Stump Socks How Many Should I Wear
Stump Socks – “How Many Should I Wear?”
A question which is frequently asked by new patients and also by physiotherapists and nurses is, “How do you decide how many stump socks to wear?”.
Irrespective of the level of amputation, most patients will wear one or more stump socks with their prosthesis. Stump socks are used to give protection to the stump and also to accommodate volume changes.
By changing and washing the socks daily, a healthy environment can be maintained within the socket and the risk of infection reduced. Sufficient stump socks will be supplied from WestMARC to allow you to wash them frequently.
Following the initial amputation, your stump may be oedematous (retaining fluid) and as the wound heals, the fluid reduces and the stump may become smaller.
On the other hand, some people who have been very ill prior to the amputation may be well below their usual weight, and will subsequently gain weight as they return to better health. Their stump may increase in size accordingly.
Trans-Tibial (below-knee) Amputees: The Fit of the PTB Socket
The type of limb prescribed mostly for this level of amputation is the PTB, or PatellaTendon Bearing prosthesis and is shaped to distribute weight in a particular way throughout the stump.
Providing the stump remains the same as when the cast was taken, most of the stump pressure will be on the patella tendon and on the area either side of the tibia.
The patella-tendon liesbetween the patella (knee-cap) and the top of the tibia (shin bone) and is a robust tendon capable of tolerating quite large loads.The soft tissue areas at either side of the tibia are pre-compressed by the shape of the socket, which helps to stabilise the stump within the socket and to relieve pressure at the distal end of the tibia.
When the leg is first fitted, the prosthetist will try the prosthesis with one terry-towelling sock. They will expect to feel some resistance as the liner is pushed upwards onto the stump towards the patella tendon. If there is little resistance felt, they will add further socks, either thick or thin, until the correct fit is achieved.
If, on pushing on the liner, there is too much resistance, they willchange the thick sock for a thinner one.
When the liner is fitted to the prosthetist’s satisfaction, and the patient has walked on leg, the stump will be examined for pressure marking. Usually there will be an indentation at the patella tendon and generalised sock marking. If the tendon indentation is at the bottom of the patella instead of at the tendon, generally this suggests that the stump is sinking a little too far into the socket and a thicker sock, or extra sock, should be added.
If the ‘tendon mark’ is low on the tendon, or pressing on the tibia, this suggests that the socket is too tight. This may be accompanied by redness across the condyles (knee bones). In this case, the fit can be improved by using a thinner sock or removing a sock, if a number of them are being worn.
By altering the stump socks to accommodate volume changes, we are usually able to maintain socket fit for some time.
Unfortunately, the stump does not always change in size uniformly. The knee, or proximal area of the stump, may stay the same while the fleshier distal (bottom) of the stump may reduce in size. Adding another sock may make the leg too tight at the knee, in this situation, so adding a half socket at the bottom may be worthwhile.
When changing the number of socks no longer helps, further adjustments may be carried out by adding pads to particular areas of the socket or adding linings to part of the socket.
Trans-Femoral (above–knee) Amputees: The Fit of the Quadrilateral Socket
The fit of the trans-femoral socket is sometimes more difficult to assess as the superficial anatomy of the stump is not so obvious.
The posterior shelf of the socket provides a generous surface to support the ischial tuberosity, or bottom bone, and the gluteal muscles
The anterior part of the socket brim (front edge) is shaped to support the tissues at the front of the stump and to hold the body weight back onto the seating area. The back to front dimension of the socket is important as this can determine whether the patient is supported by the seating correctly, or is allowed to slide forward.
The medial wall of the socket (inside edge) is contoured to suit the more prominent bony and tendonous structures, and the lateral wall (outside) supports the outside of the stump.
Initially the prosthetist will try the leg on with a terry towelling sock and will hope to feel a little resistance as the patient slides into the socket. If the socket seems too tight, a thinner one will be tried. The patient will stand, supported by the parallel bars. On asking the patient to lean forward at the hip, the prosthetist can check at the socket seating for the ischial tuberosity. On straightening up again, the rest of the socket brim can be examined.
If all of the stump tissue is contained in thesocket brim, the tuberosity is supported on the seating and the patient is comfortable on weight-bearing, the likelihood is that the socket is a good fit.
If there is a roll of flesh above the socket edge, which is not being contained in the socket, the stump may have increased in size since the cast was taken and a thinner sock may be advised.
If the patient feels an intolerable pressure at the anterior or medial wall of the socket, they may be sinking too far into the socket due to volume reduction and may benefit from a thicker sock, or additional socks, for increased comfort.
Again, as with the trans-tibial stump, the volume may not change uniformly and half-socks, linings, pad or further adjustments may be required.
Patient Review
Routinely, new patients will be reviewed at a 4-6 week interval after delivery of the first prosthesis and socket adjustments may be required at that time. Socket problems should be resolved, if possible, at that visit but the designated prosthetist can be contacted prior to the review for advice.