Case Study of A Post-operative Transfemoral Amputee during the Pre-Prosthetic Phase of Rehabilitation: Amputee case Study

Title

Case Study of a Post-operative Transfemoral Amputee during the Pre-Prosthetic Phase of Rehabilitation 

Abstract

Left transfemoral amputee with left PCL tear, grade 3 lateral meniscus tear, grade 2 MCL & LCL, left rotator cuff tear and fracture left 4th and 5th digits on left hand. Patient presents with pain, inability to walk on level surface, up & down steps due to poor balance & weakness in both hands & right leg. Patient needs assistance to do hygienic needs & dress self. Physiotherapy included desensitization, strengthening, range of motion exercises, ambulating with an assistive device and pain management. Outcome is reduced pain, increase in strength & range of motion independent with walking aid.

Key Words

Amputation due to Trauma or Infection, Transfemoral Amputation, Diabetic, Desensitization

Client Characteristics

72 year old male farmer (animals and crops) with diagnoses of left above knee amputation, Right posterior cruciate ligament tear, grade 3lateral meniscus tear, grade 2 medial and lateral collateral ligament tear, left rotator cuff tear and fracture left 4th and 5th digits on left hand. Patient is hypertensive and diabetic greater than 10 years with a drug history of metformin and enalapril. Patient also has a history of haemorrhoids which was surgically removed in 2004.Patient was riding a bicycle when he was hit by a car December 28, 2015. Patient fell on left upper extremity X-rays showed left 4th & 5th digit fracture & fracture left femur, tibia, and foot. Patient was placed on traction but the left lower extremity became infected and a transfemoral amputation. POP was applied to his left hand & MRI done on his right knee showing PCL tear, grade 3 lateral meniscus tear, grade 2 MCL & LCL tear & on left shoulder rotator cuff tear Referred for physiotherapy in April 2015 for strengthening & pain management.

Examination Findings

Complaining of right knee pain at rest and on weight bearing as NRS 9/10, left shoulder and lateral thigh pain on NRS 5/10. Special tests done that were positive are drop arm, empty can for the left shoulder while valgus stress test, McMurray's test and Apley's test right knee. Posture of left hip is in flexion

ICF Findings[1]:

Body and Structure (Impairments) :

Musculoskeletal:

  • Decrease Range of Motion right knee flexion, shoulder flexion, abduction and external rotation and in left metacarpophalangeal and proximal interphalangeal joint flexion
  • Decrease muscle strength throughout all muscle groups for right lower extremity and for the left hip & shoulder all movements
  • fair bilateral grip strength
  • Scar on stump tender and adherent
  • Poor dynamic and static standing balance

Somatosensory:

  • Phantom pain and residual limb pain
  • Shoulder pain

Activity Limitations:

  • Impaired mobility
  • Toileting
  • Dressing
  • Ambulating on level surface up & down steps
  • Self -care
  • Hand and arm use
  • Preparation of meals
  • Transferring oneself

Participation Restrictions:

  • Inability to farm
  • Difficulty going to church

Environmental Factors:

  • Choice of walking aide as he is unable to use steps with walker but due to shoulder pain unable to use crutches
  • Health services available including physiotherapy but due to distance from home unable to attend as often as he would like to
  • Good family and church support
  • Patient has been creative in getting family member s to make and purchase exercise equipment for home use.

Clinical Hypothesis

The patient's main problems overall are shoulder pain, decreased range of motion, decreased muscle strength, decreased grip strength and difficulty ambulating with assistive device as a result of shoulder pain and decreased digit range of motion and grip strength. Physiotherapy management will therefore aim at achieving and maintaining painfree shoulder increase in range of motion, increase in grip strength and increase in muscle strength in upper and lower extremities so patient will be better able to complete activities of daily living such as hygienic needs and dressing self independently. Also patient will be able to ambulate with assistive device without pain and discomfort. Once these short term goals are achieved patient will be able to manage a prosthesis once the funds are available. Patient is compliant with home exercise program. He is self-motivated and has good church and family support. He seems emotionally well and always willing to participate in activities. He has a very good prognosis.

Intervention

  • Massaging the stump
  • Finger tapping
  • Desensitization with towel
  • Walker training
  • Transfer training from bed to chair/chair to bed
  • Heat therapy and transcutaneous electrical neuromuscular stimulation for shoulder pain management
  • Gripping exercises for both hands.
  • Passive stretch to right knee
  • Right lower extremity strengthening exercises which included, SLR, SLA, SLE, knee extension and flexion with weights, one-legged bridging, sit to stand. Left SLR, SLA, and SLE with weights
  • Encouraged to lie prone to prevent left hip flexion contracture.
  • Upper extremity strengthening exercises which includes Arm ergometry, shoulder pulley, shoulder wheel, wall climbing, left shoulder flexion, extension abduction, internal and external rotation, and elbow flexion and extension strengthening exercises with weights.

Outcome

So far the outcome is reduced frequency of phantom pain, increase in strength by a grade of 1 since initial assessment for all muscle groups. Patient now has functional range of motion for knee flexion and extension for right knee over a 2-3 month period. Decrease in left shoulder and right knee pain to minimal after 3 treatment sessions. Patient is ambulating with walker better each time especially as shoulder pain lessens and as strength in upper and lower extremity increases.

Discussion 

In this case patient's amputation was secondary to infection after a trauma. Patient had a compound open fracture (Type IIIB). Thus in order to save the patient's life a transfemoral amputation had to be done as days after the incident healing was failing as infection was developing. The wound was cultured and antibiotics given before amputated. This is good as several authors suggest that early amputation and prosthetic fitting are the preferred alternative to salvage of a questionably functional lower limb especially after a massive trauma. The patient views when discussing his condition with the surgeons was that even though it will be hard for him to live without the leg if losing it will save his life then he will take that option. He is very grateful since and is quite enthused about rehabilitation. He has a positive attitude and is progressing very quickly. Patient is uncertain if he will be able to afford prosthesis but is working to achieve functionality so that if he gets the funds he will get one and if not he will still be able to do as much as possible for himself. Outcome measures that can be further looked at includes Functional Independence Measure (FIM), Complete General Health Questionnaire and Prosthesis Evaluation Questionnaire (PEQ). Also stump bandaging can be added to patients' intervention to facilitate shaping of the stump. As said in Chapter 2B of Atlas of Limb Prosthesis 'Amputation should not be considered a failure but another therapeutic modality'[2]

[3]

References

  1. World Health Organisation; ICF Framework -Amputee
  2. Sanders. Roy, Helfet. David; Atlas of Limb Prosthetics: Surgical, Prosthetic and Rehab Principles- The Choice between Limb Salvage and Amputation: Trauma
  3. Bowler. J; Exercise for Amputees. The Choice between Limb Salvage and Amputation Infection.