Amputations

Original Editor - The Open Physio project.

Top Contributors - Cornelia Barth, Laura Ritchie, Rachael Lowe, Saeed Dokhnan and Adam Vallely Farrell  

Introduction

Amputation is the removal of an extremity by trauma, prolonged constriction, medical illness or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventative surgery for such problems. A special case is that of congenital amputation, a congenital disorder, where fetal limbs have been cut off by constrictive bands. In some countries, amputation of the hands, feet or other body parts is, or was used as a form of punishment for people who committed crimes. Amputation has also been used as a tactic in war and acts of terrorism; it may also occur as a war injury.[1]

Causes of amputations 

Congenital 

  • Congenical limb deficiency [2]
  • Phocomelia: "a congenital deformity in which the limbs are extremely shortened so that the feet and hands arise close to the trunk"[3]

Acquired

  • Vascular
    • Ischaemia
    • Diabetes
    • Frostbite
    • Arterial insufficiency leading to death or decay of body tissue (gangrene)
    • Chronic leg ulcer leading to Septicaemia
  • Infection e.g. Bone infection (Osteomyelitis)
  • Malignant tumours e.g. sarcoma (cancer of the connective tissue)
  • Trauma (limb buried under / crushed by heavy object, limb damaged by car accident, stabbing, gunshot, animal bite etc.); in some cases leading to
    • Traumatic amputation: a physical (non-surgical) separation of the limb in the course of the traumatic event
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Levels of amputation

Transfemoral Amputation
Upper Limb
  • Forequarter
  • Shoulder Disarticulation (SD)
  • Transhumberal (Above Elbow AE)
  • Elbow Disarticulation (ED)
  • Transradial (Below Elbow BE)
  • Hand/ Wrist Disarticulation
  • Transcarpal (Partial Hand PH)

Lower Limb

  • Hemipelvectomy
  • Hip Disarticulation (HP)
  • Transfemoral TF (Above Knee AKA)
  • Knee Disarticulation (KD)
  • Transtibial TT (Below Knee BKA)
  • Ankle Disarticulation
  • Symes
  • Partial Foot PF (Chopart)
  • Toe amputation


Surgical procedures 

Initially, the arterial and venous supply are ligated to prevent hemorrhage (bleeding). The muscles are transected and the bone is sawed through with an oscillating saw. Sharp and rough edges of the bone are filed down, skin and muscle flaps are then transposed over the stump.

Distal stabilisation of the muscles is recommended, allowing for effective muscle contraction and reduced atrophy. This in turn allows for a greater functional use of the stump and maintains soft tissue coverage of the remnant bone. Muscles should be attached under similar tension to normal physiological conditions.

  • myodesis: the muscles and fascia are sutered directly to the distal residual bone for better prosthetic control
  • myoplastic: suture to opposite muscle in the residual limb to to each other and to the periosteum or to the distal end of the cut bone for weight bearing purposes

Ideal stump

  1. Skin flaps: skin should be mobile, sensation intact, no scars
  2. Muscles are divided 3 to 5 cm distal to the level of bone resection
  3. Nerves are gently pulled and cut cleanly, so that they retract well proximal to the bone level to reduce the complication of neuroma

Location of pulses

Femoral Triangle
  • Foot pulse (Medial malleolus or dorsum of the foot)
  • Popliteal (behind the knee)
  • Femoral (within the femoral triangle)
  • If a leg has been amputated because of gangrene, the remaining leg is examined for a puls


  



  

Special investigations

Doppler Ultrasound

  • X-rays
  • CT scan
  • Angiogram (outlines blood vessels)
  • Doppler ultrasound (occlusion of vessels)
  • Venogram and arteriogram
  • Radioactive dye injected into the blood

Arterial insufficiency

  • Surgery to improve circulation
  • Bypass grafts (autogenous graft uses a vein to bypass the obstructed area)
  • Synthetic grafts

Management

Please find below links to more detailed pages on the management of amputees

Buerger’s exercises

[4]
  • Stimulates collateral blood flow in the patient’s leg
  • It is performed for 20 min.
  • The leg is elevated until the toes go white, then lowered, then level
  • Repeat 2-3 times to improve collateral circulation

Connective tissue massage

Dynamic stump exercises

Balance and gait retraining

[5]

Short wave diathermy (SWD)

Through the pelvis to warm the arteries (contraindicated in patients with arterial insufficiency because the warmth leads to increased metabolism, causing a greater demand for nutrients, which are not available)

Post-operative care

  • Maintain function in the remaining leg and stump to maintain peripheral circulation
  • Maintain respiratory function (important with smokers and those patients under general anaesthesia)

Stump care

[6]
  • For hygiene and skin care see handout on amputations
  • A hip flexion Contracture may develop because of elevation to reduce swelling
  • Stump bandaging is done to ‘cone’ the stump, thereby preventing oedema, which occurs because there is no muscle pump and the stump hangs
  • Swelling must be prevented to allow proper attachment of the Prosthesis, and the prevention of Pressure sores
  • The stump sock is put on first, then the prosthesis
  • The prosthesis must be cleaned and maintained (Children who are still growing, grow out of their prostheses)

Mobility Aids

  • The choice of mobility aids depends on the level of fitness, strength, balance skills of the individual: 
    • Walking frame
    • Axillary crutches
    • Elbow crutches
    • Walking stick 
  • For bilateral lower limb amputees a wheelchair is often indicated (high energy expenditure during gait with prostheses)

Complications

Some of the most common complications associated with amputation include;

  • Oedema
  • Wounds and infection
  • Pain (Phantom limb)
  • Muscle weakness and contractures
  • Joint Instability
  • Autonomic dysfunction

See here, for more detailed information on post-operative complications following an amputation.

References

  1. Wikipedia. Amputation. http://en.wikipedia.org/w/index.php?title=Amputation (accessed 29 May 2014).
  2. Day HJB. The ISO/ISPO classification of congenital limb deficiency. Prosthetics and Orthotics International 1991; 15: 67-69.
  3. MedlinePlus. Medical Dictionary, phocomelia. http://www.merriam-webster.com/medlineplus/phocomelia (accessed 29 May 2014).
  4. ladybessviernes, UDM PT Students. Buerger Allen's Exercise. Available from: http://www.youtube.com/watch?v=jQUFmOmX35o [last accessed 01/12/12]
  5. Clegstories. Clegstories. Gait Training with C-Leg®: Sitting Down and Standing Up. Available from: http://www.youtube.com/watch?v=_lBkrLZ4PGo [last accessed 08/12/12]
  6. Richard Major. Physiotherapy Stump or Residual Limb Wrapping. Available from: http://www.youtube.com/watch?v=T1SA_6hzTxQ[last accessed 08/12/12]