AMPUTATION

DEF - surgical removal of a part or whole limb

INDICATIONS - traumatic conditions ,
vascular conditions , neoplastic
conditions ,infective conditions , congenital
conditions
 AMPUTATIONS
• TYPES OF AMPUTATIONS - closed
amputation - skin is closed after
amputation
• open amputation -skin is not closed after
amputation it is followed by other surgical
procedures like secondary closure , plastic
repair , revision of stump , reamputation
 AMPUTATION
• guillotine amputation - this is emergency
amputation done as life saving measure
• this is done in case of gross crush injury of
limb . gas gangrene
• the incision is circular around the limb at
the site of bone section and all tissues are
cut at same level and wound is left open to
provide free drinage
 AMPUTATION
• CLASSICAL AMPUTATION - these are
planned amputation where regular skin
flaps are raised and wound is closed after
removal of limb
• REVISION AMPUTATION - this is done as
second stage of guillotine amputation
• those with very unstisfactory stump
 AMPUTATIONS
• Levels of amputation - upper limb
• forequarter amputation
• shoulder disarticulation
• above elbow amputation
• elbow dis articulation
• below elbow amputation
• wrist disarticulation
 AMPUTATION
• Lower limb - hindquarter amputation
• hip disarticulation
• above knee amputation
• knee disarticlation
• below knee amputation
• symes amputation -
• amputation of foot through articulation of ankle
with removal of malleoli of tibia and fibula
• bone removed - talus, calcaneus ,
cniform ,cuboid , navicular , MT , phalanges
 AMPUTATION
• Bones retained - tibia , fibula , small
section of malleoli
• heal pad and sub cutaneous tissue are
sutured to distal end of tibia for wt bearing
• principals of amputation - tourniquet is
used unless there is arterial insufficiency
• skin flap are cut so that their combined
length equals 1.5 times the width of the
limb at the site of amputation
 AMPUTATION
• for below knee a long posterior flap is
used
• muscles are divided distal to proposed site
of bone section
• opposing group are sutured over the bone
end to each other and to periostium
• nerves are divided proximal to the bone
cut to ensure cut nerve end will not bear
weight
 AMPUTATION
• the bone is cut across the proposed level
• main vessles are tied , tourniquet is
removed and every bleeding point is
ligated
• skin is sutured
• suction drain is put
• figure of 8 bandage is applied to improve
its shape for limb fitting
 AMPUTATION
• complications of amputation -
• haematoma - causes -inadequate
haemostasis , loosening of suturs ,
inadequate wound drinage
• it result in delayed wound healing and
infection
• it should be aspirated and pressure
bandage is given
 AMPUTATION
• infection - causes - PVD , diabetes ,
haematoma
• wound should not be closed whenever
surgeon is in doute about vascularity of
muscle
• any discharge from wound should be
treated promptly with appropiate
antibiotics
 AMPUTATION
• NEUROMA - development of bulbous
swelling at cut nerve end
• it is tender and causes pain on weight
bearing
• pain is relived by local hydrocortiosone
injection , ultrasound therapy , TENS
 AMPUTATION
• PHANTOM LIMB - in this condition pt feels
that limb is still present and may feel pain
in some areas that dose not exist
• Rx - assurance , analgesics , stump
exercise , regularity in use of prosthesis
 AMPUTATION
• PTmanagment of amputations -
• assessment - general medical information
• cause of amputation
• associated disease , symptoms
(neurpathy,visual disturbance , cp
disease ,renal failure , congenital
anomalies )
 AMPUTATIONS
• current physiological state (post surgical
cp status , vital signs , duration of time out
of bed , pain )
• medications
• skin - scar (healed , adherent , flat )
• moisture (moist , dry , scaly )
• sensation( absent , diminished ,
hyperethesia )
 AMPUTATIONS
• grafts ( location , type , healing )
• dermatological lesions ( psoriasis ,
eczema ,)
•
• residual limb length - bone length
• below knee - measured from medial tibial
plateau
• above knee - measured from ischial
tuberosity or grater trochanter
• soft tissue length
• residual limb shape - cylindrical , conical ,
bulbous
• vascularity - pulse , colour , temp ,
edema ,pain , trophic changes
• ROM - goniometric measurement are
necessary for amputed side
• hip flexion , extension , abd , add are
measured in early post operative period
after below knee amputation
 AMPUTATION
• measurement of knee flexion and
extension are taken if dressing allows
• hip flexion and extension abd and add
maeasurements are taken several days
after surgery following above knee
amputation
 AMPUTATIONS
• muscle strength - gross MMT of upper
extremities and uninvolved lower extremity
is performed early in post operative period
• with below knee amputation good strength
in hip extensors and flexors is needed for
satisfactory prosthetic ambulation
• with above knee amputation uses hip
extensors and abductors to a great extent
strength of these muscles should be
monitored
 AMPUTATIONS
neurological assessment - pain ( phantom
pain , neuroma , incisional )
neuropaty
cognitive status
emotional status
 AMPUTATIONS
functional assessment - transfers (bed to
chair , to toilet , to car )
moblity
home/family situtation
ADL
circumferential measurement - it is taken as
soon as dressing allows
for below knee or symes measurement is
started at medial tibial plateau and taken
every 5 to 8 cm
 AMPUTATIONS
length is measured from medial tibial
plateau to end of the bone
circumferential measurement of above knee
is started from ischial tuberosity or greater
trochanter and taken every 8 to 10 cm
length is measured from ischial tuberosity
or greater trochanter to end of the bone
 AMPUTATIONS
• managment of amputation -
• residual limb care - pt should apply crape
bandage 24hrs a day except when bathing
• edema managment - application of crape
bandage
• elevation
• intrmittent compression unit
• encourage movements of stump
 AMPUTATIONS

