AMPUTATION

Amputation is the removal of a body extremity by trauma or surgery

Circulatory disorders
• Diabetic foot infection or gangrene (the most common reason for non-traumatic
amputation)

• Σεπ σ ι σ with peripheral necrosis

Neoplasm
• Cancerous bone or soft tissue tumors (e.g. osteosarcoma, osteochondroma,
fibrosarcoma, epithelioid sarcoma, ewing's sarcoma, synovial sarcoma,
sacrococcygeal teratoma)

Με λ α ν ο µ α

Trauma
Amputation
Classification and external
resources
ICD-10 T14.7
MeSH D000673

• Severe limb injuries in which the limb cannot be spared or attempts to spare the
limb have failed

• Τρα υ µ α τ ι χ amputation (Amputation occurs usually at scene of

accident, where the limb is partially or wholly severed). This would be the case of
a trapped limb with no other way to extract without harm to other parts of the
body.

• Amputation in utero (Amniotic band)

Deformities
• Deformities of digits and/or limbs

• Extra digits and/or limbs (e.g. polydactyly)

Infection
• Bone infection (osteomyelitis)

Other
• Sometimes professional athletes may choose to have a non-essential digit
amputated to relieve chronic pain and impaired performance. Australian Rules
footballer Daniel Chick elected to have his left ring finger amputated as chronic
pain and injury was limiting his performance.[6] Rugby union player Jone
Tawake also had a finger removed.[7] NFL safety Ronnie Lott had the tip of his
little finger removed after it was damaged in the 1985 NFL season.

Why do patients need to undergo amputations?

The vast majority of amputations are performed because the arteries of the legs
have become blocked due to hardening of the arteries (atherosclerosis). Blockages in
the arteries result in insufficient blood supply to the limb. Because diabetes can
cause hardening of the arteries, about 30-40% of amputations are performed in
patients with diabetes. Patients with diabetes can develop foot/toe ulceration and
about 7% of patients will have an active ulcer or a healed ulcer. Ulcers are recurrent
in many patients and approximately 5-15% of diabetic patients with ulcers will
ultimately require an amputation. Because hardening of the arteries occurs most
commonly in older men who smoke, the majority of amputations for vascular disease
occur in this group. Diabetes may be an important factor in nearly 40% of patients
undergoing major amputation (Moxey et al 2010).

When hardening of the arteries becomes so severe that gangrene develops or pain
becomes constant and severe, amputation may be the only option. If amputation is
not performed in these circumstances infection can develop and threaten the life of
the patient. Sometimes bypass surgery can be performed to avoid amputation, but
not all patients are suitable for bypass surgery. Before amputation, the limb can
cause serious problems with infection and pain and may even be a threat to the life
of some patients.

Less commonly serious accidents can lead to the loss of a limb, as can the
development of a tumour or cancer in a limb. These amputations tend to occur in
younger patients.

About 370 new referrals are made to the NZ artificial limb board annually of which
about 300 (70%) are due to vascular causes and diabetes. Over the period 2003-
2008 in the UK there were approximately 5 major amputations (above or below
knee) per 100,000 people (Moxey et al 2010

What are the risks of amputation surgery?

There are significant risks attached to undergoing an amputation if you are elderly
and have hardening of the arteries. In this group of patients the chances of dying in
hospital after a major amputation are somewhere between 10% and 20%. In other
words between 1 in 10 and 1 in 5 patients, undergoing a major amputation for
hardening of the arteries, will die in hospital. This is why amputation is always a last
resort and your surgeon will not advise you to undergo this operation unless it is
absolutely necessary. Remember these statistics also mean that 4 out of 5 patients
undergoing an amputation will do well.

If you are younger and healthy and undergo amputation because of an injury or a
tumour, the risks of an amputation are usually much less.

In a UK study examining amputations over the previous 5 years the overall chance of
dying from an above knee amputation was 21.4% and was 11.6% for a below knee
amputation (Moxey et al 2010). For minor amputations there was a 3.6% risk of
dying.

TALIPES

How is it diagnosed?
Talipes can be detected antenatally by ultrasound scan. If you don't have a scan during
pregnancy, then diagnosis will be made during your newborn's checks at birth.

