Amputation: removal of a body extremity by

trauma or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. Amputations can be classified into two categories: Congenital or acquired amputation. Congenital amputation: When an individual is born without a limb. Congenital amputations are classified according to the site or the level of limb absence. Acquired amputation: When an individual has a limb removed by operation due to trauma, infection, diabetes and/or vascular impairment. Levels of amputations Lower limb Partial toe: any part of one or more toes Terminal symes: partial resection of DP Lesser digit amp: Preserving part of the PP prevents drifting Toe disarticulation: at the MP joint Partial foot/ray resection: 3, 4,5 metatarsal and digits Transmetatarsal: midsection of all metatarsals o Lisfranc-disarticulation of all metatarsals and digits o Chopart-disarticulation at the midtarsal joint leaving calcaneus and talus Symes: (Named for James Symes, 1800)Ankle disarticulation with attachment of heel pad Long transtibial: >50 tibial length Transtibial: between 20-50 tibial length Short transtibial: <20 tibial length-trauma usually Knee disarticulation: Through knee joint, femur intact Long transfemoral: >60% femoral length Transfemoral: between 35-60% femoral length Short transfemoral: <35% femoral length Hip disarticulation: Through hip joint, pelvis intact Hemipelvectomy: resection of lower half of the pelvis Hemicorporectomy: Both LE and pelvis below L4-L5 Amputation Levels - Upper limb Trans phalangeal Finger disarticulation Trans metacarpal Trans carpal Wrist disarticulation through wrist

Below elbow Long trans-radial: >50 radius length Trans-radial: between 20-50 radius length Short trans-radial: <20 radius length Elbow disarticulation through elbow Above elbow Long trans-humeral: >50 Humerus length Trans- Humeral: between 20-50 Humerus length Short trans- Humeral: <20 Humerus length Shoulder disarticulation through shoulder Forequarter including clavicle and scapula Indications Vascular Diseases - atherosclerosis Vascular Diseases - DM Traumatic Injury Thermal and Electrical Injury Frostbite Tumour Congenital deformity Vascular gangrene, resting pain DM neuropathy Trauma compound #, BV rupture, mangled extremity, crush injury, associated severe soft tissue/ bone loss, secondary complications etc. Tumour osteosarcoma, Evings, gaint cell, chondro/ fibro sarcoma Congenital limb deformities or absence of limb is a possible cause, but more rare. Transverse- Limb ends at location of deficit Longitudinal- a total or partial absence of a structure along the long axis of a segment, beyond which normal skeletal elements may exist. (ieabsence of a tibia with a normal foot) Amelia- absence of a whole limb Apodiaabsence of a hand or foot Adactylia-absence of fingers or toes with MC or MT Aphalangia- absence of finger or toes Phocomelia- flipper limb due to absence of a limb segment Types Emergency/ Guillatine Elective/ Classical Staged Revision Important Issues for the Patient/Family to Understand Time Frame of Recovery Realistic time frame to help avoid unrealistic goals Usual expectation of 12-18 month Emotional Adaptation

Differs for everyone Physical adaptation differ for amputation type Prosthetic plan Role of P&O, PT, Funding, Expectations of the prosthesis Functional Outcome Pre operative assessment Physical assessment CNS, ANS, Special senses Cardio-pulmonary status Strength of trunk, limb muscles Mobility of limb joints Balance and coordination Motor and Sensory Social assessment Pre-op PT In ward / dept Chest physiotherapy Bed mobility Transfer techniques Joint Mobility exercises Strengthening exercises Wheelchair mobility Walking if possible Rx for existing problems Post-op PT Hard dressings Protects Edema control Semirigid dressings Unnas dressings (gauze+ZnO, gelatin, glycerine & calamine) Soft Dressings (SD) Compression bandages Shrinkers, Elastic wraps Physical therapy Occupational therapy Psycho/Social therapy IPOP Improves outcomes Helps with challenging cases Enhances value of rehab care Maximizes potential for future prosthetic use Functional Management empowers patient, family & rehab team Reduce pain Prevent contractures and maintain strength Protect wound site Early ambulation prevent bed rest complications Reduce falls Speed-up the training and adjustment period Improve balance and safety during transfers