• Proper hygiene and skin care - keep

stump clean and dry
• avoid abrasions , cuts , other skin
problems
• friction massage in which the layers of skin
sub cutaneous tissues , muscles are
moved over the underlying tissue this can
be used to prevent or moblize adherent
scar
 AMPUTATIONS

• massage is done gently after wound is

healed and no infection is present
• gentle friction massage to moblise scar
tissue helps to decrease hypesensitivity of
residual limb to touch and pressure
• positioning - it is a mojor goal of early post
operative program to prevent secondary
complications such as contractures of joint
 AMPUTATIONS
• contractures can develop as a result of
muscle imblance or fascia tightness
• in below knee amputation full ROM in the
hip and knee particulariy in extension is
needed while sitting the pt can keep the
knee extended by using posterior splint or
a board attached to wheel chair
• in above knee amputation pt needs full
ROM in hip particularly in extension and
abduction , prolong sitting is avoided
 AMPUTATIONS
• CONTRACTURES - mild contractures
respond to manual moblisation or active
exercise
• modrate to sever contractures are treated
by passive streatching , hold relax ,
resisted motion to antagonistic muscle
• most effecive way of reducing knee flexion
contracture is to fix pt with PTB
 AMPUTATIONS
• exercise - program is designed individually
and includes strengthening , balancing ,
coordination activites
• hip extension , abduction , knee
extension ,flexion power is important for
prosthetic ambulation
 AMPUTATION
• MOBLITY STAGE - it is a stage of
moblisation and restoration of functional
independance
• it starts with crutch walking
• normal pelvic alignment , reciprocal
movements of stump should be
maintained while walking
• elderly pt may require practic in parallel
bars
 AMPUTATIONS
• PROSTHEIC STAGE - parts of prosthesis
• socket - into which the stump fits
• suspension - to fix stump properly
• joint - to replace those ampuated
• prosthetic foot
 AMPUTATIONS
• above knee prosthesis -
• socket - it is a quadrilateral H type socket
in which most of body wt is transmitted
through ischial seat and posterior brim of
the socket
• suspension - it is a double swilvel pelvic
band with multi axial Jt providing all
movements at hip
 AMPUTATION
• knee mechanism - it is hand operated or
semi automatic locking mechanism
• foot - it is uniaxial or multi axial SACH foot
• below knee prosthesis - 2 types
• 1) conventional prosthesis with thigh
corset
• 2) petellar tendon bearing prosthesis
 AMPUTATIONS
• Conventional prosthesis with thigh corset
• it is preferred for Pt with unstable knee Jt
• flexion deformity
• very short stump , anasthetic stump ,
patellar malformation
• thigh corset - it is made of blocked leather
with steel uprights and front fastening
 AMPUTATIONS
• socket - it is a proximal wt bearing socket
made of metal , wood , moulded polyester
resin it extends 3 cm proximal to lower
pole of patella
• suspension - rigid pelvic band ,shoulder
strap , or waist belt suspension may be
used
• knee - uni axial knee jt
• feet - uni axial foot
 AMPUTATIONS
• patellar tendon bearing prosthesis -
• socket - soft inner socket with a hard
covering is set in slight flexion at knee to
ensure correct wt bearing
• major wt bearing is on the petellar tendon
area
• wt bearing areas - patellar tendon area,
medial flare of tibia and tibial condyles ,
lateral flare of tibia
 AMPUTATIONS
• wt relieving areas - distal end of tibia ,
crest of tibia , tibial tubercle , head of fibula
and medial and lateral insertion of
hamstrings
• suspension - elastic stocking suspension
and supra condylar cuff
• feet - uniaxial , multiaxial SACH foot
 AMPUTATIONS
• symes prosthesis -
• socket - there are 3 conventional socket
designs for symes
• posterior opening socket - it is cut down to
the level of malleoli and is constructed as
removable section that is held by veletrose
straps this is used for more bulbous
residual limb
