Amputation of Amputation of extremitiesextremities

Definition Definition

Cutting of the extremity through the boneCutting of the extremity through the bone

While ………..While ……….. Cutting through the joint is disarticulationCutting through the joint is disarticulation

indications indications

Amputation can be regarded as a Amputation can be regarded as a treatment and not tragedytreatment and not tragedy

indications :-indications :-

3.3. Dead ( or dying ) limbDead ( or dying ) limb

4.4. Dangerous limbDangerous limb

5.5. Damn nuisance limb Damn nuisance limb

Dead or dying limb Dead or dying limb

1.1. Peripheral vascular disease ( 90% )Peripheral vascular disease ( 90% )

2.2. Sever traumatized limb Sever traumatized limb

3.3. Burns Burns

4.4. Frostbite Frostbite

Dangerous limbDangerous limb

2.2. Malignant tumors Malignant tumors

3.3. Lethal sepsisLethal sepsis

4.4. Crush injury leading to crush syndrome Crush injury leading to crush syndrome

Damn nuisance Damn nuisance

Remaining the limb is more worse than Remaining the limb is more worse than having no limb at all …. Because ofhaving no limb at all …. Because of :- :-

2.2. Pain Pain

3.3. Gross malformation Gross malformation

4.4. Recurrent sepsisRecurrent sepsis

5.5. Sever loss of function Sever loss of function

Varieties of amputationsVarieties of amputations

ProvisionalProvisional amputationamputation When primary healing is unlikely When primary healing is unlikely The limb amputate as distal as the causal The limb amputate as distal as the causal

factor will allow factor will allow Skin flap suture loosely over a pack Skin flap suture loosely over a pack Re-amputation perform when stump Re-amputation perform when stump

condition is favorable condition is favorable

Definitive end-bearingDefinitive end-bearing When weight is taken through the end of When weight is taken through the end of

the stumpthe stump The scar must not be terminal The scar must not be terminal Bone end must be solid (cut near the joint)Bone end must be solid (cut near the joint) Example through knee , syme’sExample through knee , syme’s

Definitive non-end-bearingDefinitive non-end-bearing Commonest variety Commonest variety All upper limb & most lower limb All upper limb & most lower limb

amputations are come under this typeamputations are come under this type The scar can be terminalThe scar can be terminal

Amputations Amputations at the sites of at the sites of election election

The The “ sites of election ”“ sites of election ” are are determined by :-determined by :-

3.3. the demand of the prosthetic design the demand of the prosthetic design

4.4. local function e.g bellow the most distal local function e.g bellow the most distal palpable arterial pulsation palpable arterial pulsation

Too short a stumpToo short a stump slips out slips out from the prosthesis from the prosthesis

Too long a stumpToo long a stump painful , painful , ulcerate , complicates the incorporation of ulcerate , complicates the incorporation of the joint in the prosthesis the joint in the prosthesis

Now a day the skill of prosthesis make Now a day the skill of prosthesis make amputation possible at any level amputation possible at any level

P r in c ip le s P r in c ip le s

o f o f

t e c h n iq u e t e c h n iq u e

Tourniquet is used unless there is Tourniquet is used unless there is vascular insufficiency vascular insufficiency

Skin flaps are cut so that there combined Skin flaps are cut so that there combined length equals one & half the width of the length equals one & half the width of the limb at the site of the amputationlimb at the site of the amputation

Equal flaps are for upper limb & trans-Equal flaps are for upper limb & trans-femoral amputations , long posterior femoral amputations , long posterior flap for bellow – knee flap for bellow – knee

Muscle cut at distal level from the level of Muscle cut at distal level from the level of the bone proposed the bone proposed

MyoplastyMyoplasty …. When the muscles …. When the muscles sutured together over the bone sutured together over the bone

A raw nerve end should not bear weight A raw nerve end should not bear weight

D i v i d e t h e D i v i d e t h e n e r v e n e r v e p r o x i ma l p r o x i ma l t o t h e t o t h e b o n e c u tb o n e c u t

Saw is used to make the bone ends Saw is used to make the bone ends smooth , and for beveling the tibia smooth , and for beveling the tibia interiorly interiorly

