Ammarah Sabzwari

The removal of body extremity by trauma,

prolonged constriction or intentional

surgical removal of any body part or limb

for the purpose to remove diseased tissue

or relieve pain.

• Circulatory Disorders

• Neoplasm

• Trauma

• Deformities

• Infections

• Athletic Performance

• Legal Punishment

• Snake bite

1. Leg Amputation

2. Arm Amputation

3. Face Amputation

4. Breast Amputation

5. Genital Amputation

6. Self Amputation

Open/Guillotine Amputation

(wound open)

Closed/Flap Amputation

(wound close)

“An Amputation in which there is a direct cut

instead of making flaps”

• It is done due to presence of infection and

performed until the infection become clear

and skin become healthy.

• Cross section of skin is left open for drainage

and skin traction is applied to prevent

retraction.

“An Amputation in which one or two broad

flaps of muscular and cutaneous tissue are

retained to form the cover over the end of

the bone”

• It is done when there is no infection is

present.

Levels of Amputation depends on the

following factors:

• Extend of disease

• Healing potential of stump

• Rehabilitation of the patience

Levels of Amputation is divided on the basis of

body region:

• Upper limb Amputation

• Lower limb Amputation

• Trans-phalangeal or Finger Amputation

• Trans-carpal or Partial hand Amputation

• Wrist Disarticulation

• Trans-radial or below elbow(BE) Amputation

• Elbow Disarticulation

• Trans-humeral or above elbow(AE)

Amputation

• Shoulder Disarticulation

• Inter-scapular thoracic:

Removal of entire shoulder girdle

• Hemipelvectomy:

Removal of Leg, Hip and Pelvis

• Trans-femoral or Above Knee(AK) Amputation

• Knee Disarticulation

• Trans-tibial or Below Knee(BK) Amputation

• Symes:

Amputation through Ankle

• Toe Amputation

• Trans-metatarsal Amputation

• LisFranc:

Amputation of the metatarsals

• Chopart:

Amputation of tarsals leaving

Calcaneous and Talus.

• Prigoff:

Amputation of foot, calcaneous are

put in the end of tibia for weight.

• Emotional Support and Encouragement

• Opportunity to express

• Occupational and social rehabilitation

• Neurovascular and functional status of

extremity

• Circulatory status and function of unaffected

limb

• Signs and Symptoms of infection(culture

required)

• Nutritional status

• Current medications

Closed amputation can be done by two ways.

1. Myodesis

2. Myoplasty

Also called Fish Mouth Technique.

Suturing of muscle or tendon to the bone.

Both flaps are equal in length.

Both flaps are equal to 3/4 of the diameter of the limb.

Scar is form at the end of the stump.

Suturing of muscle to the periosteum or to the fascia of opposing musculature.

Both flaps are unequal in length.

Make the longer flap equal to the diameter of the limb, and the shorter one equal to half of its diameter.

Scar is form at the anterior of the stump.

Long posterior flap technique

Skewed flap technique

Tibia cut 10-15cm from knee joint line.

Fibula cut 1-1.5cm shorter than tibia.

Long posterior flap marked with length 5cm

longer than the diameter of the calf at the

cut end of the tibia.

Incision marks for skin flaps marked on skin, Anterior junction b/w the two flap is at least 2cm from tibia crest.

Posterior junction 180˚ from anterior junction.

Posterior flap of gastrocnemius is trimmed and fashioned to cover the distal end of tibia and fibula.

Myoplasty of posterior flap to the periostium and deep fascia of the anterior tibia compartment

Antero-medial and Postero-lateral fascio-cutaneous flaps are closed in an oblique fashion.

Scar line runs from Antero-lateral to Postero-medial.

• Heal the surgical wound

• Minimize pain

• Protect the amputated limb from trauma

• Preserve and improve the ROM and strength

of the entire body

• Reduce swelling and begin shaping the

amputated limb

• Enable the patient to learn to use

appropriate mobility aids

• Begin controlled weight bearing

• Accomplish functional activities

• Facilitate psychological adjustment to the

lost limb

• As soon as skin is healed bandage the stump

• For legs, sew two bandage of 15cm end to

end

• For arms, sew two bandage of 10cm end to

end

• Roll the bandage tightly, then wind it around

the stump

• Apply more tension to the end of the stump,

then to its base or it will become bulbous

• Reapply the bandage several times a day

until the prosthesis is fitted

• Don’t use the adhesive strapping it may tear

the skin of the stump

• Remove-able rigid plastic dressing is used if

the patient has needed immediate fitting of

prosthesis

• Wash the stump at least once everyday.