How is it treated?
There are different approaches to treatment but all have the same focus: to try and stretch
out the child's foot so that it looks and functions normally. "The structures are contracted
and the child is effectively on his toes. Initial treatment is non-operative and involves
manipulation, splints and casts to encourage the foot to adopt the right position," says Mr
Paterson.

. Surgery

The posteromedial release surgery aims to loosen and lengthen tightened ligaments and
tendons in the medial and posterior parts of the feet. To hold the corrected position after
surgery, the feet are casted bi-weekly for six weeks and then splinted or braced for
another six weeks. Surgeons usually wait until the child is one year old, but some begin
operating when it is clear that non-surgical methods fail to correct talipes

OSTEOPOROSIS
Osteoporosis is a disease of bones that leads to an increased risk of fracture

Signs and symptoms

Osteoporosis itself has no specific symptoms; its main consequence is the increased risk
of bone fractures. Osteoporotic fractures are those that occur in situations where healthy
people would not normally break a bone; they are therefore regarded as fragility
fractures. Typical fragility fractures occur in the vertebral column, rib, hip and wrist.

Risk factors
Risk factors for osteoporotic fracture can be split between non-modifiable and
(potentially) modifiable. In addition, there are specific diseases and disorders in which
osteoporosis is a recognized complication. Medication use is theoretically modifiable,
although in many cases the use of medication that increases osteoporosis risk is
unavoidable.

Diagnosis
Multiple osteoporotic wedge fractures demonstrated on a lateral thoraco-lumbar spine
X-ray
A scanner used to measure bone density with Dual energy X-ray absorptiometry.
The diagnosis of osteoporosis can be made using conventional radiography and by
measuring the bone mineral density (BMD).[34] The most popular method of measuring
BMD is dual energy x-ray absorptiometry (DXA or DEXA). In addition to the detection
of abnormal BMD, the diagnosis of osteoporosis requires investigations into potentially
modifiable underlying causes; this may be done with blood tests. Depending on the
likelihood of an underlying problem, investigations for cancer with metastasis to the
bone, multiple myeloma, Cushing's disease and other above-mentioned causes may be
performed.

Medication
Just as for treatment, bisphosphonate can be used in cases of very high risk. Other
medicines prescribed for prevention of osteoporosis include raloxifene, a selective
estrogen receptor modulator (SERM).
Estrogen replacement therapy remains a good treatment for prevention of osteoporosis
but, at this time, is not recommended unless there are other indications for its use as well.
There is uncertainty and controversy about whether estrogen should be recommended in
women in the first decade after the menopause.
In hypogonadal men testosterone has been shown to give improvement in bone quantity
and quality, but, as of 2008, there are no studies of the effects on fractures or in men with
a normal testosterone level.

PAGET'S
Paget's disease is a chronic condition of bone characterized by disorder of the normal
bone remodeling process

What are Paget's disease symptoms?

Paget's disease commonly causes no symptoms and is often incidentally noted when X-
ray tests are obtained for other reasons. However, Paget's disease can cause bone pain,
deformity, fracture, and arthritis. The bone pain of Paget's disease is located in the
affected bone. The most common bones affected by Paget's disease include the spine, the
thigh bone (femur), the pelvis, the skull, the collarbone (clavicle), and the upper arm bone
(humerus).
The symptoms of Paget's disease depend on the bones affected and the severity of the
disease. Enlarged bones can pinch adjacent nerves, causing tingling and numbness.
Bowing of the legs can occur. Hip or knee involvement can lead to arthritis, limping, as
well as pain and stiffness of the hip or knee. Headache, loss of vision, and hearing loss
can occur when bones of the skull are affected. With very widespread Paget's disease, it
is possible to develop congestive heart failure due to an increased workload on the heart.

Diagnosis
Paget's disease may be diagnosed using one or more of the following tests:

• Pagetic bone has a characteristic appearance on X-rays. A skeletal survey is

therefore indicated.

• An elevated level of alkaline phosphatase in the blood in combination with

normal calcium, phosphate, and aminotransferase levels in an elderly patient are
suggestive of Paget's disease.