Control volume change Goals Prevent Contractures Reduce Post Surgical Edema Improve Bed Mobility Pain Management Protect limb from trauma Emotional care Promote limb activity Establish trunk stability Prevention of Falls Begin Ambulation Early post op care Handling the stump & stump care Active movements Static exercises Aid bed mobility Bridge, roll, move, sit, push-up, pull-up Aid psychological acceptance Chest physiotherapy Exercise to remaining limbs IPOP fitting and training Stump care Protective dressing rigid/ semi/ soft Drain care Positioning Pain management Edema mangement Mobilization exercises Static exercises Wound care Prevention of contractures Joint positioning Adequate support (pillow, sand bags etc) Passive exercises Active exercises Avoid prolonged sitting Anti-deformity position Transfers Care about drains, catheter Methods: Standing pivot Back/ forward Sliding board Stump care Balance Wheelchair Dressing, toileting practice Edema control Elevation Exercises Bandaging

Rigid dressing Shrinker socks Intermittent variable air pressure machines IPOP/ EPOP Pneumatic pylon Post surgical assessment Patient History Social History Prior level of activity/employment Living environment/community access General health Health behaviors Medical History Chief complaints Medications Communication, affect, cognition, language and learning style Losses or abnormalities of anatomic, physiologic, psychological or mental structure or function Physical impairments Aerobic capacity and endurance Anthropometric measurements Circumference in cm Document anatomical landmarks Skin assessment warm cool abnormally warm Stump length From tibial tubercle or ischial tuberosity to end of bone or soft tissue Shape Bulbous Conical Cylindrical-best for total contact prosthesis Vascularity: both legs Capillary refill time <3 sec Pulses-Femoral, Popliteal, Posterior Tibial, Dorsal Pedal 0=absent 1+diminished 2+normal 3+increased ROM Strength Sensory integrity

Skin sensitivity with SemmesWeinstein Monoflimament 5.07 touch or higher = protective sensation Cognitive impairment (arousal, attention, cognition) Psychological Impairments (depression, anxiety) Social Impairment (social support, financial) Activity Limitation Restrictions of the ability to perform at the level of a whole person Assistive and adaptive devices Self-care: ADLs Gait Balance Ergonomic and body mechanics Disability Inability to perform, or limitation in the performance, of actions, tasks, and activities expected in social roles Accessibility/ Barriers Ability to return to work Safety Exercises Sitting Balance, rhythmic stabilization, mobility, strengthening, stretching Supine Mobility, weights Side lying Prone Kneeling 2 or 4 point Dynamic stump exercises Desensitization exs Mechanical resisted exs Contracture treatment Scar treatment Hopping Balance Crutch muscles exs Transfers Complications Hematomas Infections Necrosis Neuroma Phantom sensations Phantom pain

Deep venous thrombosis Terminal overgrowth Bony spurs Contractures

Contractures - Treatment: Active/ Resisted muscle work. PNF Diligent positioning Stretching Modalities: ice, POP, splints, Mobilizations, UST etc. Gait/ Prosthetic correction Adherent scar Due to slowly healing wound/ previous surgery/ grafts Problem in prosthetic fitting, flexibility Treatment: Mobilize massage, UST Stretching Weight bearing Neuroma Neuroma may develop post surgery at the end of a nerve. Subject to pressure from the prosthesis socket. Pain upon weight bearing can be relieved with cortisone injection to area or ultrasonic therapy. TENS Stump sensations Phantom Limb Pain random sharp shooting pains or spasms, coming in bursts. Phantom Limb Sensation feeling of finger twitches, itches or sensation in the missing limb. TENS Desensitization

Choke syndrome A potentially serious cause of residual limb pain that should be detected. If the prosthetic socket fits tightly around the proximal residual limb, but the distal residual limb is not in good socket contact, there will be obstruction of venous outflow, and distal limb edema will develop. If unchecked, erythema, induration, and eventual skin breakdown ensues. Treatment is a socket revision. Pre-prosthetic activities Dressing practice Transfers Wheelchair activities UL strengthening ADL Pre-prosthetic assessment Stump assessment ideal stump Activity Prosthetic measurement General fitness Complications An ideal stump No/ less scar Optimal length Good mobility Good strength Functional No phantom pain/ sensation No neuroma Weight bearing sensitivity Stable volume

