The Young, Diabetic Amputee: Amputee Case Study

Title

The Young, Diabetic Amputee

Abstract

In Trinidad and Tobago, 60%- 70% of people with diabetes suffer from medium to severe forms of neuropathies and severe forms of diabetic neuropathies lead to limb amputation[1]. The majority of lower limb amputations done in this country are as a result of diabetic foot. The patient in this case was diagnosed at a young age and had a right transfemoral amputation.

Key Words

Transfemoral, diabetes, phantom limb sensation, complications due to diabetes.

Client Characteristics

History of Present Complaints: Patient presented with a right gangrenous foot, fever and nausea. Surgeons performed a transfemoral amputation. Post operatively, he developed septic shock and jaundice and remained intubated and ventilated in the ICU for 2 days. The stump was infected and patient was put on IV antibiotics. His physiotherapy treatment began day 2 post- op in the ICU and continued throughout his hospital stay.

Past Medical History:

  • Type II Diabetes
  • Left foot ulcers (treated conservatively but hyperpigmentation present on toes)
  • Diabetic neuropathy in finger tips and feet
  • Good exercise tolerance
  • Nil cardiovascular or renal issues
  • Nil previous limb weakness or joint issues
  • Nil allergies
  • Past Surgical History: Nil


Medication:

  • Insulin
  • Diamicron

Examination Findings

Subjective:

Patient had a Glasgow Coma Scale Score of 15/15.The stump was bandaged and swollen and held in abduction. Initially patient complained of stump pain, phantom limb sensation and numbness in left leg. Additionally he displayed weakness in bilateral upper limbs, weakness in right stump and had nil movement in his left leg. He was intubated and ventilated.

Objective:

  • Right hip was held in abduction.
  • Range of Motion for bilateral upper limbs was decreased and patient had grade 2/5 strength in all movements. He had no movement in his left lower limb
  • Right hip range of motion was decreased and grade 2/5 strength was noted for all movements.
  • The patient was unable to bridge, complete a straight leg raise on the left and hand function was fair. He was able to hold on to and lift objects but could not put objects to his mouth or on his head.
  • His bed mobility was poor and required maximum assistance when turning in bed.

ICF Findings:

  • Body Functions and Structures:,Musculoskeletal System- Weakness of limbs,decreased upper and lower limb range of motion and Phantom limb sensation
  • Activity Limitations: Phantom limb sensation,unable to ambulate, unable to complete activities of daily living,Participation Restrictions:Unable to work and drive.Positive personal factors- lives with family,Negative personal factors- Overweight,Type II diabetes
  • Positive environmental factors- flat house, negative factors uneven terrain.

Clinical Hypothesis

The patient's main problem was generalized muscle weakness. Due to sepsis, medication and immobilization during his ICU stay his muscle strength had decreased not only in the amputated limb but in all four limbs and his trunk. The weakness caused his decrease in range of motion and trunk control therefore, the patient was unable to turn and sit up in bed independently. Along with general weakness, the patient had swelling over the stump and phantom limb sensation.

Intervention

Treatment began in the ICU and at that time the patient was treated with deep breathing exercises, segmental breathing exercises and postural drainage. In terms of limb exercises he was given passive range of motion exercises for the left lower limb and right stump. Those exercises included hip flexion, abduction, adduction and extension. Left knee flexion and extension were done along with left ankle flexion, extension, inversion and eversion. Active assisted range of motion exercises were done for both shoulders, elbows, wrists and fingers. Tapping was applied over the stump for management of phantom limb sensation. The left leg was re-sensitized by stroking proximally to distally with cotton.

He became stronger during his stay in the High Dependency Unit so his exercises were progressed to include bridging, assisted pull up in bed, assisted supine to left and right side lying turning in bed. He was also assisted from supine to sitting over the edge of the bed with the left foot on the floor. Upper limb resisted exercises began using a 2lb weight.

The patient was transferred to a surgical ward and treatment progressed to resisted lower limb exercises with yellow Thera Band. Static sitting balance exercises began and were progressed to dynamic sitting balance exercises. He was taught to move from sitting to standing with the use of a walker. At this point static and dynamic standing balance exercises began. He was next taught to ambulate with the walker.

Outcome 

The patient was treated until he was discharged home. At that point he had no complaints of pain or phantom sensation. During his stay on the high dependency unit he attained grade 4/5 upper limb strength bilaterally and began feeding himself, tidying himself, donning and doffing his shirt and his own passive exercises to the right stump and left leg. When sent to the surgical ward he attained grade 4/5 lower limb strength. His exercise tolerance improved and his walking speed and walking distance were steadily improving.

At the time of discharge he was able to ambulate without any gait deviations with his walker to the bathroom, tidy himself, don and doff his clothes and feed himself independently.

Discussion

This patient was diagnosed at a young age with diabetes and his amputation was a result of complications due to diabetes. He had a history of peripheral vascular disease, diabetic neuropathy and left foot ulcers. The patient's medical history showed predisposing factors for amputation[2]. His surgical complications were also mainly due to diabetes. The incision site became infected within one week of surgery and this prolonged his hospital stay and slowed his healing rate[3]. His progress slowed during this time but improved when the infection was resolved.The goals for this patient were to resolve residual limb pain, phantom limb sensation, increase overall strength and return this patient to his previous level of independence. By discharge from hospital the patient was ambulant and independent with all activities of daily living. His rehabilitation must continue as an outpatient and will require intervention from an occupational therapist[4] to supplement the work of the physiotherapist in attaining the skills and office adjustments required to allow his return to work. Return to driving may not be possible until he has acquired a prosthetic limb.

References

  1. EPIDIMIOLOGY SITUATION IN TRINIDAD & TOBAGO The Diabetes Epidemic by K Nicholls
  2. Reiber, G. E., Vileikyte, L., Boyko, E.J., del Aguila, M., Smith, D.G. Lavery, L.A., Boulton, A.J. (1999). Causal Pathways for incident lower extremity ulcers in patients with diabetes from two settings. Diabetes Care 22: 157-162
  3. Coulston, J E, Tuff V, Twine C P, Chester J F, Eyers P S and Stewart A H R (2012) Surgical Factors in the Prevention of Infection Following Major Lower Limb Amputation. European Journal of Vascular and Endovascular Surgery, 43 (5), pp.556-560
  4. Burger, H. Marincek, C. (2007). Return to work after lower limb amputation. Disability & Rehabilitation, 29(17), 1323-1329