• Wash the stump at night it will minimize

swelling.

• Don’t let the stump soak in bath.

• Wet the skin thoroughly with warm water.

• Use mild fragrance-free soap or an antiseptic

cleaner.

• Work up a foamy lather. Use more water for

more suds.

• Rinse with clean water, making sure all

traces of soap are gone. A soapy film left on

the skin may be an irritant.

• Dry a stump thoroughly and carefully.

• Use light dusting of an un-medicated talcum.

• Don’t use astringents.

1. All turns of the bandage are diagonal. Don’t

use circular turns of the bandage because

this will restrict the blood flow to stump

and could cause pressure areas or other

more serious problems.

2. Pressure should graduate from very firm at

the end of stump to moderate at the top of

the bandaging. It is extremely important

not to make bandage too tight at the top.

3. No skin should show on stump after it is

bandaged except for the joints which

should not usually be bandaged. This allows

free movement of the joint.

4. If the bandage become loose or too tight,

take it off, re-roll the bandage and re-

apply it before an artificial limb is fitted.

This should be done at least 4 times every

day and before retiring at night. Stump

should be bandage for 24 hrs/day before

the patient get his prosthesis.

5. Figure 8 ace bandage wrap: If the patient

have an above knee amputation, the whole

stump must be bandaged right up to the buttock

crease. It is also necessary to pass some of the

turns around the patient’s waist to act as an

anchor.

6. Never bandage the stump so tightly as to

be painful as this may cause pressure areas

or restrict blood flow.

7. The bandage should be applied with the

limb straight. If the limb is bent when

bandaged, contractures will form…!

“In some cases Physiotherapist or

Doctor may decide this instead of wearing

bandages. All the time patient has to wear an elastic 2-way stretch compression stump

shrinker. These shrinkers are shaped like a sock and pulled over stump. They are

not as effected as bandaging but are much

easier to use.”

• Wearing a sock can help to draw perspiration away from the skin.

• The stump sock need to be changed everyday and washed as soon as possible.

• Wash with mild soap and warm water.

• Rinse thoroughly.

Early Management includes:

Pain Management

Skin Disorders and their Management

Psychological consequences of Amputation

Post-amputation Limb pain is often the result

of surgical trauma, wound healing

complications, tissue loading effects, local

scarring, and central neuropathic

phenomenon.

Direct result of the surgical trauma to bone, nerve,

and soft tissue.

It can be resolve within three weeks or less, as

with pain following any major surgical procedure.

It is sharp, localized to the surgical site, usually

self limiting and resolves as the edema decreases

and the surgical wound heals.

Management

• Intravenous or epidural delivery of pain medication

via patient controlled analgesia (PCA pump).

• Oral analgesic medication by post-operative day 3

or 4.

Extrinsic residual limb pain is usually mechanical in origin related to the prosthetic socket or other prosthetic components.

Intrinsic residual limb pain is often due to• Underlying disease process

• Surgical trauma

• Bone abnormality

• Local scar

• Neuroma

• Central neuropathic phenomenon

Residual limb pain may result from infection,

ischemia, tumour recurrence, joint dysfunction,

or stress fractures.

It is generalized limb pain and usually requires

medical and surgical intervention.

Intrinsic residual limb pain resulting from

surgical trauma may be due to poor

surgical technique such that the bone is

improperly trimmed, wound dehiscence,

as well as ischemia resulting in

inadequate closure due to poor

vascularisation of the muscles and skin.

Bony overgrowth at the distal end of the

residual limb most often occurs in

children and only occasionally in adults.

This bony overgrowth often results in a

bone spicules.

Management

• Socket modifications to offload pressure over

painful areas.

• Surgical intervention.

Entrapment of nerves in scar tissueoccurs within the surgical incision atall levels.

This pain is usually exacerbated withshear force or pressure directly to thehealed scar tissue.

Treatment• Prosthetic modification.

• Injections, Medication intervention.

• Surgical intervention rarely provides adequate relief.

Neuromas at the surgical site are the most

common etiology of intrinsic residual limb pain.

Neuromas result of the normal nerve regrowth

during the healing process.

Treatment

• Non-steroidal anti-inflammatory drugs

• Tri-cyclic anti-depressants

• Anti-convulsants

Residual limb pain may also be the

manifestation of autonomic nervous

system abnormalities involving the

sympathetic post-ganglion neurons after

peripheral nerve injury.