Prosthetic fitting

Types: Endoskeletal/modular Exoskeletal/crustacean, plastic/ fabric/ fiber, temp - permamant Types: 1. Postoperative pros. 2. Initial pros. 3. Preparatory pros. 4. Definitive pros. 5. Special use pros. Parts: Prosthetic Socket Prosthetic hip/ knee/ ankle joint Prosthetic locks Prosthetic elbow/ wrist joint Prosthetic foot/ hand Prosthetic suspension Terminal devices Prosthetic controls Prosthetic foot Nonarticulated SACH, Jaipur, SAFE Articulated single and multiple axis Shank Exoskeletal/ Endoskeletal Socket Lined/ Unlined/ symes Suspension Straps/cuff, distal pin, supracondylar brim, thigh corset, vacuum assisted, silicon Knee unit single axis, polycentric Knee lock manual, friction brake, spring, dial Hip unit Socks Sheaths, Liners Terminal devices cosmetic/ functional Control- manual/ mechanical/ electric/ myoelectric/ no Pressure-tolerant areas for B/K Patellar tendon Pretibial muscles Posterior aspect of the residual limb over the upper portion of the gastroc-soleus muscles Lateral shaft of fibula Medial tibial flare Pressure-sensitive (relief) areas Tibial crest, tubercle, and condyles Fibular head Distal tibia and fibula

Hamstring tendons Pressure-tolerant areas for A/K Ischial tuberosity Gluteal muscles Lateral side of the residual stump Greater trochanter Pressure-sensitive (relief) areas Disto-lateral end of femur Pubic symphysis Perineal area SACH Post operative flat heeled foot; For immediate prosthesis Good lateral stability The weight 20 percent less than the regular molded foot. Resistance to the toe break is less than standard SACH. Used for swimming and water skiing. Used with flat heeled shoes such as tennis shoes. Shock absorption and motion provided by the material and structure. Heel wedge compresses at heel strike The shape and length of the wooden keel provide the smooth rocker motion and support. Foam rubber sole and nylon belting resistance to toe extension. External keel provide more stability than internal keel. SAFE Stationary attachment flexible endoskeletal (SAFE): Like windlass effect At heel off the bands tithens to create a semirigid toe lever. Flexible keel is used to adapt in irregular surfaces. Long plantar ligament band span the arch to stabilize that when wearer stand. The anterior surface of the Bolt Block is cut at 50 degrees and the inferior surface is rounded to provide a subtalar- like surface. It has no mechanical joint. Prosthetic training Donning & Doffing Gait training Parallel bar, crutch/ walker/ cane Plain/ stair/ ramp Balance/ wt transfer/ coordination Exercises with prosthesis

Assessment of prosthetic gait Correction of gait deviation components Assessment as in post-op and in addition Prosthetic checkout- identify and check componentry Stump checkout Static assessment in sitting and standing Status of stump Without prosthesis With prosthesis Other foot Prosthesis wear time progressionDon/Doff prosthesis:Weight shifting, balance followed by gait training Functional skills/ADLs Reintegration to work and leisure activities. Symes Symes amputation is an ankle disarticulation (the removal of the foot through the joint) with removal of the malleoli (the two rounded protrusions on either side of the ankle) then forward rotation of the heel pad over the end of the residual tibia. A rigid prosthetic socket is an important part of fitting a Symes amputation. The socket has a soft interior liner and usually extends up to just below the persons knee. Other socket designs that are sometimes used include the Canadian Syme and the bladder-type Syme. The Canadian Syme has an opening in the back, making it easier to put on. The short space between the end of the residual limb and the floor means that a standard prosthetic foot usually has to be modified in order to fit correctly. Possible foot choices include the Solid Ankle Cushion Heel (SACH) foot or a carbon reinforced energy-storing foot.

Quadrilateral Socket
- traditional quadrilateral socket has narrow anteroposterior diameter to keep the ischium positioned back and up on top of the posterior brim of the socket for wt bearing; - anterior wall of the socket is 5 to 7 cm higher than the posterior wall to hold the leg back on the ischial seat; - anterior pain, a frequent complain, should be adressed by very local relief, such as, padding over the anterior superior iliac spine; - if the anterior wall is lowered or relieved, the ischium will slip inside socket and totally alter load transfer and pressure areas; - eventhough the lateral wall is contoured to hold the femur in adduction the overall dimensions of the quadrilateral socket are not anatomic and provide poor femoral stability in the coronal plane; - disadvantages: - lack of medial proximal stabilizing force.