Amputation

A brief introduction to Amputation...

1. AMPUTATION Ammarah Sabzwari

2. What is amputation? The removal of body extremity by trauma, prolonged constriction or intentional surgical removal of any body part or limb for the purpose to remove diseased tissue or relieve pain.

3. causes Circulatory Disorders Neoplasm Trauma Deformities Infections Athletic Performance Legal Punishment Snake bite

4. Types of Amputation Leg Amputation Arm Amputation Face Amputation Breast Amputation Genital Amputation Self Amputation

5. Principle of Amputation Open/Guillotine Amputation (wound open) Closed/Flap Amputation (wound close)

6. Open/guillotine amputation “An Amputation in which there is a direct cut instead of making flaps” It is done due to presence of infection and performed until the infection become clear and skin become healthy. Cross section of skin is left open for drainage and skin traction is applied to prevent retraction.

7. Closed/flap Amputation “An Amputation in which one or two broad flaps of muscular and cutaneous tissue are retained to form the cover over the end of the bone” It is done when there is no infection is present.

8. Levels of amputation Levels of Amputation depends on the following factors: Extend of disease Healing potential of stump Rehabilitation of the patience Levels of Amputation is divided on the basis of body region: Upper limb Amputation Lower limb Amputation

9. Upper limb amputation Trans- phalangeal or Finger Amputation Trans-carpal or Partial hand Amputation Wrist Disarticulation Trans-radial or below elbow(BE) Amputation Elbow Disarticulation Trans-humeral or above elbow(AE) Amputation Shoulder Disarticulation Inter-scapular thoracic: Removal of entire shoulder girdle

10. Lower limb amputation Hemipelvectomy: Removal of Leg, Hip and Pelvis Trans-femoral or Above Knee(AK) Amputation Knee Disarticulation Trans-tibial or Below Knee(BK) Amputation Symes: Amputation through Ankle Toe Amputation Trans-metatarsal Amputation

11. Cont…. LisFranc : Amputation of the metatarsals Chopart : Amputation of tarsals leaving Calcaneous and Talus. Prigoff : Amputation of foot, calcaneous are put in the end of tibia for weight.

12. Pre-operative psychological care of the patient Emotional Support and Encouragement Opportunity to express Occupational and social rehabilitation

13. Pre-operative assessment of limb Neurovascular and functional status of extremity Circulatory status and function of unaffected limb Signs and Symptoms of infection(culture required) Nutritional status Current medications

14. Surgical techniques for Amputation

15. Closed amputation techniques Closed amputation can be done by two ways. Myodesis Myoplasty Also called Fish Mouth Technique.

16. Myodesis myoplasty Suturing of muscle or tendon to the bone. Both flaps are equal in length. Both flaps are equal to 3/4 of the diameter of the limb. Scar is form at the end of the stump. Suturing of muscle to the periosteum or to the fascia of opposing musculature. Both flaps are unequal in length. Make the longer flap equal to the diameter of the limb, and the shorter one equal to half of its diameter. Scar is form at the anterior of the stump.

17. Trans-tibial amputation techniques Long posterior flap technique Skewed flap technique

18. Long posterior flap Tibia cut 10-15cm from knee joint line. Fibula cut 1-1.5cm shorter than tibia. Long posterior flap marked with length 5cm longer than the diameter of the calf at the cut end of the tibia.

19. Skewed flap Incision marks for skin flaps marked on skin, Anterior junction b/w the two flap is at least 2cm from tibia crest. Posterior junction 180˚ from anterior junction. Posterior flap of gastrocnemius is trimmed and fashioned to cover the distal end of tibia and fibula. Myoplasty of posterior flap to the periostium and deep fascia of the anterior tibia compartment Antero-medial and Postero -lateral fascio -cutaneous flaps are closed in an oblique fashion. Scar line runs from Antero-lateral to Postero -medial.

20. Post-operative care of the patient Heal the surgical wound Minimize pain Protect the amputated limb from trauma Preserve and improve the ROM and strength of the entire body Reduce swelling and begin shaping the amputated limb Enable the patient to learn to use appropriate mobility aids

21. Cont… Begin controlled weight bearing Accomplish functional activities Facilitate psychological adjustment to the lost limb

22. Stump management As soon as skin is healed bandage the stump For legs, sew two bandage of 15cm end to end For arms, sew two bandage of 10cm end to end Roll the bandage tightly, then wind it around the stump Apply more tension to the end of the stump, then to its base or it will become bulbous

23. Cont… Reapply the bandage several times a day until the prosthesis is fitted Don’t use the adhesive strapping it may tear the skin of the stump Remove-able rigid plastic dressing is used if the patient has needed immediate fitting of prosthesis

24. Stump washing Wash the stump at least once everyday. Wash the stump at night it will minimize swelling. Don’t let the stump soak in bath. Wet the skin thoroughly with warm water. Use mild fragrance-free soap or an antiseptic cleaner. Work up a foamy lather. Use more water for more suds.