• Βον ε σ χ α ν σ are useful in determining the extent and activity of the

condition. If a bone scan suggests Paget's disease, the affected bone(s) should be
X-rayed to confirm the diagnosis
Medical therapy prior to surgery helps to decrease bleeding and other complications.
Patients who are having surgery should discuss treatment with their physician. There are
generally three major complications of Paget's disease for which surgery may be
recommended.

• Fractures — Surgery may allow fractures to heal in better position.

• Severe degenerative arthritis — If disability is severe and medication and physical

therapy are no longer helpful, joint replacement of the hips and knees may be
considered.

• Bone deformity — Cutting and realignment of pagetic bone (osteotomy) may help
painful weight bearing joints, especially the knees.
Complications resulting from enlargement of the skull or spine may injure the nervous
system. However, most neurologic symptoms, even those that are moderately severe, can
be treated with medication and do not require neurosurgery.

GOUT
Gout (also known as podagra when it involves the big toe[1]) is a medical condition
usually characterized by recurrent attacks of acute inflammatory arthritis—a red, tender,
hot, swollen joint
SIGN&SYMPTOMS
Gout can present in a number of ways, although the most usual is a recurrent attack of
acute inflammatory arthritis (a red, tender, hot, swollen joint).[2] The metatarsal-
phalangeal joint at the base of the big toe is affected most often, accounting for half of
cases.[3] Other joints, such as the heels, knees, wrists and fingers, may also be affected.
[3] Joint pain usually begins over 2–4 hours and during the night.[3] The reason for onset
at night is due to the lower body temperature then.[1] Other symptoms that may occur
along with the joint pain include fatigue and a high fever.[1]HYPERLINK \l "cite_note-
PM2010-2"[3]
Long-standing elevated uric acid levels (hyperuricemia) may result in other
symptomatology, including hard, painless deposits of uric acid crystals known as tophi.
Extensive tophi may lead to chronic arthritis due to bone erosion.[4] Elevated levels of
uric acid may also lead to crystals precipitating in the kidneys, resulting in stone
formation and subsequent urate nephropathy.[5]

Cause
Hyperuricemia is the underlying cause of gout. This can occur for a number of reasons,
including diet, genetic predisposition, or underexcretion of urate, the salts of uric acid.[2]
Renal underexcretion of uric acid is the primary cause of hyperuricemia in about 90% of
cases, while overproduction is the cause in less than 10%.[6] About 10% of people with
hyperuricemia develop gout at some point in their lifetimes.[7] The risk, however, varies
depending on the degree of hyperuricemia. When levels are between 415 and 530 μmol/L
(7 and 8.9 mg/dL), the risk is 0.5% per year, while in those with a level greater than 535
μmol/L (9 mg/dL), the risk is 4.5% per year

Medication
Diuretics have been associated with attacks of gout. However, a low dose of
hydrochlorothiazide does not seem to increase the risk.[15] Other medicines that have
been associated include niacin and aspirin (acetylsalicylic acid).[4] Cyclosporine is also
associated with gout, particularly when used in combination with hydrochlorothiazide,
[16] as are the immunosuppressive drugs ciclosporin and tacrolimus.[6

Diagnosis
Gout on X-ray of a left foot. Typical location at the big toe joint. Note also the soft
tissue swelling at the lateral border of the foot.
Gout may be diagnosed and treated without further investigations in someone with
hyperuricemia and the classic podagra. Synovial fluid analysis should be done, however,
if the diagnosis is in doubt.[1] X-rays, while useful for identifying chronic gout, have
little utility in acute attacks.[6]

Treatment
The initial aim of treatment is to settle the symptoms of an acute attack.[30] Repeated
attacks can be prevented by different drugs used to reduce the serum uric acid levels.[30]
Ice applied for 20 to 30 minutes several times a day decreases pain.[2]HYPERLINK \l
"cite_note-pmid11838852-30"[31] Options for acute treatment include nonsteroidal anti-
inflammatory drugs (NSAIDs), colchicine and steroids,[2] while options for prevention
include allopurinol, probenecid and febuxostat. Lowering uric acid levels can cure the
disease.[6] Treatment of comorbidities is also important
An orthopedic cast, body cast or surgical cast, is a shell, frequently made from plaster,
encasing a limb (or, in some cases, large portions of the body) to hold a broken bone (or
bones) in place until healing is confirmed. It is similar in function to a splint