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DEFINATION:
Amputation is the 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.
Amputated finger approx 1 in 13,066 or 0.01% or 20,816 people in USA
INCIDENCE :
20,816 349 annual cases in Victoria
• Disease
• Congenital Disorders
The accidents most likely to result in amputation are traffic accidents,
followed by farm and industrial accidents.
Amputations in the case of disease are performed as a lifesaving measure.
The diseases that cause the most amputations are peripheral vascular disease
(poor circulation of the blood) and cancer.
Congenital disorders or defective limbs present at birth are not amputations,
but rather are a lack of part or all of a limb. A person with a limb deficiency
can usually be helped by use of an artificial limb. Sometimes amputation of
part of a deformed limb or some other type of surgery may be desirable
before the application of an artificial limb.
TYPES OF AMPUTATION
The list of types of Amputation mentioned in various sources includes:
• Amputated finger
• Amputated thumb
• Amputated arm
• Amputated toe
• Amputated leg
• Amputated lower leg
Amputated finger:
Conditions that may require amputation of the finger include infection,
gangrene, frostbite, atherosclerosis, bone infection and cancer
Amputated thumb:
Conditions that may require amputation of the thumb include infection,
gangrene, frostbite, atherosclerosis, bone infection and cancer
.
Amputated arm:
Conditions that may require amputation of the toe include infection,
gangrene, frostbite, atherosclerosis, bone infection and cancer. Prosthetics
are often worn following an arm amputation.
DIAGONOSTIC STUDIES
History and physical examination
Physical appearance of soft tissue
Skin temperature
Sensory function
Arteriography
Venography
Transcutaneous ultrasonic Doppler studies
Level of Amputation
Above-knee amputations may be performed through the
distal femur(supracondylar), the midfemur(diaphyseal), or
lessertrochanter (high
above-knee amputation) . Above-kneeamputations
performed for tumors of the distal femur or sarcomas of the
distal thigh tend to be performed at a higher level than
standard above-knee amputations. By contrast, tumors of
the leg are treated with thestandard above-knee amputation.
As a rule, any lengthof femur makes prosthetic fitting easier
than none. Even
amputations at the subtrochanteric level are preferred to hip
disarticulation; if 3–5 cm of bone distal to the lesser
trochanter remain, the patient can be fitted with a prosthesis
in a manner used for above-knee amputation.The main
factors that determine the type of flaps to be constructed are
the soft-tissue extent of the tumor, areas of prior irradiation,
and previous scars.
Level of osteotomy and cross-sectional anatomy for
supracondylar,diaphyseal, and high above-knee amputation.
Higher above-knee amputations are generally used for
primary bone sarcomas of the distal femur. Low above-knee
amputations are used for bone sarcomas of the leg,
especially those involving the popliteal fossa or arterial
trifurcation. High above-knee amputation is preferable to hip
disarticulation, even though the osteotomy is only a few
centimeters below the greater trochanter. With the hip joint
intact, movement of the prosthesis is greatly facilitated.to
avoid local recurrence and no attempt is made toadhere to
standard flaps. At this level a skin or muscle flap of almost
any length will heal in the young patient. Furthermore, it is
not necessary to use equal flaps; longposterior, anterior, or
medial flaps will all heal rapidly.
SURGICAL TECHNIQUE
Muscle Reconstruction
Muscle reconstruction around the femur is essential to
ensure a functional extremity. In addition, the bone end must
be adequately covered and padded with muscles in order to
avoid pressure from the prosthesis. The quadriceps and the
hamstrings are tenodesed to each other by covering the
bone end . The hip flexors are stronger than the extensors;
thus, the hamstrings should be cut longer than the
quadriceps and
Above-knee Amputation
Incision. The skin flaps are marked. The main factors that
determine the type of flaps are the extent of the soft-tissue
tumor, areas of prior radiation, and previous scars. The
greatest priority is to avoid local recurrence and no attempt
is made to adhere to standard flaps; at this level a skin or
muscle flap of almost any length will heal primarily in a
young patient. It is not necessary to utilize equal flaps; long
posterior, anterior, and medial flaps will heal. tolerated by
these patients than by below-knee amputees. A temporary
prosthesis provides the patient the advantage of training
with a simple and adaptable
device. It also becomes a backup to the permanent
prosthesis, which is fabricated when the residual limb has
stabilized in volume and matured to allow full-time wear. Two
critical elements are selection of the knee joint mechanism
and suspension system. Many designs, with varying degrees
of durability, gait parameters, weight, and stability, are
available. Selection of an appropriate product is dependent
on patient-specific factors such as age, weight, type of daily
activities, and desired sports activities, and requires close
consultation with the prosthesist.
