# Situation: A 58-year-old man with type 2 diabetes mellitus and severe peripheral arterial disease of the left leg has had a nonhealing ulcer over the left heel for 2 months. Magnetic resonance imaging (MRI) shows osteomyelitis of the calcaneus. Antibiotics and debridement fail, and he undergoes a left above-knee amputation. Which positioning plan should the nurse follow from the third postoperative day?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630533  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 58-year-old man with type 2 diabetes mellitus and severe peripheral arterial disease of the left leg has had a nonhealing ulcer over the left heel for 2 months. Magnetic resonance imaging (MRI) shows osteomyelitis of the calcaneus.

Antibiotics and debridement fail, and he undergoes a left above-knee amputation. Which positioning plan should the nurse follow from the third postoperative day?

## 보기

1. Supine only; a pillow under the limb to limit swelling
2. Sitting up most of the day; the limb resting flat
3. Prone periods several times a day; a pillow under the limb
4. Prone periods several times a day; no pillow under the limb **✔ 정답**

**정답: 4**

## 해설

After an above-knee amputation, the hip tends to stay flexed, leading to a hip flexion contracture that prevents prosthetic walking. After the first 24 hours the nurse avoids pillows under the residual limb, limits prolonged sitting and head elevation, and has the client lie prone several times a day as tolerated.

## 심화 해설

The main postoperative threat to walking
After an above-knee amputation, the muscles that flex the hip are no longer balanced by the weight and leverage of the lower leg, and the client tends to keep the hip bent while sitting or lying with the residual limb raised. Over days, the hip flexor muscles and joint capsule shorten, producing a hip flexion contracture. A hip flexion contracture prevents the client from standing straight in a prosthesis, so preventing it is a key goal from the first days after surgery.

Why prone lying and no pillow
Prone lying for periods several times a day, as tolerated, stretches the hip flexors and keeps the hip fully extended. No pillow under the residual limb after the first 24 hours keeps the limb flat; a pillow lifts the limb and flexes the hip, which is exactly the position that leads to contracture. In the first 24 hours, the limb may be briefly elevated to reduce swelling, but by the third postoperative day elevation is no longer appropriate. Prolonged sitting and raising the head of the bed for long periods are also limited because both keep the hip flexed.

| Plan | Effect on the hip | Correct? |
| --- | --- | --- |
| Prone periods, no pillow under the limb | Extended | Yes |
| Prone periods with a pillow under the limb | Partly flexed | No |
| Supine only with a pillow | Flexed | No |
| Sitting up most of the day | Flexed | No |

Why each distractor fails
The supine-only plan leaves out prone lying and adds a pillow, both of which favor contracture. Sitting up most of the day keeps the hip at about 90 degrees of flexion for hours. The plan with prone periods and a pillow under the limb has the right idea about prone lying but defeats it by raising the limb. Only the plan with prone lying and no pillow keeps the hip extended.

Other parts of residual limb care
Other measures include keeping the residual limb adducted, not abducted, which prevents an abduction contracture; avoiding a pillow between the thighs; doing range-of-motion and strengthening exercises; and shaping the limb with elastic wrapping or a shrinker for prosthetic fitting. Because of his peripheral arterial disease and diabetes, careful wound and skin inspection is also essential.

Exam takeaway
Key point After an above-knee amputation, prone lying several times a day and no pillow under the residual limb after 24 hours prevent hip flexion contracture.

## 임상 시나리오

Positioning After Above-Knee AmputationPreventing hip flexion contracture
The hip tends to stay flexed after an above-knee amputation, leading to a hip flexion contracture that prevents walking with a prosthesis.

After the first 24 hours, do not place a pillow under the residual limb. Have the client lie prone several times a day as tolerated, and limit prolonged sitting.

Keep the limb adducted, encourage range-of-motion exercise, and shape the limb with wrapping or a shrinker.

CautionA pillow under the limb or long hours of sitting keep the hip flexed. Even with prone periods, raising the limb defeats the purpose.

## 핵심 개념

- **Above-knee amputation** — Surgical removal of the leg above the knee, also called transfemoral amputation.
- **Hip flexion contracture** — Shortening of hip flexor muscles and tissues that keeps the hip bent and prevents full extension.
- **Residual limb** — The remaining part of a limb after amputation, formerly called the stump.
- **Prone position** — Lying face down, which extends the hip and stretches the hip flexors.

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