Amputation.pptx is a presentation that describes the role of physiotherapy after amputation

Amputation in pediatric surgery and Physiotherapy

1. Amputation Alaa A. Moustafa Assistant professor of pediatric surgery Minia university hospitals

2. History Amputatio : latin noun from verb amputare Amputare : to cut off or cut away, derived from Amb , about and Putare , to prune or to lop The verb “ amputare ” was employed to cutting off the hands of criminals.

3. Definition Amputation is the removal of limb, part or total from the body. Disarticulation is removing the limb through a joint. Generally the amputation of lower limb are more common than those of upper limb.

4. Incidence Age : common in 50 – 70 year Gender : male – 75% Female – 25% Limbs : lower limbs 85% Upper limbs – 15%

5. Indications of amputation Trauma : RTA, gun shot Malignant tumors Nerve injuries & infection Extreme heat & cold – burn, gangrene Peripheral vascular insufficiency Congenital absence of limbs or malformation Severe infection

6. Causes of Amputation Natural causes Accidental causes Ritual, punitive & legal amputations Cold steel & gunshot causes

7. Natural causes of limb loss Congenital absence Arterial disease Frostbite Ergot and other toxins Wound infections Diabetes mellitus Dietary deficiencies Tumors

8. Accidents causes Falls when running or from heights Crushing by trees Savaging by crocodiles and sharks Effects of earthquakes, tsunamis and Violent storms

9. Ritual, Punitive & Legal Amputations Curing local pain In removing deformity Infection or gangrene In saving lives

10. Cold steel & Gunshot causes Iron & steel weapons evolved fingers & hands Destructive gunshot wounding, associated with mortal sepsis Boiling oil

11. Types of amputation Closed Amputation Open Amputation (Guillotine Operation)

12. Closed Amputation It is done as an elective procedure. After amputations, the soft tissues are closed primarily over the bony stump. E.G., Above knee, below knee etc.

13. Open Amputation (Guillotine Operation) It is done as an emergency procedure. E.G. Life threatening infections After amputations, the wound is left open & not closed. 2 types depending upon the skin flaps:  Open amputation with inverted skin flap  Circular open amputation

14. Principles of Close Amputation Tourniquets: desirable except in ischemic limbs. Level of amputation: it is very important to fit the prosthesis. Skin flaps : good skin coverage is important. Skin should be mobile & sensitive. Muscle: is divided at least 5cm distal to the level of intended bone section & sutured.

15. Principles of Close Amputation cont … Nerves: cut proximally & allowed to retract. Large nerves are ligated before division. Blood vessels: doubly ligated & cut. Then the tourniquet is released & hemostasis is completed. Bone: section above level of muscle section. Drains: removed after 48 – 72 hours.

16. Principles of Close Amputation cont … Compression dressing : either elastic or a rigid plaster dressing fitting immediately. Absolute bed rest with limb elevation : this is acceptable for the conventional prosthesis with adequate vascularity. Limb fitted: conventional prosthesis is fitted a minimum of 8 – 12 weeks after surgery. Rigid dressing with temporary pylon prosthesis maybe elected as an alternative.

17. Principle of open amputation Indication: Severe infection Severe crush injuries Types: Open amputation with inverted skin flaps: it is a common choice. Circular open amputation: wound is kept open & closed 2 ry by suture, skin graft or re-amputation.

18. Principle of open amputation cont … following amputation: Rigid dressing concept (pylon): POP cast is applied to the stump over the dressing after surgery. Soft dressing concept: the stump is dressed with the sterile dressing & elastocrepe bandage applied over it.

19. Complication of amputation Hematomas Infections Necrosis Contractures Neuromas Stump pain Phantom sensation Hyperesthesia of stump Stump edema Bone overgrowth Causalgia

20. Amputation - Complications Phantom Limbs : Some amputees experience the phenomenon of phantom limbs; they feel body parts that are no longer there. Limbs can itch, ache, & feel as if they are moving. Scientists believe it has to do with neural map that sends information to the brain about limbs regardless of their existence.

21. Amputation – Complications cont … In many cases, the phantom limb aids in adaptation to a prosthesis, as it permits the person to experience proprioception of the prosthetic limb.

22. Amputation – Complications cont … Painful adhesive scar formation An adherent painful scar over the surgical incision poses a problem in process of rehab. It may obstacle in fitting prosthesis. Early mobilization of the painful scar is recommended with other therapeutic Modalities

23. Amputation – Complications cont … Flexion deformity Deformity complicates the process of prosthetic fitting &Ambulation.

24. Hyperesthesia of the stump: This is another annoying symptom that is difficult to control. Re-amputation results only in reproducing the symptom at a higher level.

25. Principle consideration to amputate Preservation of life Improvement of general health Restoration of function Reduction of pain

26. WHAT’S AFTER ?

27. After an amputation, the patient must have the rehabilitation program and what can be achieved with cooperation explained. For the elderly the main aim is to achieve independence but for the young adult a high level of physical activity can be attained. Rehabilitation of lower limb amputations the rehabilitation program can be divided into:  The preoperative period.  The post–operative period: pre–prosthetic stage. prosthetic stage.

28. I- Preoperative period

29. If possible, the patient should be assessed and treated by the physiotherapist before surgery. The longer the preoperative treatment the greater its value. An assessment of the physical, social and psychological states of the patient should be made.

30. Physical assessment Assess the: Muscle strength of the upper limbs, trunk and lower limb apart from affected limb below the level of amputation. Joint mobility, particularly the joint proximal to the amputation level. Respiratory function. Balance reactions in sitting and standing. Functional abilities. - The examination findings should be recorded for comparison at a later date.

31. Social assessment The patient’s social circumstances should be noted: family and friend’s support, living accommodation, (stairs, ramps, rails, width of door, wheelchair accessibility) proximity of shops.

32. Psychological assessment Note the patient’s psychological approach to amputation and the motivation to walk.

33. Following assessment A treatment program should include: Breathing exercises to clear secretions in the lungs because many vascular patients are smokers. Strengthening exercises Mobilizing exercises for hip extension (and knee flexion and extension for bk level). Bed mobility : moving up and down the bed, rolling to prone and back to supine. Wheelchair mobility : the ability to stop, start, turn and control the wheelchair. The patient should have a wheelchair supplied preoperatively because it will be necessary for at least a few weeks post–operatively. Stabilizations for the trunk in sitting and standing.

34. II- Post–operative Period of Amputation

35. Preprosthetic stage The patient’s bed should have a firm mattress and be adjustable in height with a rope ladder of monkey pole and a cradle. Postoperatively the patient requires regular and adequate analgesics to combat pain which may arise from the wound site or the phantom of a limb. Uncontrolled pain may limit the rehabilitation program

36. Aims of treatment To prevent post–operative complications. To prevent deformities. To control stump edema. To maintain strength of whole body and increase strength of muscles controlling the stump. To maintain general mobility. To improve balance and transfers. To re–educate walking. To restore functional independence. To treat phantom pain.

37. Phantom pain There is pain or sensation in the stump or ‘phantom limb’ and its incidence is higher in patients with a severely painful limb preoperatively. It should be explained to the patient that it is due to memory of the amputated part in the cortex and nerve impulses still traveling through nerve fibers in the part, but the pain is only temporary and will gradually fade within a year. Persistent severe phantom pain may be helped by non–invasive treatment. The patient should be given adequate analgesic preoperatively and be encouraged to handle the stump postoperatively to reduce its sensitivity. A number of modalities can be tried such as transcutaneous nerve stimulation (TENS), interferential, acupuncture, ultrasound and percussion manually or electrically.