The Immediate
Postsurgical Period
Nearly every amputee feels
quite depressed immediately
after the surgery, except
possibly those who have
suffered intense pain for a
period just prior to the
amputation. This depression is
usually replaced early by a
will to resume an active life.
The dressing applied by the
surgeon is either "rigid,"
usually made of plaster-of-
Paris, or "soft," using ordinary
cotton bandaging techniques.
When the rigid dressing is
used it is left in place for 10 to
14 days during which time
most of the healing takes
place. Sometimes a simple
aluminum tube, or "pylon",
and an artificial foot are
attached to the rigid dressing
so that walking, or gait,
training can begin even before
the healing period is complete.
When the soft dressing is used, elastic bandages are used soon after surgery
to aid circulation. The bandages are removed and reapplied throughout the
day. (Instructions for application of elastic bandages are given in the next
section.)
Regardless of the type of dressing used, exercises are extremely important to
prevent contractures (tightening of the muscles) which, when present,
prevent efficient use of a prosthesis. Some "Don'ts" that will help prevent
muscle tightening, or contractures, are shown above.
It is most important that the prescribed exercises be carried out regularly,
and the positions shown above be avoided if the greatest benefit is to be
obtained from the prosthesis.
PREPROSTHETIC COMPLICATIONS
Delayed Healing
Delayed healing may be related to several factors that can be operative singly or in
combination. These include inappropriate amputation-level selection, sub-optimal
operative technique, inadequate postoperative management, and infection.
A common cause of delayed healing is inappropriate amputation-level selection. This
can, to a large extent, be obviated by proper use of the vascular laboratory as an aid in
level selection. Noninvasive techniques such as segmental Doppler studies and
transcutaneous oximetry mapping can yield valuable information. Delayed healing can
also be due to suboptimal operative technique. Handling dysvascular skin with forceps,
attempting to close the skin under tension, or placing excessive closure tension on muscle
of questionable vascularity can result in ischemic changes leading to dehiscence. Even
with minimal closure tension, skin edges may be made ischemic by the placing of too
many sutures, especially mattress sutures . It is better to place a few widely spaced
sutures and reinforce the wound with adhesive paper strips . There is also little need for
subcutaneous sutures in most amputations if good myofascial and fascial closures are
done. Removal of skin sutures prior to firm initial healing of the amputation wound may
also lead to dehiscence, especially in the immunocompromised or dysvascular patient.
Prior to any definitive treatment of dehiscence other than debridement, the patient should
be thoroughly reevaluated to determine the reason for wound failure. The preoperative
vascular studies should be reassessed to be sure that the level previously selected was
correct. If the patient's wound healing potential was not evaluated preoperatively, it
should be done at this point. This would include a determination of serum albumin level
to ascertain nutritional status and a total lymphocyte count to assess immunocompetency.
If these are deficient, further surgery should be delayed until nutrition is normalized. In
chronic renal failure, this may not be possible, and one may be forced to proceed without
this assurance. Although it is good practice for patients to permanently discontinue the
use of nicotine or at least delay resumption until the wound is well healed, it is common
to find them smoking within a day or two of surgery. Rather than have another
immediate failure due to smoking, the surgeon has the option to refuse surgical treatment
beyond debridement on these patients if they fail to comply with this request, so long as
life is not threatened. If vascular studies and nutritional parameters are normal and the
patient stops the use of nicotine, treatment should proceed with the most appropriate
technique.
