Miss PM: Tansfemoral Amputation: Amputee Case Study

Title

Miss PM: Transfemoral Amputation

Abstract

This case study is about a young woman that lives in a township on the outskirts of the Cape Town Metropolitan. She had an Above-Knee Amputation in 2013 and received her prosthesis in January 2015. She was then admitted in July 2015 to the Western Cape Rehabilitation Centre in Cape Town, South Africa, during her mid-year school holiday, because she was still struggling to return to her previous level of function using the prosthesis.

Key Words

Transfemoral, Young, Active, Gait, Prosthesis, Community

Client Characteristics

19 Year old female who had a right Above Knee Amputation in 2013 due to Osteosarcoma. No previous medical history. She received initial physiotherapy intervention in the acute hospital setting and was discharged with 2 x elbow crutches, self exercises and an out-patient appointment. She does not have a good record of keeping her appointments but she did receive her prosthetic leg in January 2015. She was attending school again and living at home with her family. They live in an informal settlement called Zola. They have electricity in the house and running water available. She has to cook water in a kettle if she wants warm water to wash with. She is able to perform all her activities of daily living (wash, dress, etc.) independently. To wash, she uses a bucket that she carries in her arms while hopping back to bed from the tap. She is able to assist with domestic chores, but not to the same extend that she was before. She walks to the small shop just down the road from her house to buy some groceries.
She walks to school for an hour and her friends help her by carrying her bag. She enjoyed playing sports at school. These included women's rugby and soccer.


Client's goals:

  • To attend school.
  • Needs to walk 2 kilometers over uneven rough terrain while carrying a schoolbag.
  • To assist her family with domestic chores
  • Cooking, cleaning etc.
  • To participate in sports again

Examination Findings

Main complaints:

Feel pain under buttock when walking more than 300 meters.
The leg feels too long.
Self-reported outcome measure: Walks to train station (1.5 kilometres) in 1 hour; feels pain under buttock bone.

Mobility:

Currently walking with the prosthesis donned (Ischial containment Above Knee suction socket) using two crutches. Able to walk without crutches but then her gait pattern is poor and energy and time consuming.
Able to dress in standing, occasionally supporting with one hand.
Independent bed mobility and transfer to floor and back up.


Posture in standing:

Anterior: Decreased weight transference onto prosthesis. Prosthetic leg slightly externally rotated. Prosthetic knee fractionally higher than normal knee.
Lateral: Lordotic posture. Normal knee in hyperextension


Gait Analysis(no crutches):

Hip hitching, circumduction, poor weight transference onto prosthesis, abducted prosthesis, lateral trunk falling. Less than neutral hip extension.
Muscle length:Decreased hip extension- residual limb [iliopsoas/quadriceps shortening:Thomas Test (-20Ëš from neutral)].
Muscle strength: Weak gluteus maximus and medius(residual limb) and abdominal stabilisers
Skin: No hypersensitivity. Wound well healed and mobile scar.


Outcome measures:

Berg Balance Scale:49/56

Timed Get up and Go:15.3 seconds

6minute walk test:150meters

Dynamic Gait Scale: 21/26"

Clinical Hypothesis

Two issues needs to be addressed:
1. Pain/discomfort on Ischial Tuberosity(IT) when walking longer distances.
2. Poor gait pattern (abducted leg, poor weight-shift, trunk bending).


1. On closer inspection, it seems that the patient's prosthesis is donned incorrectly in a slightly more externally rotated position than it should be. This could be the reason for the discomfort on the IT. Another possibility is that the inadequate hip extension during gait due to muscle shortening of hip flexors is increasing lumbar lordosis through anterior pelvic tilt and causing sheer forces on the skin between the IT and the prosthetic containment part of the socket. A third possibility is that the prosthesis is too long or that the residual limb does not fit snugly all the way into the socket due to leg having increased in size (hypertrophy after increased activity of wearing prosthesis since January 2015 vs edema due to not bandaging and not wearing prosthesis because of pain/discomfort/too much effort)

2. The internal contributing factors could be hip abductor tightness of residual limb, hip adductor weakness, pain under the IT, increased residual limb size and thus not fitting well and fear or lack of confidence transferring weight onto the prosthesis.
|The external contributing factors could be that the prosthesis is too long, the prosthesis not donned correctly or the socket too small or the socket abducted in alignment.

