Traumatic transtibial amputation complicated by type 2 diabetes: Amputee Case Study

Original Editor ­ Dianne Vandepas

Title

Traumatic transtibial amputation complicated by type 2 diabetes

Abstract

66 year old female with underlying type two diabetes sustained traumatic right tibial/fibular # and subsequently transtibial amputation due to poor wound healing. Pt seen by physiotherapist in the acute post-surgical and pre-prosthetic phases in an acute inpatient setting. Patient initially the denial stage of grief and unwilling to participate in therapy but was able to progress to become a motived prosthetic candidate with successful discharge.

Key Words

amputation, diabetes, traumatic, acute, rehabilitation

Client Characteristics

  • Demographic Information: female, 66 years old, currently on disability for back surgery due to spinal stenosis
  • Medical Dx: open tibial/fibular fracture - Patient fell and sustained an open tibial/fibular compound fracture. Patient did not realize severity of injury due to drug use and decreased sensation in LEs and therefore only presented to the hospital three days after the fall. Patient underwent open reduction external fixation (ORIF). Wound was not closing and patient brought back to the operating room for an incision and drainage - intraoperative decision made by surgeon for transtibial amputation.
  • Co-morbidities: diabetes type 2, spinal stenosis, IV drug user, smoker

  • Previous care or treatment: none

Examination Findings

Subjective Ax: Patient lives in a house that has many steps with her boyfriend. Patient is an active IV drug user and likely going through detox. Patient in the denial state of grief during the initial assessment. Patient reporting that she wanted physiotherapist to leave so she could "go home and die".

PMHx: type two diabetes, spinal stenosis with surgical decompression 3 years ago, HTN, A fib, peripheral neuropathy in bilateral LEs


Patient's Goals: to return home and get back to "normal"

Physiotherapy Goals: Patient to be able to independently transfer with no gait aide from level surfaces. Patient to be able to self propel in a manual wheelchair.Patient to maintain full and pain free ROM. Patient to increase strength of UEs and LEs to 5/5 MMT.

Physical Performance Measures: Barthel Index of ADLs: 5/20
ICF:


  • BS&F:  Decreased strength of bilateral hip flexors to 3/5;Decreased hand dexterity bilaterally; Decreased sensation to intact limb; Hypersensitivity of stump;  Open wound on stump

  • AL:Inability to transfer independently; Inability to toilet independently; Inability to dress independently; Inability to self propel wheelchair; Inability to ambulate

  • PR:Unable to return to current home;Difficulty finding employment
  • EF: Home environment not wheelchair accessible; Fixed income (on disability); Main support circle contains IV drug users

  • PF: Currently in the denial stage of grief;IV drug user; Type 2 diabetes; Peripheral neuropathy; Left transtibial amputation

Clinical Hypothesis

66 y.o. Female admitted to the hospital due to fall and subsequent open tibial/fibular fracture. Patient underwent failed ORIF resulting in a left transtibial amputation.

At the time of initial assessment, patient is quiet and reclusive and providing vague answers. Patient is independent with bed mobility and requires moderate assistance of two people to transfer using a sliding board. Patient's main areas for improvement in the acute post-surgical and pre-prosthetic phase are mood and motivation, strengthening, transfer training, and independent wheelchair propulsion. Physiotherapy to address these issues by utilizing education, possible referral to social work/psychology, exercises, and transfer training.

Intervention

  • Education: Stump wrapping/compression socks.
  • Daily stump inspection

  • Desensitization: Touch with hands progressed to different textures Edema Management: Post-operative rigid dressing --> stump wrapping attempted but unsuccessful due to decreased dexterity. Compression socks utilized increasing wearing tolerance. Self massage techniques.
  • ROM/Positioning: Prone lying beginning with 3 minutes and slowly progressing to 30 minutes. When in supine no pillow under knees and no crossing legs in bed. Stump on leg board in w/c to prevent knee flexion contracture
  • Strengthening: Ankle pumps intact limb. Static quads progressed to weighted knee extension. Static hamstrings progressed to weighted knee flexion in prone. Prone lying hip extension progressed to weighted. Hip abduction progressed from supine to side lying and AROM to weighted. Hip adduction progressed from supine to side lying and AROM to weighted. Bridging with stability ball under stump. Hip flexion in supine progressed from AROM to weighted. Transversus abdominus activation. Shoulder press. Elbow flexion. Elbow extension progressed to chair pushups. Scapular retraction.
  • Early Mobility and Transfers: Bed mobility progressing from use of 1⁄2 bed rail and HOB elevated to flat bed with no rails. Sit to stands pulling at wall bar.
  • Transfer training from different surfaces: began using slide board but progressed to pivot transfer with assist as necessary. Wheelchair propulsion.
  • Respiratory: Deep Breathing and coughing

Outcome

At the time of discharge the patient was able to independently dress, toilet, bathe, transfer, and self propel a wheelchair. The patient met the requirements of the prosthetist for casting and was scheduled for a casting the following week.

The patient was scheduled to come in as an outpatient two times per week for one and a half hours each session to work on strengthening, gait training, and interaction with other amputees and various points along their rehabilitation path. The patient was not able to return back to her previous home due to inaccessibility but was being discharged to retirement home for respite stay while she was looking into finding an accessible apartment.

This patient had many obstacles to overcome with the combination of a traumatic amputation, spinal stenosis, and type 2 diabetes. As Fleury et al conclude in their review of the literature of rehabilitation in older amputees, it is easy to predict those who will be successful with their prosthetics but difficult to predict those people that will not use or predict how long one will use a prosthetic[1]. In this sense the only thing a physiotherapist can do is work to the best of their ability, with the most recent evidence based practice in mind, and attempt to empower the patient through education.

Discussion

The study by Stineman et al showed that acute post-operative inpatient rehabilitation both increased the likelihood of one year survival and discharge home[2] thus reinforcing the importance of the role that physiotherapists play in the acute post-operative stage. Management in this stage is often predictable as there are specific goals to attain in order to be appropriate for a prosthesis such as full ROM, functional strength, core stability, balance, independent transfers, etc[3]. In the treatment plan above it was chosen to not promote single leg stance or hopping for mobility with a walker or with crutches. This is because hopping shifts the patient's center of balance over their intact leg, which is detrimental to proper gait pattern when prosthesis is donned (advanced prosthetic centre rehab manual). Although an early walking aide would have been ideal, these are not available in this setting and mobility was therefore limited to the wheelchair. Overall, this patient was a success in the post-operative and pre-prosthetic rehabilitation phases. This patient was able to transition from requiring two people for all transfers to being independent with ADLs and ready for discharge and prosthetic fitting.

References

  1. Fleury AM, Salig SA, Peel NM. Rehabilitation of the older vascular amputee: a review of the literature. Geriatr Gerontol Int. 2013;13:264-273
  2. Stineman MG, Kwong PL, Xie D, et al. Prognostic differences for functional recovery after major lower limb amputation: effects of the timing and type of inpatient rehabilitation services in the veterans health administration. PM R. 2010;2(4)232-243
  3. Gaily RS, Clark CR. Physical therapy management of adult lower-limb amputees. Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. American Academy of Orthopedic Surgeons,1992