Treatment is determined by the length and depth of the dehiscence. If skin separation is
minor, the residual limb may be allowed to heal by secondary intention following
conservative debridement under adequate antibiotic coverage. Often a temporary
fiberglass or plaster of paris cast helps in the healing of such cases. If wound edge
separation due to necrosis is confined to the skin, local debridement that avoids trauma to
skin of marginal viability is called for. This may be followed by split-thickness skin
grafting once adequate granulation tissue forms. Dehiscence with moderate wound
separation can be managed by adequate debridement and secondary closure without
tension by utilizing a minor wedge excision with minimal bone shortening .
If infection is the sole cause of dehiscence, the wound should be widely opened for
drainage and appropriate antibiotics given. Once the wound is clean and granulating well,
the decision can be made to allow healing by secondary intention, with delayed split-skin
grafting coverage of granulating areas, or to revise proximally and maintain the same
anatomic level if an adequate soft-tissue envelope for the bone can be constructed. In the
presence of gross necrosis or failure of the wound to produce adequate granulation tissue,
the choice is limited to a revision amputation.
If peripheral vascular parameters are poor, before proceeding to a higher anatomic level,
for instance, from transtibial to transfemoral, transcutaneous oximetry can be utilized to
determine the potential for skin healing slightly more proximally in the same limb
segment. Evaluation should begin with baseline transcutaneous oxygen pressure (Tcp02)
determinations on room air at the site of proposed revision. If less than 40 mm Hg, the
measurements may be repeated after the patient has been breathing 100% 02 at 1 atm for
20 minutes. If Tcp02 values then meet or exceed 40 mm Hg, postoperative hyperbaric
oxygen (HBO) therapy may be considered. In selected cases, readings can be taken in the
hyperbaric chamber while the patient is breathing 100% 02 at 2.4 atm. If Tcp02 levels are
still borderline, consideration should be given to amputation at the next higher anatomic
level, followed by HBO therapy if Tcp02 readings are borderline at that level.
On occasion, repeated attempts at healing a trans-femoral amputation in cases of severe
dysvascularity result in wound dehiscence due to necrosis at a higher level. The next
proximal level is a hip disarticulation, with no assurance that this level will heal. If
necrosis then recurs, the patient is at great risk of death due to the difficulty of
controlling a wound at that level without involving the pelvic structures. It is sometimes
best to merely debride high transfemoral wounds in a manner so as to avoid trauma to
wound edges of marginal viability. This is done by leaving a residual rim of necrotic
tissue approximately 2 to 3 mm in width. In this way, the marginally viable skin beyond
the necrosis is not traumatized by the scalpel. This will often stop the inexorable spread
of necrosis attendant upon repeated aggressive debridement. This small rim of necrotic
tissue should separate spontaneously. Gauze dressings applied moist and removed dry
three times daily will encourage the formation of granulation tissue, which will lead to
either healing by secondary intention or the production of a suitable bed for a split-skin
graft. This is, of course, combined with improvement of nutrition and cessation of
smoking. HBO treatments are again a useful adjunct in management if pretreatment test
results are favorable.
In older dysvascular patients, falls in the early postoperative period are common due to
problems with balance, coordination, and weakness during crutch or walker ambulation.
Direct falls on a partially healed amputation wound can result in massive dehiscence and
leave the bone exposed. Cleansing, debridement, and closure should be done on an
emergency basis to prevent infection, flap shrinkage, and prolonged delay in prosthetic
fitting . This complication is usually prevented by application of a cast to the midthigh
with the knee in full extension each week for 3 weeks. This will also allow wound
inspection at weekly intervals and afford an opportunity for a full range of motion of the
knee prior to application of each cast.
Contractures
The joint immediately proximal to an amputation site tends to develop contractures if full
range of motion is not initiated early in the postoperative phase. Contractures most often
occur as a result of the patient keeping the residual limb in a comfortable flexed position.
In lower-limb amputees, a variety of contractures may occur. These are serious
complications that will interfere with proper prosthetic gait and increase the energy
requirements of ambulation.
