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Amputations are caused by:

áÊ Accidents
áÊ {isease
áÊ ’ongenital {isorders

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.

’ongenital 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.

The distribution of amputations by cause is shown below:

There are slightly more than 1.5 amputees per 1000


persons in the United States and ’anada. Therefore, the
present total in the United States is approximately
380,000.

There are more "below-knee" (trans-tibial) amputees


than any other type as can be seen from the chart below.

Surgeons preserve the knee joint whenever it is practical


to do so and will fashion the stump at the lowest practical
level. Very short stumps make fitting extremely difficult
and very long below-knee stumps are prone to circulation
problems.
The Syme's amputation, which is essentially removal of the foot at the ankle, usually
results in a stump that will bear a substantial part of the body weight over the end.

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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 "{on'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.



   
  

In general the earlier a prosthesis is fitted the better it is for the amputee. One of the
most difficult problems facing the amputee and the treatment team is edema, or
swelling of the stump, owing to the accumulation of fluids. Edema will be present to
some extent in all cases, and it makes fitting of the prosthesis difficult, but certain
measures can be taken to reduce the amount of edema.

The use of a rigid dressing seems to control edema. After the rigid dressing has been
removed and when a prosthesis is not being worn, elastic bandages are used to keep
edema from developing.

The patient is taught the proper technique for bandaging and is generally expected to
do this for himself as shown on the next page.

For the average adult, one or two elastic bandages four inches wide are used. {uring
the course of the wrapping, tension is used to maintain about two-thirds of the
maximum stretch.

The stump should be bandaged constantly, but the bandage should be changed every
four to six hours. It must never be kept in place for more than 12 hours without re-
bandaging. If throbbing should occur, the bandage must be removed and rewrapped.

Special elastic "shrinker socks" are available for use instead of elastic bandages, and
while not considered by some to be as effective as a properly applied bandage, a
"shrinker sock" is better than a poorly applied elastic bandage.

Whether an elastic bandage or a shrinker sock is used, it should be removed at least


three times daily and the stump should be massaged vigorously for 10-15 minutes.
The bandage or sock must be reapplied immediately after the massage.
 

Regardless of the functions provided by the most sophisticated mechanical devices,
the most important factors in the usefulness of an artificial leg are fitting of the socket
and alignment of the various parts with respect to the body and with respect to each
other. Fitting and alignment are difficult procedures that require a great deal of skill
on the part of the prosthetist and a great deal of cooperation on the part of the patient.
{uring fitting and alignment of the first prothesis, it is necessary for the prosthetist to
train the amputee in the basic principles of walking in order for the prosthetist to
arrive at the best set of conditions for the amputee. Fitting affects alignment,
alignment affects fitting, and both affect comfort and function. In addition, extensive
training is carried out later by the physical therapist.

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1.Ê Start with the bandage held in place on the inside of the thigh just above the
knee and unroll the bandage so that it is laid diagonally down the outer side of
the stump while maintaining about two-thirds of the maximum stretch in the
bandage.
2.Ê Bring the bandage over the inner end of the stump and diagonally up the outer
side of the stump.
3.Ê Bring the bandage under the back of the knee, continue over the upper part of
the kneecap and down under the back of the knee.
4.Ê Bring the bandage diagonally down the back of the stump and around over the
end of the stump. ’ontinue up the back of the stump to the starting point on the
inside of the thigh and repeat the sequence in a manner so that the entire stump
is covered by the time the roll is used up. The end of the bandage is held in
place with the special clips that are provided. It is important that the tightest
part of the bandage be at the end of the stump.
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Fitting as soon after surgery as possible also helps to
combat edema. A preparatory prosthesis is frequently used
for several weeks or months until the stump has stabilized
before the "permanent", or definitive, prosthesis is
provided.
The socket of the preparatory prosthesis may be made of
either plaster-of-Paris or a plastic material, and is usually
attached to an artificial foot by an aluminum tube often
called a "pylon". The aluminum pylons are usually
designed so that the position, or alignment, of the foot with
respect to the socket can be changed when necessary.
Although a variety of shoes may be worn with artificial limbs, the patient
should consult with the prosthetist before selecting the shoes to be used because
heel height is a major factor in alignment of the artificial leg. A belt about the
waist is usually used to help keep the prosthesis in its proper place on the
stump. At least one prosthetic sock is worn between the socket and the body to
provide for ventilation and to protect the skin from rubbing. Most prosthetic
socks are woven of virgin wool, but socks of synthetic yarns are also used.
Three thicknesses are available: 3 ply, 5 ply, and 6 ply. Additional socks can be
used to compensate for stump shrinkage if the amount of shrinkage is not too
great. The prosthetist and therapist can suggest the sock or socks to be used, but
only the patient can determine the proper selection. (A chart to guide in
selection of sock thickness is shown in ’are of the Stump.)