Fibula is cut 3 cm shorter Fibula is cut 3 cm shorter

Remove the tourniquet and stop bleeding Remove the tourniquet and stop bleeding

Suture the skin without tensionSuture the skin without tension

Apply suction drain Apply suction drain

Bandage the stump tightly Bandage the stump tightly

Aftercare Aftercare

Evacuate the hematoma as soon Evacuate the hematoma as soon Elastic bandaging the stump for shrinkage Elastic bandaging the stump for shrinkage Exercise the musclesExercise the muscles Keep joints mobileKeep joints mobile Advice using the prosthesis Advice using the prosthesis

A mp u t aA mp u t at i o n s t i o n s o t h e r o t h e r t h a n t h a n t h e t h e s i t e s s i t e s o f o f e l e c t ie l e c t io no n

upper limb amputations upper limb amputations

Interscapulo - thoracic Interscapulo - thoracic Disarticulation of the shoulder Disarticulation of the shoulder Transradial amputation Transradial amputation Amputations in the hand Amputations in the hand

Lower limb amputationsLower limb amputations

Hemipelvectomy Hemipelvectomy Disarticulation through the hip joint Disarticulation through the hip joint Transfemoral ( at least 12 cm )Transfemoral ( at least 12 cm ) Around the knee ( Stokes – Gritti )Around the knee ( Stokes – Gritti ) Through knee Through knee Transtibial ( 14 cm )Transtibial ( 14 cm ) Above the ankle ( Syme’s ) Above the ankle ( Syme’s ) Mid-tarsal joint ( chopart )Mid-tarsal joint ( chopart ) Tarsometatarsal joint ( lisfranc ) Tarsometatarsal joint ( lisfranc )

Complications Complications of the of the

amputation amputation stump stump

Stump is the terminal Stump is the terminal segment of the limb segment of the limb remaining after the remaining after the amputation amputation

Early complicationsEarly complications

1.1. Secondary hemorrhage Secondary hemorrhage

2.2. Breakdown of the skin flaps Breakdown of the skin flaps (may be due to ischemia or (may be due to ischemia or excessive suture tension )excessive suture tension )

3.3. Gas gangrene Gas gangrene

Late complicationsLate complications

Skin Skin eczema eczema purulent lumps purulent lumps fissuring & ulceration fissuring & ulceration infected epidermoid cyst infected epidermoid cyst Squamouse cell carcinoma Squamouse cell carcinoma Verrucous hyperplasiaVerrucous hyperplasia

MMuscleuscle .. If excessive muscle left , it will .. If excessive muscle left , it will produce unstable , loose cushionproduce unstable , loose cushion

ArteryArtery… poor vascularity gives … poor vascularity gives cold cold blue color stump blue color stump liable to ulcerateliable to ulcerate

Nerve Nerve .. Painful neuromas attached to the scar Painful neuromas attached to the scar

Phantom limbPhantom limb

A feeling that the amputated A feeling that the amputated limb still present limb still present

Its difficult to be treatedIts difficult to be treated

Joint Joint the joint above the site of amputation the joint above the site of amputation

may become stiff or deformed may become stiff or deformed Deformities are fixed flexion & fixed Deformities are fixed flexion & fixed

abduction in above knee ….. Fixed flexion abduction in above knee ….. Fixed flexion in bellow knee amputations . in bellow knee amputations .

Bones Bones terminal bone spur may cause pain & terminal bone spur may cause pain &

infection infection Stump bone fracture may result from Stump bone fracture may result from

sever osteoporosis sever osteoporosis

prosthesisprosthesis

Ideal prosthesis Ideal prosthesis

1.1. Fits comfortably Fits comfortably

2.2. Function well Function well

3.3. Looks presentableLooks presentable

4.4. Fit as soon after the operation Fit as soon after the operation

In the upper limb the distal portion is In the upper limb the distal portion is detachable & can be replaced detachable & can be replaced

In lower limb weight can be transmitted In lower limb weight can be transmitted through the greater trochanter , tibial through the greater trochanter , tibial tuberocity , patellar tendon , upper tibia or tuberocity , patellar tendon , upper tibia or soft tissues soft tissues

Electrically powered limb is present now Electrically powered limb is present now

Some real photos Some real photos of amputationof amputation

thanksthanks