Patients with partial-foot amputations between the transmetatarsal and Syme ankle
disarticulation levels are likely to develop an equinus deformity due to the relatively
unopposed action of the triceps surae. This may be prevented during tarsometatarsal
(Lisfranc) and midtarsal (Chopart) amputations by reattaching the extrinsic muscle-
tendon units of the foot to more proximal bony structures in a balanced fashion and by
lengthening the Achilles tendon percutaneously. A postoperative cast applied with the
partial foot in a plantigrade position will prevent contractures until a definitive prosthesis
is made. A plastic ankle-foot orthosis fitted with an anterior ankle strap can be similarly
used. If, despite these precautions, a contracture later develops, a second percutaneous
Achilles tendon lengthening or revision to the Syme ankle disarticulation level may be
required.
Transtibial amputees, especially those with a short tibial segment, are prone to develop
knee flexion contractures in the first or second week postoperatively . For this reason, a
circumferential rigid dressing of plaster of paris or fiberglass with the knee in full
extension is advised until the wound heals sufficiently to allow the removal of sutures.
This is replaced weekly for 3 weeks with a full range of knee motion at each change. The
patella should be well padded to prevent pressure necrosis of the prepatellar skin. Even
with a cast in place, pillows should not be placed under the residual limb, or a hip flexion
contracture may be encouraged.
Severe knee flexion contractures are virtually impossible to reduce by exercise once they
become fixed. In amputations not done for vascular insufficiency, hamstring lengthening
and release of the posterior knee joint capsule should be considered. The dysvascular
amputee with a short contracted residual limb may be fitted with a bent-knee prosthesis,
which is functionally no better and cosmetically inferior to that for a knee
disarticulation . Occasionally, moderate knee contracture in a proximal-third amputation
may be improved by fitting a prosthesis with the foot in slight equinus to provide a knee
extension moment on foot contact.
At the transfemoral level of amputation, a hip flexion-abduction contracture can be
devastating because the already high energy requirement for ambulation at this level is
further increased by contracture. Again, prevention is the key. During transfemoral
amputations, flexion-abduction contracture can be discouraged by a balanced myodesis,
including reattachment of the adductor magnus tendon to the lateral aspect of the femur
as it is held in adduction and extension . Postoperatively, pillows under the thigh are
forbidden. Within a few days of surgery, the patient should be taught to lie prone for 15
minutes three times a day to stretch out any early flexion contracture and to actively
adduct the residual limb to prevent abduction contracture. Active extension of the
residual limb while flexing the opposite thigh to the chest is also effective. Excessive
wheelchair use, which encourages contractures, is discouraged by early walking with
crutches or a walker.
An alternative approach may be used in anticipation of prosthetic use by vigorous
transfemoral amputees. A unilateral hip spica is applied in the operating room
immediately following wound closure. Application is easily done by lifting the patient by
the opposite leg. The benefits are analogous to those achieved by postoperative casting of
transtibial amputees. The hip is aligned to discourage contractures, distal constriction
edema from bandaging is avoided, and the wound is protected from shear and direct
pressure, thereby reducing pain. At the first cast change, a pylon and foot may be added
to convert it to a preparatory prosthesis.
At the short transfemoral level, flexion contracture of up to 25 degrees may be
accommodated by prosthetic alignment, but hip extensor power, needed for good
prosthetic knee stability, is compromised. As one progresses distally to the midthigh
level, it is increasingly difficult to compensate prosthetically for a hip flexion
contracture. Even then, the resulting cosmesis of the prosthesis will leave something to
be desired. More than 15 degrees of hip flexion contracture will require a marked
compensatory increase in lumbar lordosis that, even if available, may lead to low back
pain.
When prescribing a prosthesis in cases with significant flexion contracture of the hip or
knee, the patient and family must be forewarned of the relatively grotesque appearance
of the prosthesis. Otherwise, if the patient and family do not understand the rationale for
this initial fitting in the hope that prosthesis usage will tend to decrease the contracture,
they may be very dissatisfied with the prosthesis and reject it.