 AMPUTATIONS
• medial opening socket - design has a window
cut to allow the malleoli to pass through
• stove pipe construction - it is the strongest
design with no flaps or window cut in the socket
instead a soft insert is built up into a tapered
cylinder to slide into the socket
• foot - because of limited space availible distally
foot section is limited for syme level amputation
2 most common designe are low profile dynamic
response foot , sach foot
 AMPUTATIONS
• SACH foot - solid ankle cushion heel
• it consist of wooden keel which terminates
at a point corresponding to MTP jt
• the rigid section is covered by rubber
• the posterior portion acts as a shock
absorber and permits plantar flexion in
early stance
 AMPUTATIONS
• upper limb prosthesis -
• fore quater amputation - here the
prosthesis mearly serves a cosmatic
purpose a sleeve fitter prosthesis with a
plastozoata cap padded inside with forarm
and retraining straps is used
• shoulder disarticulation -
• shoulder piece - extended cap to hold the
prosthesis
 AMPUTATIONS
• Elbow piece - it can be flexed by pulling on
flexion cord with the protractor of the
shoulder
• hand piece - either cosmatic or splint hook
type
• above elbow prosthesis - it is same as
shoulder disarticulation prosthesis except
the elbow flexion is more stronger due to
the action of the arm muscles along with
protractors of shoulder
 AMPUTATIONS
• below elbow prosthesis - here there is a
cup socket attached to the terminal device
through an operational cord the terminal
device can be activated through a loop
harness
• wrist disarticulation prosthesis - in this a
split socket forarm and wrist rotation
devices is provided a devise can be
provided to lock for supination and
pronation
 AMPUTATIONS
• MOBLITY PHASE -
• the prosthesis is applied and cheaked in
functional position
• pt standing in parallel bars with feet 2
inches apart is ideal position for cheaking
LL prosthesis
• upper extermity prosthesis is cheaked with
pt in sitting position
 AMPUTATIONS
• proper wt transfer on wt bearing areas
should be ascertained
• overall fitting of the socket is cheked , wt
bearing areas should not be bitting into the
flesh
• wt bearing should not cause discomfort on
terminal end of the stump
• corset should provide proper support
without discomfort on wt bearing
 AMPUTATION
• prosthetic jt should be cheked for axis , arc
,and movement with and without
prosthesis
• base - rocking mechanism SACH uniaxial
or biaxial foot of the brace should be
checked properly both with and without
prosthesis
 AMPUTATIONS
• length - accurate check of length is
necessary in lower extermity prosthesis it
is done by using the shortening blocks and
observing standing posture
• re- education with prosthesis -
• once fitting of prosthesis is done the
process of training and re-education of
amputee begins for functional use of
prosthesis
 AMPUTATIONS
• Correct method of application and removal
of prosthesis is taught
• early detection of any complications
arising due to prosthesis
• function of various components of
prosthesis and overall limitations on the
activites of prosthetic limb
• gait training in LLamputee and functional
training in ULamputee
 AMPUTATIONS
• guidance on proper maintence of
prosthesis
• gait training - training in parallel bars -
• standing balance with equal wt on both
legs
• correct method of wt transfer on individual
leg
• wt transfer on both legs alternately
 AMPUTATIONS
• pnf technique of resistive gait rhythmic
stablisation and approximation are
emphasised
• normal coordinated stepping in parallel
bars with bilateral hand support to be
initiated as early as possible
• progress to single hand support
• raising to standing from sitting and sitting
from standing
 AMPUTATIONS
• side walks and turning
• sitting , standing , negotiating slopes and
stairs , getting up from floor should be
taught
• once pt is proficient in parallel bars he is
made to walk on foot marks on floor in
front of mirror
 AM PUTATIONS

