The Diabetic BK Amputee: Amputee Case Study

Original Editor ­ Marika Warner

Title

The Diabetic BK Amputee

Abstract

This case presentation outlines the care, protocols, and special considerations used with a below-knee amputee in clinical practice. The clinical setting is Regent Park Community Health Centre. This is a multidisciplinary primary practice and health promotion facility in downtown Toronto. Residents of Regent Park include low-income populations, immigrants and refugees, non-status individuals, and the homeless. As such, clients of the health centre face significant health inequities and barriers to health access.

Key Words

below knee, diabetic, Canada, bulbous, diabetes, peripheral vascular disease

Client Characteristics

  1. Demographic information: retired male, age 64 years, resent non-status immigrant

  2. Medical diagnosis: diabetes mellitus (poorly controlled), diabetic gangrene
  3. Co-morbidities: anaemia, decreased hearing , cigarette smoker, daily alcohol drinker

  4. Previous care or treatment: left 4th toe amputation 2014, ongoing wound care, single point cane

Examination Findings

  • HPI: Short L BKA March 30 2015; home d/c April 4 2015. Using 2ww indoors w assistance from family.
  • Currently dependent on family for shopping, meal prep, & assistance w ADL (bathing, toileting, dressing).
  • Reports some phantom sensation. Denies residual limb pain but c/o some pain in sound limb w WB. Surgical incision healing well, f/u w surgeon scheduled. Skin of sound limb intact.
  • PMH: DM; PVD; L 4th toe amputation 2014; L transmetatarsal amputation February 2015; ischemic gangrene L foot March 2015; decreased hearing L ear.

  • SHx: Immigrated to Canada 2014. Retired. Lives in apt w wife, son, dtr, son-in-law & grandchild. Wife & son able to provide assistance. No hobbies/interests identified. Does not drive; son-in-law able to give rides, or family uses taxi. Currently using loaner w/c outside of apt.
  • Meds: Gabapentin, metformin, ramipril, Crestor, ferrous fumarate, tecta, ducosate sodium, ASA.
  • 
Self-Report Outcome Measures: Not used d/t significant language barrier.
  • Physical Performance Measures: 2MWT, TUG, Berg, AMP.
  • Subjective: Son present to interpret; client does not speak English. No barriers to access apt. Client is not left at home unattended.
  • Chief complaints: Reduced mobility (unable to ambulate independently); fatigue; decreased energy.

  • Current services: Family doctor and nurse at this centre.

  • Goals: Walk independently inside home, perform ADL (bath, toilet, basic meal prep) independently, transfer into and out of car independently.
Physical Examination

Clinical Hypothesis

64-year-old male 10 days post left short below knee amputation for diabetic gangrene demonstrates decreased muscle strength throughout residual limb, sound limb, and bilateral upper extremities, and decreased independent mobility. Poor management of residual limb has resulted in bulbous shape. Client would benefit from ongoing PT intervention to address strength, mobility, and phantom sensation; to provide education to client and family; and to manage residual limb in preparation for prosthesis. This PT will refer client to specialty amputee service for prosthetic rehabilitation when health insurance has been secured.

Intervention

  • Client & son instructed re: residual limb bandaging; wrapping supplies provided.
  • Education provided re: phantom sensation, positioning, residual limb massage & scar mobilization. Residual limb massage by PT.
  • Prone stretching of L hip flexors.
  • Gait training using 2ww. T/f training.
  • Bilat LE strengthening exercises including modified bridging, hip abd & add, prone hip ext, seated bilat hip abd, knee ext, supine SLR, R ankle DF; standing strengthening exercises in SLS on R w UE support.
  • Provision of home program w instruction sheets (strengthening exercises, stretches, stump massage, scar massage, wrapping).
  • Referrals made to 3 local prosthetic rehabilitation services. Discussed referrals and preferred rehab site with client & son.
  • Application made for Ontario Health Insurance Plan. Liaised with GP, RN & surgeon regarding rehab referrals.
  • Followed up with intake coordinator at various rehab services to arrange for client's admission and to update regarding status. Arranged for accessible public transportation service to access daily rehab appointments.
  • Client discharged from community PT services when accepted to rehab program and start date given.

Outcome

The client progressed well regarding lower extremity strength, and mobility. With treatment, the shape and stability of his residual limb also improved. By the time he was discharged to a rehab service, the limb was suitable for introduction of a prosthetic limb. Activity tolerance and standing balance also progressed well.

Discussion

In hindsight, upper extremity strengthening exercises would have been a valuable addition to this client's treatment program[1]. Specific upper extremity strengthening could have increased his ease of transfers and ambulation; improved his gait pattern with the two wheeled walker; improved safety by reducing risk of falls; and contributed to overall positive outcomes. However, in general the treatment provided prepared this client well for prosthetic use.

This patient is at increased risk of amputation of his remaining sound limb over the next 5-10 years [2][3]. Special care will need to be taken to protest and observe the right leg and foot to prevent any small wounds that could lead to gangrenous infection and eventually to an amputation [4]. Aggressive treatment must be put in place immediately if any wounds occur in the remaining limb[5]. Safety must be paramount in the ongoing care of this client as a fall could be devastating to his health status[1]. Steps should also be taken towards smoking cessation as this puts the client at increased risk of complications[2].

References

  1. 1.0 1.1 The Diabetic Amputee - http://www.physio-pedia.com/The_Diabetic_Amputee
  2. 2.0 2.1 Diabetic Amputation Rates in Canada: Not Good News, http://www.themayerinstitute.ca/diabetic-amputation-rates-in-can ada-not-good-news/
5. Izumi, Y., Satterfield, K., Lee, S. and Harkless, L., 2006, Risk of Reamputation in Diabetic Patients Stratified by Limb and Level of Amputation: 10-year observation, http://care.diabetesjournals.org/content/29/3/566.long
  3. Diabetes Care, March vol. 29 no. 3 566-570
6. Pecoraro RE, Reiber GE, Burgess EM., 1990, Pathways to diabetic limb amputation. Basis for prevention., Diabetes Care. 1990 May;13:513-21. - See more at: http://www.physio-pedia.com/The_Diabetic_Amputee#sthash.NfsK SqmB.dpuf
  4. Reducing the Risk of Complications - Diabetes, http://www.phac-aspc.gc.ca/cd-mc/diabetes- diabete/complications-eng.php
  5. Diabetes Mellitus - Ontario Wound Care, http://www.ontariowoundcare.com/diabetes.htm