In children, knee and hip flexion contractures can be stretched out by ignoring their
presence and fitting the patient with conventional alignment techniques. Spontaneous use
will usually stretch the contractures without other special treatment.
Contractures also occur in upper-limb amputations. Limitation of glenohumeral
abduction and forward flexion is common in short transhumeral amputations. Elbow
flexion contracture occurs readily in a short transradial case. Either can be easily
prevented by instituting range-of-motion exercises as soon as postoperative pain has
subsided at 5 to 7 days. Gentle muscle-strengthening exercises begun at 2 to 3 weeks
postoperatively are also helpful. If contractures become fixed, even an extensive program
of stretching may be ineffective and require selective release of contracted muscles to
allow fitting of a prosthesis.
POSTPROSTHETIC COMPLICATIONS
Insensitive Skin
Amputees with diminished sensation in the residual limb are seen quite commonly. The
largest group are diabetics, but other neurologic disorders such as my-elomenigocele,
Hansen's disease, and alcoholic neuropathy are also seen. These patients are not deterred
by pain from continuing to walk on a locally ischemic or ulcerated residual limb and
must be taught to remove their prostheses at regular intervals for skin inspection,
especially during the early phases of prosthetic use. Areas of skin blanching and/or
erythema should be noted by the prosthetics team for prompt corrective action. Multiple
short periods of daily ambulation will usually allow gradual skin adaptation. The
presence of insensate but otherwise normal skin on the residual limb should not be
considered an indication for more proximal amputation. It does, however, demand
precise prosthetic fitting and attentive follow-up care.
Poor Fit
After a variable period of use, most amputees find that prosthetic fit can no longer be
effectively adjusted by further socket padding and additional stump socks. With an
excessive number of sock plies, usually 10 to 15, the socket/residual-limb interface is
disturbed, as manifested by a reduction in rotational control and an increased tendency to
piston. In these cases, the prosthesis no longer fits properly, and a new socket is needed
promptly if dangerous, costly skin breakdown is to be avoided. On the other hand, many
problems are easily corrected with minor sock or socket adjustments. All team members
should therefore be aware of the signs of both loose and tight socket fit, especially at the
transtibial level. Evaluation of a residual limb for prosthetic pressures is exactly the same
as evaluation of a foot for shoe fitting. One looks for areas of prolonged erythema after
walking in the prosthesis, erythema in abnormal places, callus or bursa formation, and
local tenderness under erythematous areas.
Relative socket looseness will commonly cause excessive direct and shear forces over the
tibia and fibula, fibular head, tibial tubercle, and distal end of the patella as the residual
limb enters the socket too deeply. This problem is usually related to residual-limb
volume decrease by atrophy or weight loss. Relative socket tightness will cause direct
tibial tubercle pressure on the patellar tendon bar and verrucous hyperplasia of the limb
end due to loss of distal contact. This problem is often related to wearing excessive sock
plies or due to weight gain. Pressure and shear forces result in inflamed and/or ulcerated
areas of skin in either case.
Another transtibial problem of fit related to distal circumferential shrinkage is usually
associated with ill-defined pain in the residual limb. In this case, the amputee has good
suspension at the socket inlet but relative freedom of motion distally so that the residual
limb moves inside the socket like a clapper in a bell and strikes the anterior socket wall
each time the knee is extended during swing phase. There is no sign of inordinate
prosthetic pressure, but it may be noted, during donning or doffing of the prosthesis, that
while there is a snug fit proximally, there is room distally for an examining finger or that
a soft insert feels loose. A weight-bearing radiograph of the residual-limb/socket
interface is useful to confirm the presence of a distal void. Often, the same situation leads
to choking. This problem may sometimes be corrected by filling in the socket
posteriorly.
Lower-limb edema resulting from renal and/or cardiac disease will adversely affect
socket fit. If these amputees are unable to use their prosthesis for any reason, such as any
sudden change in their health, it may be impossible to get the socket back on. It is
extremely important that they have appropriate shrinker socks to wear in bed. If they are
admitted for treatment of their underlying condition, compression of the residual limb
should be started promptly while in the hospital rather than being neglected for a period
of several days. The edema can become relatively chronic, and resumption of ambulation
can be very difficult as one struggles to shrink the residual limb again.