• RE-EDUCATION OF UPPER EXTERMITY

AMPUTEE -
• ABOVE ELBOW - moblity to be concentrated to
scapulohumeral and scapulothoracic motions
along with neck and trunk
• strength and endurance of flexors , extensors ,
and adductors of shoulder , powerful arm flexion
is needed for producing strong flexion at
prosthetic elbow while extension is neededfor
controlling the locking mechanism of prosthetic
elbow jt
 AMPUTATIONS
• Below elbow amputee - for FA and wrist
amputee the moblity of the shoulder girdle,
shoulder jt and elbow needs to be
improved but emphasis should be given to
FA
• prosthesis can not perform pronation and
supination it can have a device to lock the
FA in functional position
• strengthing exercise for shoulder complex
 AMPUTATIONS
• training of prosthetic controls - 4 controls
are necessary to operate UE prosthesis
• in the begining the pt is trained to perform
basic movements
• when proficiency is attained then
coordination of individual motions can be
taught for operation of prosthesis
 AMPUTATIONS
• below elbow elbow signal control system
• pt with FA amputation or wrist
disarticulation use below elbow signal
control system to operate the prosthesis
• 3) -above elbow duel control system - pt
with above or through elbow amputation
uses the duel control system
• here the arm flexion control motion is used
to teach prosthetic operation
 AMPUTATIONS
• with the prosthetic elbow unlock flexion at
the shoulder produces flexion at the elbow
of the prosthesis
• with prosthetic elbow locked flexion at the
shoulder operates the terminal device
• to begin with combined operation of elbow
flexion by flexing the shoulder and locking
the elbow by protraction of shoulder is
taught once amputee archived this he is
trained to operate the terminal device
 AMPUTATIONS
• above elbow triple control system -the
amputee is first trained to control elbow
flexion and elbow lock
• elbow flexion is produced by arm flexion
control motion , locking of the elbow is
archieved by arm extension control motion
operation of the terminal device is
achieved by controlled shruging motion on
the normal side
• general principals of amputation ---
• always use touniquet except in cases of
vascular disease
• mark the flap properly and then make skin
incision
• equal ant -post flaps are desirable
• aim at ideal stump
• skin division is farthest , followed by fascia
• muscle and bone each of them divided a
little more proximal to the preceding tissue
• proximal part of flap should contain full
thickness of tissue from skin to bone ,
where as the distal part of flap should
contain only fascia and skin to allow good
closure of wound
• do not strip the periosteum more than
required
• take care of sharp spikes of bone and
make them round
• nerves to be pulled a little and then divided
• major vessles are ligated
• always release tourniquet before closure
• close over a drain
• good stump bandage