25. Cont… Rinse with clean water, making sure all traces of soap are gone. A soapy film left on the skin may be an irritant. Dry a stump thoroughly and carefully. Use light dusting of an un-medicated talcum. Don’t use astringents.

26. Stump dressing All turns of the bandage are diagonal. Don’t use circular turns of the bandage because this will restrict the blood flow to stump and could cause pressure areas or other more serious problems. Pressure should graduate from very firm at the end of stump to moderate at the top of the bandaging. It is extremely important not to make bandage too tight at the top.

27. Cont… No skin should show on stump after it is bandaged except for the joints which should not usually be bandaged. This allows free movement of the joint. If the bandage become loose or too tight, take it off, re-roll the bandage and re-apply it before an artificial limb is fitted. This should be done at least 4 times every day and before retiring at night. Stump should be bandage for 24 hrs/day before the patient get his prosthesis.

28. Cont… Figure 8 ace bandage wrap : If the patient have an above knee amputation, the whole stump must be bandaged right up to the buttock crease. It is also necessary to pass some of the turns around the patient’s waist to act as an anchor.

29. Cont… Never bandage the stump so tightly as to be painful as this may cause pressure areas or restrict blood flow. The bandage should be applied with the limb straight. If the limb is bent when bandaged, contractures will form…!

30. shrinker “ In some cases Physiotherapist or Doctor may decide this instead of wearing bandages. All the time patient has to wear an elastic 2-way stretch compression stump shrinker . These shrinkers are shaped like a sock and pulled over stump. They are not as effected as bandaging but are much easier to use.”

31. Stump sock Wearing a sock can help to draw perspiration away from the skin. The stump sock need to be changed everyday and washed as soon as possible. Wash with mild soap and warm water. Rinse thoroughly.

32. Management Early Management includes: Pain Management Skin Disorders and their Management Psychological consequences of Amputation

33. Pain management

34. Post-amputation limb pain Post-amputation Limb pain is often the result of surgical trauma, wound healing complications, tissue loading effects, local scarring, and central neuropathic phenomenon.

35. Immediate Post-operative pain Direct result of the surgical trauma to bone, nerve, and soft tissue. It can be resolve within three weeks or less, as with pain following any major surgical procedure. It is sharp, localized to the surgical site, usually self limiting and resolves as the edema decreases and the surgical wound heals. Management Intravenous or epidural delivery of pain medication via patient controlled analgesia (PCA pump). Oral analgesic medication by post-operative day 3 or 4.

36. Extrinsic/intrinsic residual limb pain Extrinsic residual limb pain is usually mechanical in origin related to the prosthetic socket or other prosthetic components. Intrinsic residual limb pain is often due to Underlying disease process Surgical trauma Bone abnormality Local scar Neuroma Central neuropathic phenomenon

37. Underlying disease process Residual limb pain may result from infection, ischemia, tumour recurrence, joint dysfunction, or stress fractures. It is generalized limb pain and usually requires medical and surgical intervention.

38. Surgical trauma Intrinsic residual limb pain resulting from surgical trauma may be due to poor surgical technique such that the bone is improperly trimmed, wound dehiscence, as well as ischemia resulting in inadequate closure due to poor vascularisation of the muscles and skin.

39. Bone abnormalities Bony overgrowth at the distal end of the residual limb most often occurs in children and only occasionally in adults. This bony overgrowth often results in a bone spicules . Management Socket modifications to offload pressure over painful areas. Surgical intervention.

40. Local scar Entrapment of nerves in scar tissue occurs within the surgical incision at all levels. This pain is usually exacerbated with shear force or pressure directly to the healed scar tissue. Treatment Prosthetic modification. Injections, Medication intervention. Surgical intervention rarely provides adequate relief.

41. neuroma Neuromas at the surgical site are the most common etiology of intrinsic residual limb pain. Neuromas result of the normal nerve regrowth during the healing process. Treatment Non-steroidal anti-inflammatory drugs Tri-cyclic anti-depressants Anti- convulsants

42. Central pain Residual limb pain may also be the manifestation of autonomic nervous system abnormalities involving the sympathetic post-ganglion neurons after peripheral nerve injury. This manifestation is classified as Complex Regional Pain Syndrome (CRPS) or Causalgia .

