Case study of Rehabilitation of High Above knee Amputation in young adolescent patient: Amputee Case Study

Title

Case study of Rehabilitation of High Above knee Amputation in young adolescent patient

Abstract

Case study of the rehabilitation of (Rt) high above knee amputation of a young adolescent patient following road traffic accident, because of short stump a double socket with TES belt is prescribed to increase the leverage and reduce the energy expenditure during ambulation along with multi axial knee joint with dynamic foot prosthesis is prescribed.

Key Words

High above knee, short stump, double socket, total contact, moderate pain in the stump.

Client Characteristics

Young Saudi male high school student of 18 years of age referred to our Physical medicine and rehabilitation center for prosthetic rehabilitation from the central hospital of our region with a diagnosis of right above knee amputation. High above knee amputation was done a month ago following a road traffic cacident, which lead to crushing injury to right lower limb.

There is no relevant past medical history, apparently young, healthy man on bilateral axillary crutches with present complains of moderate pain in the stump. During his hospital stay inpatient physiotherapy were given to him, which include stump positioning, education on stump care and ROM exercises and strengthening exercises were taught.

Examination Findings

  • Right above knee amputation following crush injury secondary to road traffic accident one month ago, complaining of moderate pain in the stump.
  • Presently using bilateral axillary crutch for mobility, very much interested to get an artificial limb as soon as possible, concern about his ability to drive the car again.
  • The Activities-specific Balance Confidence (ABC) Scale for him is around 80%
  • 
The most recent activity affected is driving the car and going to school, he is too shy and worried to attend the school in axillary crutches.
  • AMPUTEE MOBILITY PREDICTOR ASSESSMENT TOOL - AMPnoPRO Score=30/39, K4


Objective Assessment:

  • Mild redness at the end of the stump , short stump and cylindrical in shape. Stump length at the level of the greater trochanter.
  • Stump apparently looks in moderate flexion and abduction.

  • Tenderness over the stump end

  • Pain: Perception of pain in VAS scale 5/10
  • 
Range of motion: Right Hip: Full and terminally mild pain in extension and adduction

  • Muscle power: Right hip : Flexors:5/5 ,Extensors:4/5 , Abductors:5/5. Adductors=3/5

  • Gait:patient using bilateral axillary crutch using three point gait for his mobility and ADL.

Clinical Hypothesis

This amputee has short stump along with the physical problem includes overacting of hip flexors and abductors and weak Adductors. The environmental problem includes being a right-sided amputee limits his ability to drive the car and goes to school. Emotional problem, he is too shy to go to school using axillary crutches.

Intervention

Interdisciplinary meeting was held where the patient too was present and the findings were discussed and decided to give above knee prosthesis With the specification of Ischial weight bearing total contact double socket for energy conservation, multi axial knee joint and dynamic foot is prescribed as the patient being a young adolescent with good musculature around stump, the cast was taken on the same day.

Weekly 5 days patient attended physiotherapy department for 3 weeks the physiotherapy treatment includes:

  • 
Desensitization of stump end, which include massaging the stump, rubbing different fabrics at the stump.
  • Strengthening exercises to hip adductors extensors were done and stretching of the hip abductors and flexors were done for three weeks.
  • Patient educations were done regarding stump care, regular massaging of the stump and the positioning of the stump, instructed the patient to 15 mins prone lying, at least three times a day along with bandaging of the stump at the end of the session to keep the hip in neutral position were done.
 Counseling were done regarding his ability to drive car again as being a right above knee amputee he was given information regarding availability of modification of car accelerator system.

Outcome

  • At the end of the third week pain at the stump end was 2/10 on VAS.
  • Range of motion was full and pain free and Hip adductor strength was 3+/5 extensor were 5/5.
  • initial prosthesis was applied and checks were done while patient walked in the parallel bar initially with support and later on without support and he complained of mild pain at ischial area. Prosthesis removed and inspected the area no skin abrasion were found. Next day added soft lining on the socket brim and again took the trail this time patient had no pain in his ischial area.
  • Balancing exercises at parallel bar were taught with prosthesis and the patient was given final prosthesis last week.
  • Along with education on donning and doffing of prosthesis re emphasise on stump care.
  • Now the patient is able to walk with prosthesis on different terrain and able to perform ADL with out any degree of difficulty.

Discussion

Instead of conventional total contact socket, a total contact double socket were used for the prosthesis, as conventional total contact prosthesis has few disadvantages which includes:

  1. difficulty in wearing the socket in a sitting position
  2. difficulty in obtaining a favourable disposition of the stump soft tissues in the socket
  3. difficulty in avoiding stump perspiration problems
  4. difficulty in modifying the socket shape according to the changes of the stump circumference
  5. difficulty in obtaining a comfortable fit
  6. weight

To over come this problem double socket using laminated polypropylene sheet were used for this prosthesis. Because of the reduced weight and ease in handling the internal socket, donning is easy in a standing or sitting position. The wearer can easily insert his stump into the internal socket and then into the external socket in one pushing motion.

References

  1. http://www.healthcare.uiowa.edu/igec/falls-prevention-toolkit/01 - practice-fall-gait-assessment/assets/ABC-Scale.pdf  
  2. http://www.physio-pedia.com/images/f/fa/AmpNoPro.pdf
  3. https://members.physio-pedia.com/open-ebooks/gailey-amputee-balance/
  4. http://www.oandplibrary.org/alp/chap27-01.asp
  5. http://www.oandplibrary.org/poi/pdf/1981_03_129.pdf