Injured tissues heal best and are less painful when supported and placed at rest. When the injured limb or amputation site is immobilized and the appropriate local pressure and elevation protocols are applied, the inflammatory response and edema associated with early healing is minimized. Immobilization, application of gentle distal pressure and infrequent dressing changes are tenets of good post surgical care. It is essential that each new generation of amputation surgeons be schooled on the importance of these tenets. Curiosity on the part of the surgeon can prompt overly frequent dressing changes and unnecessary inspection, and these practices generally do more harm than good. It is unfortunate that forthright principles of safe, sterile surgery are often over looked or abjectly ignored in these modern days of miracle drugs, magical wound ointments and medicinal gels that promise the impossible.

Rigid dressings can be fabricated using a variety of materials, including conventional plaster of Paris, elastic plaster of Paris, thermoplastic materials, and any number of other splinting materials. The dressing is applied at the end of surgery and is typically changed in intervals of five to fourteen days. Proper rigid cast protocol requires a therapeutic degree of terminal pressure while promoting a sterile, dry wound surface with no restrictions to hinder circulation. No proximal constriction should be applied to the dressing and the dressing must be adequately suspended to maintain distal pressure. Maintaining distal pressure is aided by means of a compressible material placed at the site of surgery, such as close-cell foam or distal end pads. Suspension is initially managed by molding the cast as it sets and is later reinforced by the devices such as waist belts or shoulder harnesses. Careful attention to suspension will minimize the distal ‘falling away’ of the cast, a process by which the cast slips down away from the end of the stump. When a cast falls away, terminal edema can develop, often with dire results. At this point in the healing process, patients should try straight leg-raises and towel pull exercises in order to provide intermittent pressure and control edema.

The primary objection to the rigid dressing as a postsurgical form of management is that the dressing itself prohibits frequent inspection of the operative site. However, that rigid dressing prevents frequent inspection of the wound site actually proves to be advantageous. Any experienced surgeon knows that an operative site heals best when properly supported, undisturbed and uncontaminated, and the rigid dressing promotes this environment. However, unusual pain, temperature, leukocytosis or other evidence of complications does require cast removal and wound inspection, which is indeed more difficult with a rigid dressing.

The Immediate Post-Surgical Prosthesis
The immediate postoperative prosthetic device can serve as a socket and temporary prosthetic limb in both upper and lower extremity amputations. There are tremendous physical and psychological rehabilitative advantages to applying a prosthesis immediately. Provided with a replacement limb immediately following surgery, the patient avoids a limbless period and therefore some degree of functional restoration begins immediately. The patient’s general physical and mental state benefit from early physical activities. Comparative studies show less patient pain and faster patient mobilization in cases in which postoperative prostheses were employed immediately. The overall amputee rehabilitation period, including hospitalization and the time allotted for limb maturation, are shorter with immediate fit systems. During this period, the encouragement and enthusiasm of the amputation team should not be underestimated. Positive voices and encouragement are essential in directing the patient’s rapid return to regular activity levels.

Although some of the benefits of the immediate fit systems have not been statistically documented, positive experiences reported world-wide support many of the assertions made by its advocates. Areas of disagreement concerning these protocols center on the injurious effects of early function, particularly limited weight bearing and its subsequent effect on wound healing. Some surgeons feel that as with rigid dressings, early application of a prosthesis limits access to the surgical site, thereby preventing inspection and the ability to identify infections early. The major concern associated with immediate fitting is potential tissue damage and wound break down when excessive stresses are applied to the amputation site early on in the healing process. In general, some distal intermediate stress reduces edema and in many circumstances facilitates early healing. Tissue damage can occur, but if the surgeon proceeds on a case by case basis, he can circumvent this trouble. Caution and experience show that early weight bearing must be individualized according to the patient’s skill, understanding and ability to comply. As always, the surgeon must take into account the particular wound and the circumstances of the healing environment.

In addition to traditional casting techniques for immediate prosthetic devices, prefabricated and custom fabricated devices are available on the market today. The makers of these devices emphasize that rehabilitation and the return of function is the primary goal of treatment.

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