This manifestation is classified as

Complex Regional Pain Syndrome (CRPS)

or Causalgia.

The phantom limb is the perceived

presence of the amputated body part.

In working with numerous amputees over

the years, specific information regarding

the various clinical problems has been

assembled and correlated in an effort to

benefit the individual amputee.

Stump and socket hygiene is important in

relation to several clinical disorders of

the skin, and accordingly, a specific

hygienic program for care of the stump

and socket has been developed.

Poor hygiene may be an important factor inproducing some pathologic conditions of thestump skin. If a routine cleansing program is notemployed, bacterial and fungal infections,nonspecific eczematization, intertrigo, andpersistence of infected epidermoid cysts caneventuate.

Amputees should be advised in a program andasked to purchase a plastic squeeze container ofa liquid detergent containing chlorhexidinegluconate, triclosan, or hexachlorophene. Theseare relatively inexpensive and available indrugstores throughout the world with andwithout a prescription.

A transtibial amputee wearing a total-contact socket must adapt to the heat,rub, and perspiration generated withinthe socket. The amputee can expect mildedema and a reactive hyperemia orredness when first becoming accustomedto the prosthesis.

These changes are the inevitable result ofthe altered conditions that are nowforced on the skin and subcutaneoustissues of the stump.

An amputee can have an acute or chronic

skin inflammatory reaction caused by

contact with an irritant or allergenic

substance.

The irritant form of contact dermatitis is

the most common and can result from

contact of the skin with strong chemicals

or other known irritants.

Nonspecific

eczematization of

the stump has been

seen in a variety of

instances as an

acute or chronic

persistent, weeping,

itching area of

dermatitis over the

distal portion of the

stump.

Epidermoid cyst is

a benign cyst

usually found on

the skin. The cyst

develop out of

ecto-dermal

tissue.

Bacterial folliculitis and furuncles or boilsare often encountered in amputees withhairy, oily skin, with the conditionaggravated by sweating and rub from thesocket wall.

It is usually worse in the late spring andsummer when increased warmth andmoisture from perspiration promotemaceration of the skin within the socket,which in turn favors invasion of the hairfollicle by bacteria.

Psoriasis

Blisters

Tumors

Chronic ulcers

People who have had an amputation due to

trauma (especially members of the armed

forces injured while serving in Iraq or

Afghanistan) have an increased risk of

developing Post-Traumatic Stress Disorder

(PTSD).

PTSD is when a person experiences a number of

unpleasant symptoms after a traumatic event,

such as ‘reliving’ the event and feeling anxious

all the time.

Loss of a limb can have a considerable

psychological impact. Many people who

have had an amputation report feeling

emotions such as grief and bereavement,

similar to experiencing the death of a

loved one.

Coming to terms with the psychological

impact of an amputation is therefore

often as important as coping with the

physical demands.

Depression

Anxiety

Denial (refusing to accept they need to

make changes, such as

having physiotherapy, to adapt to life

with an amputation)

Grief (a profound sense of loss and

bereavement)

Feeling suicidal

Talk to your care team about your thoughts

and feelings, especially if you are feeling

depressed or suicidal. You may require

additional treatment, such

as antidepressants or counselling, to

improve your ability to cope with living

with an amputation.

In medicine, a prosthesis, prosthetic,

or prosthetic limb is an artificial device

extension that replaces a missing body part.

It is part of the field of bio-mechatronics,

the science of using mechanical devices with

human muscle, skeleton, and nervous

systems to assist or enhance motor control

lost by trauma, disease, or defect.

There are five generic types of prostheses:

1. Post-operative Prostheses (within 24 hrs of

amputation)

2. Initial Prostheses (1 to 4 weeks after

amputation)

3. Preparatory Prostheses (First few months of

patient’s rehabilitation)

4. Definitive Prostheses (until the residual

limb has stabilized)

5. special-purpose prostheses

There are many factors to be considered when

a new prosthesis is prescribed, including :

Weight bearing

Suspension

Activity level

General prosthesis structure

Components

Expense

Certain unique considerations.

Physical examination should be very detailed

and record such factors as adherent scar

tissue and neuromas, ROM, edema, and

muscular development.

A careful personal history helps identify the

likelihood of weight fluctuations as well as

medical factors that may have a bearing on

prosthetic fitting, such as previous fractures,

any visual impairments, and the presence of

concomitant disease including arthritis or

diabetes.