time or at the time of presentation or after we initiated a treatment path and things got better, which as long as you're not hurting the patient is a reasonable path to pursue. I see a question here from John about what percent of your amputee patients end up having serious skin issues? Wow. Some right from the get-go, the dysvascular patients that are super sick, they're going to have significant challenges even trying to get that primary incision line to heal and having those complications where we showed edema blisters and bullous lesions in the immediate post-op period can present challenges there. I would say over time, I think as far as serious and non-serious, about 100 percent of patients are going to have dermatologic complications over time. But trying to keep those out of the serious category is the challenge. Educating your patients to not ignore problems is so hard when you give a patient a prosthetic device that as far as getting out of it is very hard to talk the patient into staying. An easy thing to go in and say is, hey, just get out of the prosthesis for a week. Well, hey, they can't walk. They can't do their job. They can't take care of their household duties, etc. With that, and they fought so hard to get to that point, so talking them out of the prosthesis is difficult. Modifying pressures, reducing wearing times, giving your skin breaks, watching for signs and symptoms of infection. Those are always very important things to do. Thank you. Yes. Help me out on the chat here, Jeremy, if you can. Yes. Similar to what you just said, I think you hinted at it, but do you recommend reduction of wear time along with modifications until the tissue loss improves, blisters, pressure issues, etc? Yeah. An old adage that I learned was, put anything on a pressure sore except the patient. That's something just to remember as a general term. The patients are putting their weight bearing in a prosthetic socket in lower limb in particular, into all of these areas that have pressure tolerance and pressure sensitive areas. The key is to reduce those pressures in the pressure sensitive areas and try to increase that in the pressure tolerant areas. It's a major challenge. We do our amputee clinic with the prosthetist there in the room. We make changes on the spot and we send people over to the office. I think that's an ideal way to manage that. But being conversational and taking pictures and sharing those with the prosthetist could be an excellent way to treat, particularly these pressure areas, but really all skin lesions. Remember, prosthetists and therapists are not versed in these dermatologic issues at all and they can't prescribe. They need your help in order to manage these issues. Next question. What red flag conditions should we always be mindful of so as not to miss and inadvertently cause poor outcomes? Yeah. Infection, infection, infection, and severe skin breakdowns. But it says skin breakdowns from mechanical injury that become infections. Watching for the pustular drainage, the development of systemic symptoms, fevers, chills, increased redness, expanding pustular drainage from any wounds, expanding lesions despite your treatment, have the patient mark on themselves with a Sharpie marker for borders of lesions. If they're growing outside of those areas, that would be a time when you might want to consider get them back in and take another look at this, see whether you need to change treatments. How do you manage patient's fear of future skin complications after healing from a lesion or infection? Well, good question. Instilling confidence in the light of fear. Yeah, that's hard to do. I think one of the most important things I've ever done with that is just telling the patients that you're always there for them, that this is what you do and you're going to follow up with them. If they have a problem, making sure the lines of communication are open, seeing the prosthetist, making sure that you talk with them, having the prosthetist feel free to share with you and creating an environment of inclusion for them. Do you recommend vitamin C, zinc, Juven, and the like to help with healing in the setting of ulcers or skin breakdown? Yes, of course. Those are good evidence-based supplements that can be used, and I think it's reasonable to do so as long as there isn't a contraindication. In regard to the scenario where Choke Syndrome treatment starts to form a blister, would you recommend continued application of positive pressure to the blister region? Will the management change if the blister opens? I'll use a specific dressing here that I just feel compelled to do. I love the dressing Optifoam thin over a blister as long as it's not too big. I've actually had patients be able to keep wearing and training, though using reduced time with the use of that dressing. It seems very good and protective. If it does open, then I would use commonly a non-adherent such as Xeroflow, Vaseline, gauze with that, and you'd have to slow down on the patient using the prosthetic device as much as you can talk them out of it. It's a negotiation for sure. Open wounds can cause decline in function as patient is out of socket and not ambulating for some time. At what point do you refer to wound care and PT? I think you've got to use everything that you have a resource for. If you have access to a wound clinic, it's mostly about them attending to it and making sure that it doesn't have worsening and that they're nurturing that wound to help with its healing. A lot of it is just about monitoring and being diligent in your cleaning and in your treatments that you've initiated. Having a good discourse and open communication with a wound clinic can be very helpful. Any experience with Botox or residual limb hyperhidrosis? The use of neurotoxins, there's literature out there. I do it in practice. I apologize that I didn't speak of that earlier, but the first line of treatment typically would be aluminum chloride solutions to reduce skin sweating. It's a very common problem in June, July, and August and much less of an issue in December, January, February. But I have used subcutaneous Botox in contact areas of in particular a gel liner and an external sleeve. Over the residual limb, I do subcutaneous injections in a grid-like pattern over the residual limb skin paying attention to it a little more proximally rather than distally. In the literature, they talk about using a cornstarch test. I really don't take the time to do that and have very reasonable outcomes even if I don't do that. But there's some excellent written articles that are out there and discuss the use of Botox and neurotoxins for residual limb hyperhidrosis. I would caution to always make sure your patients are pre-authorized for this because it's very expensive. No further questions right now. I appreciate everybody's time tonight. I hope this provides an opportunity for you to learn a little bit more about dermatologic complications in amputee patients.

dermatologic complications

amputee patients

pressure sores

contact dermatitis

prosthetic sockets

skin infections

choke syndrome

blister management

hyperhidrosis