Intervention

Goal setting was done by Interdisciplinary team with the patient.[1]
Social worker assessed client's psychosocial status and made sure that all the stages of grief has been completed.
Occupational therapist will focus on domestic and household tasks, such as cooking and doing the laundry. She will assist the client in contacting a university and researching career opportunities and learnerships.

Physiotherapy treatment focused on optimizing the patient's physical condition by

  • Improving strength of residual limb(especially hip ext. and add.), abdominals, upper limbs as well as the normal limb,
  • Improving range of hip flexors[2] and abductors of residual limb,
  • Improving dynamic standing balance,
  • Improving cardiovascular fitness and endurance,
  • Revise and ensure good bandaging technique to control residual limb size and
  • Decreasing fear and anxiety by safely approaching prosthetic gait rehab/starting with simple exercises in parallel bars[3] and then progress.Prosthetic gait rehabilitation focused even weight bearing and proper alignment, adequate transference of weight onto prosthesis during stance phase and maintaining an upright trunk, not allowing lateral falling. She must be able to perform all the following exercises without the use of crutches.


She was referred back to the prosthetist to:

  • Assess length and socket fit of prosthesis (too long/small?),
  • Check alignment of the socket (not in abduction),
  • Check pressure being exerted on IT's 

Outcome

She has an appointment with the prosthetist on 16 July 2015 from which I will then receive feedback.

  • She therefore still complains of discomfort under IT with increased distance.
  • Residual limb hip extension has improved to neutral in Thomas Test position.


She has progressed well through the different stages of gait rehab in a short time:

  • Improved weight transference onto prosthetic leg
  • Gait speed on even surface indoors: 1.1m/sec. over 20m distance
  • Able to climb stairs without holding on
  • Able to transfer to floor and get back up again with prosthesis on
  • Able to step around objects and change direction and walking speed
  • Able to walk outdoors over uneven, rough terrain, simulating that at home
  • She has to return to school on Monday and will be discharged this week after only 3 weeks of in-patient therapy.
  • Outcome measures: Berg Balance Scale: 54/56
  • Timed Get up and Go: 12.6 seconds
  • 6minute walk test: 247meters
  • Dynamic Gait Scale: 24/26

Discussion

The case of Miss PM was a challenging but enjoyable one. It illustrates that patients are still falling through cracks in our systems due to different reasons. In this case, a scholar who was unable to regularly keep to her appointments at health centres after she had been discharged because she lived far (30km) from the only centres where prosthetic screening and manufacturing could be done. This lead to her only receiving her prosthesis 2 years after her amputation. Furthermore, she was only admitted to our rehabilitation centre 5 months after she had received her prosthesis with several physical and prosthetic complications and a limited time (during school holiday-3 weeks) in which to solve them. She was educated, given exercises and obviously casted and fitted on these occasions, yet the problems of handling the rehabilitation of a person living in the townships outside of the districts covered by a specialised healthcare facility or centre as an out-patient are evident.

Good communication is necessary not only between team members but especially between the team and the patient. It is extremely important for the patient to understand what the rehab process entails and why it is important to follow up on appointments or for the patient to be honest and indicate whether she will be able to keep appointments and should then be referred out to a community healthcare centre until she can be admitted for in-patient rehabilitation.

References 

  1. Karner, M. 2014 http://www.socialworkhelper.com/2014/01/14/multidisciplinary-vs-interdisciplinary-teamwork-becoming-effective-practitioner/
  2. British Association of Chartered Physiotherapists in Amputee Rehabilitation(BACPAR). (2006) Clinical Guidelines for the Pre and Post Operative Physiotherapy Management of Adults with Lower Limb Amputation.
  3. Gailey R,S and Cutis R,C. Physical Therapy management of adult lower limb amputees. Atlas of limb Prosthetics; Surgical prosthetic and Rehabilitation Principles. Chapter 23. Abridged version. O and P Virtual Library.