Fracture
Although uncommon, fracture in a residual limb following amputation does occur
sufficiently often to warrant a careful design of treatment methods to allow an early,
effective return to prosthesis use. By applying current knowledge of the gait cycle and
energy expenditure in lower-limb amputees, certain goals in the treatment of late
residual-limb fracture become clear. The general principles of fracture management,
however, remain the same as in any other individual, but a different approach is allowed
due to the reduction in distal limb segment mass and lever arm length.
A combined American and Canadian study produced 90 cases with sufficient information
to provide both epidemiologic data and some specific recommendations for management.
The average age at injury was 50 years, with a fall while wearing the prosthesis as the
usual cause of injury. It was notable that knee joints and a thigh corset did not prevent
supracondylar fractures in transtibial amputees, nor did a hip joint with a pelvic belt
prevent fractures about the hip in transfem-oral amputees.
One important goal in the treatment of intertrochanteric fractures that applies to both
transtibial and trans-femoral amputees is the restoration of a normal neck-shaft angle to
restore hip abductor function. Although manipulation and casting often suffice in two-
part intertrochanteric fractures, those amputees with unstable fractures are best served by
open reduction and internal fixation. Displaced femoral neck fractures in both groups
may be managed either by reduction and internal fixation or by endoprosthetic
replacement. Excision of the femoral head alone will lead to an unstable gait. Instead,
femoral endoprosthetic replacement or total-hip arthroplasty may be undertaken based on
the same criteria as in any patient with otherwise intact limbs.
Because of the small residual-limb mass and lever arm length in transfemoral amputees,
most nondis-placed peritrochanteric fractures and shaft fractures can be successfully
managed by non-weight bearing alone or minispica casts after appropriate manipulation
of malaligned fractures.
In transtibial amputees, preservation of knee motion and restoration of limb alignment,
especially in more proximal femoral fractures, are paramount. Patients with stable
supracondylar femoral fractures can be mobilized rapidly by the use of the cast-brace
technique . Unstable supracondylar fractures should be fixed primarily, if possible, to
preserve knee motion. Severely comminuted supracondylar fractures unsuitable for
fixation may be managed by casting with or without preliminary skeletal traction and/or
manipulation . Moderate malunion or loss of length at the transtibial level is easily
compensated by prosthetic adjustment, but an effort should be made to avoid flexion
contracture of the knee, which is much less compensable . In displaced intra-articu-lar
fractures of the knee, joint congruity should be restored as accurately as possible.
In this study, transtibial amputees were more likely to resume the use of their prosthesis
than were trans-femoral amputees due to lesser energy demands. Operative scars did not
interfere with the fitting or use of prostheses. Only 25% required a prosthesis
modification following fracture, and all of these were transtibial amputees. Proximal
revision of amputations through the fracture site was not found to be necessary or
desirable.
Fractures of residual upper limbs are very rare. It is recommended that humeral fractures
be treated by splinting. If delayed union or nonunion ensues, open reduction, internal
fixation, and bone grafting should be considered, especially in transradial amputees.
Fractures about the elbow may be managed by open or closed methods so long as
treatment is designed to maintain elbow range of motion. In summary, good results in the
management of fractures of residual limbs may be expected if they are treated with the
same care and expertise accorded fractures occurring in intact limbs.
NURSING INTERVENTATION
The major goals of the patient may include relief of pain ,absence of
altered sensory perception , wound healing , acceptance of altered
body image ,resolution of grieving process, independence in self
care ,restoration of physical mobility ,and absence of complications .
RELIEVING PAIN
Surgical pain can be controlled effectively with opoid analgesic ,non
pharmaceutical intervention or evacuation of haematoma or
accumulated fluid . Pain may be incisional or may be caused by
inflammation ,infection and pressure on bony prominence or
hematoma muscle spasm may add to the patient discomfort.