Prosthetic socks must be changed daily to reduce the chance of irritation of the skin
and dermatitis.

Prosthetic socks require special care in laundering. Instructions are provided by the
manufacturers.

A specially woven nylon sock known as a prosthetic sheath is used by many amputees
between the skin and the regular prosthetic sock to provide additional protection from
abrasion. The sheath also allows perspiration to escape to the prosthetic sock and thus
to the atmosphere.



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Most prostheses for amputations
between knee and ankle consist
of three major parts: a socket, a
shank, or shin, and a foot.
The most common socket used is
some form of the Patellar-
Tendon-Bearing (PTB) design
where all of the weight of the amputee is carried through the stump. The PTB
socket totally encloses the stump and usually contains a "soft" liner to provide a
cushioning effect, although many amputees prefer a "hard" socket because it is
considered to be cooler. The prosthesis may be held in place by any of a
number of ways: by a cuff above the knee cap; by the shape of the brim of the
socket; or by suction between the socket and amputee produced by an elastic
sleeve or flexible inner liner of silicone and attached mechanically to the
prosthesis. Sockets are made of plastic. The shank may be either a hollow shell
(crustacean) or a tube (pylon) covered by foam and a flexible outer layer
(endoskeletal). The pylon may contain provisions so that alignment may be
adjusted at any time during the life of the prosthesis. Any of several types of
artificial feet may be used, depending upon the user¶s preference.





 


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Whether the prosthesis is to be crustacean or
endoskeletal (often called "modular") type, the
prosthetist usually begins by wrapping the stump
with plaster-of-Paris bandages to obtain a negative
mold. A positive model is made by filling the
negative mold with a mixture of plaster-of-Paris and
water, and allowing it to harden.

After modification of the model to provide the proper


characteristics to the finished socket, a plastic socket
is formed over it. The first one is usually a test, or
check, socket made of a transparent plastic to determine if further modifications are
needed.

A new method being used by many prosthetists for obtaining a modified model of the
stump involves use of a computer and automatic machinery. Known a ’A{ ’AM
(’omputer-Aided-{esign ’omputer-Aided-Manufacturing), this method permits
prosthetists to modify the model more easily since it does not require making and
carving an actual plaster model.

The socket is mounted on an adjustable leg for walking trials, and when both the
prosthetist and the amputee are satisfied, the limb is ready for the finishing
procedures. The exoskeletal shank may be of plastic-covered wood or all plastic. The
endoskeletal type uses carved foam rubber over the supporting pylon and the entire
prosthesis is encased in a either a latex or fabric stocking.

Steps in the fabrication of a plastic prosthesis for a below-knee (trans-tibial) amputee:


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The stump must be washed daily to avoid irritations and infection. Mild soap
and warm water are recommended.
The interior of plastic sockets also must be kept clean by washing daily with
warm water and a mild soap. Use of detergents should be avoided at all times.
Some amputees have found a hair dryer to be useful in drying the stump and
preparing the socket for donning.
Prosthetic socks must be applied carefully to avoid wrinkles, and should be
replaced daily with newly laundered ones; more often in warm, humid weather.
They should be washed in warm water with a mild soap. Manufacturers
recommend that socks be rotated on at least a three- or four-day schedule to
allow the fibers to retain their original position.
Reductions in the size of the stump can be accommodated by adding one or
more prosthetic socks.
Prosthetic socks are woven especially for their intended use and are available
inthree thicknesses and a variety of sizes.
The thicknesses generally available are designated 3-ply, 5-ply, and 6-ply. With
this combination, various thicknesses can be obtained as follows:
One 3-ply = 3 plies
One 5-ply = 5 plies
Two 3-ply = 6 plies;
One 3-ply + one 5-ply = 8 plies
One 6-ply sock can be used instead of two 3-ply socks.
Some amputees have found that use of a one-ply cotton filler sock provides a
satisfactory way to obtain a still finer adjustment in thickness. If the amputee
has trouble in obtaining comfort by a combination of prosthetic socks, he
should consult his prosthetist immediately.
Frequent adjustments are often required in the first year. When the prosthesis
does not feel comfortable during standing and walking, it should be removed
and reapplied. If discomfort persists, the prosthetist should be consulted.