43. Phantom limb pain The phantom limb is the perceived presence of the amputated body part.

44. Skin Disorders and their management

45. Skin problems of the amputee In working with numerous amputees over the years, specific information regarding the various clinical problems has been assembled and correlated in an effort to benefit the individual amputee. Stump and socket hygiene is important in relation to several clinical disorders of the skin, and accordingly, a specific hygienic program for care of the stump and socket has been developed.

46. Skin hygiene Poor hygiene may be an important factor in producing some pathologic conditions of the stump skin. If a routine cleansing program is not employed, bacterial and fungal infections, nonspecific eczematization , intertrigo , and persistence of infected epidermoid cysts can eventuate. Amputees should be advised in a program and asked to purchase a plastic squeeze container of a liquid detergent containing chlorhexidine gluconate , triclosan , or hexachlorophene. These are relatively inexpensive and available in drugstores throughout the world with and without a prescription.

47. Stump edema syndrome A transtibial amputee wearing a total-contact socket must adapt to the heat, rub, and perspiration generated within the socket. The amputee can expect mild edema and a reactive hyperemia or redness when first becoming accustomed to the prosthesis. These changes are the inevitable result of the altered conditions that are now forced on the skin and subcutaneous tissues of the stump.

48. Distal stump edema and hemorrhage in a transtibial amputee

49. Contact dermatitis An amputee can have an acute or chronic skin inflammatory reaction caused by contact with an irritant or allergenic substance. The irritant form of contact dermatitis is the most common and can result from contact of the skin with strong chemicals or other known irritants.

50. Contact dermatitis secondary to the use of a new plastic pad on the bottom of the socket

51. Non-specific eczematization Nonspecific eczematization of the stump has been seen in a variety of instances as an acute or chronic persistent, weeping, itching area of dermatitis over the distal portion of the stump.

52. Epidermoid cyst Epidermoid cyst is a benign cyst usually found on the skin. The cyst develop out of ecto -dermal tissue.

53. Bacterial and fungal infections Bacterial folliculitis and furuncles or boils are often encountered in amputees with hairy, oily skin, with the condition aggravated by sweating and rub from the socket wall. It is usually worse in the late spring and summer when increased warmth and moisture from perspiration promote maceration of the skin within the socket, which in turn favors invasion of the hair follicle by bacteria.

54. Superficial erosion / thickened lichenified skin

55. Other skin disorders Psoriasis Blisters Tumors Chronic ulcers

56. Psychological consequences of amputation

57. PTSD ( Post-Traumatic Stress Disorder) People who have had an amputation due to trauma (especially members of the armed forces injured while serving in Iraq or Afghanistan) have an increased risk of developing  Post-Traumatic Stress Disorder (PTSD) . PTSD is when a person experiences a number of unpleasant symptoms after a traumatic event, such as ‘reliving’ the event and feeling anxious all the time.

58. Psychological impact of amputation Loss of a limb can have a considerable psychological impact. Many people who have had an amputation report feeling emotions such as grief and bereavement, similar to experiencing the death of a loved one. Coming to terms with the psychological impact of an amputation is therefore often as important as coping with the physical demands.

59. Common negative emotions and thoughts experienced by people after an amputation include: Depression Anxiety Denial (refusing to accept they need to make changes, such as having physiotherapy, to adapt to life with an amputation) Grief (a profound sense of loss and bereavement) Feeling suicidal

60. prevention Talk to your care team about your thoughts and feelings, especially if you are feeling depressed or suicidal. You may require additional treatment, such as antidepressants or counselling , to improve your ability to cope with living with an amputation.

61. What is prosthesis? In medicine, a  prosthesis ,  prosthetic , or  prosthetic limb is an artificial device extension that replaces a missing body part. It is part of the field of bio- mechatronics , the science of using mechanical devices with human muscle, skeleton, and nervous systems to assist or enhance motor control lost by trauma, disease, or defect .

62. Types of prosthesis There are five generic types of prostheses: Post-operative Prostheses (within 24 hrs of amputation) Initial Prostheses (1 to 4 weeks after amputation) Preparatory Prostheses (First few months of patient’s rehabilitation) Definitive Prostheses (until the residual limb has stabilized) special-purpose prostheses

63. factors to be considered when a new prosthesis is prescribed There are many factors to be considered when a new prosthesis is prescribed, including : Weight bearing Suspension Activity level General prosthesis structure Components Expense Certain unique considerations.

64. PATIENT EVALUATION Physical examination should be very detailed and record such factors as adherent scar tissue and neuromas , ROM, edema, and muscular development. A careful personal history helps identify the likelihood of weight fluctuations as well as medical factors that may have a bearing on prosthetic fitting, such as previous fractures, any visual impairments, and the presence of concomitant disease including arthritis or diabetes.