Amputation stump

Amputation Stump Care

1. Amputation stump

2. History Earliest recorded prosthetic limb dates back to 484 BC ,which was a wooden limb used by a persian soldier. The oldest limb which is preserved in a museum at Italy made of copper and wood dates back to 300 BC. Ambroise Pare(french) ,in 1529 described the techniques which were discovered by hippocrates .

3. Indications Trauma Ischemia Ablation of tumor Failed limb salvage procedures Chronic infections Diabetes,electric burns and frostbite.

4. Principles of amputation Adequate blood supply of flap to be maintained. Proper marking of skin inscion Tourniquet should not be used if amputation is done for vascular diseases. Proximal part of flap should contain muscles and distal to have only skin and deep fascia. Adequate flap length. Nerve to be pulled down and cut so that it can retract and avoid neuromas. Bone should not have sharp margins

5. Post operatively regular dressings to be done .after 3 months when scar has matured and stump has become supple proper prosthesis is fitted. Stumps can be side bearing(sutures on one side),conical(sutures on end) or cylindrical. Flaps should be left open if infected.

6. Properties of IDEAL STUMP Should heal adequately by first intention. Should have rounded ,gentle contour with adequate muscle padding Should have sufficient length to bear prosthesis -For B-K –7.5 to 12.5 from tibial tuberosity -For above and below elbow 20cm stump -For A-K 23cm from greater trochanter. Should have thin scar which does not interfere with prosthetic functions.

7. Should have adequate adjacent joint movement. Should have adequate blood supply Scar should be at place where it is not exposed to pressure. Scar should be freely mobile over underlying tissues Skin should not be infolded Redundant soft tissue should not be there. Stump should be free from tenderness

8. Elective sites of amputation TIBIA- 5 to 14 cm from tibial tuberosity,8cm from sole. FEMUR – 10 to 30 cm from greater trochanter,8 cm from knee joint. RADIUS/ULNA- 8 to 17 cm from olecranon , 8 cm above wrist joint HUMERUS – 13 to 20 cm from tip of acromian , 8 cm from elbow joint

9. flap length Skin inscions should be made along the limb axis and should not be short. When crossing flexion creases inscions shouls either be oblique or transverse to avoid future flexion contractures . Diagnostic modalities like arterial doppler studies and ankle brachial pressure index can be used. Subcutaneous fat to be removed uptill 2-3 cm of wound edges. Fascia can be widely excised and to prevent muscle herniation . Muscle viability is decided on contractibility more than on rate of bleeding. Coverage can be done by local flaps,free tissue transfer and split thickness skin graft. Some authors suggest thermography or laser doppler flowmetry as methods to check for flap perfusion.

10. 1. Upper extremity Above wrist - anterior and posterior flaps of equal lengths are used Below wrist – long anterior and short posterior flaps used with tough palmar skin over stump end. Hip Racquet inscion is used so scar is anterior and lateral away from fecal contamination and pressure area over ischial tuberosity. Thigh Equal flaps so that scar falls behind the bone or long anterior flap is used so that the scar will be well above the bone end. Distal end femur – long anterior and short posterior Below knee – in adequate circulation flaps of equal lengths — in ischemic extremity a more vascular posterior flap

11. How to prepare the stump Muscles – should be divided just distal to level of bone section with muscles retracting back to the saw line.Stablisation of stump by fixation of muscle to bone( myodesis ) or bringing the muscle over end of bone and fixing it to opposing muscles ( myoplasty ) under appropriate tention . Blood vessels- double ligation of major vessels and cautery of minor vessels and check for hemostasis after removal of tourniquet. Bone – comminuted devascularised bone to be removed.Periosteum cut at saw line.Bone is cut transversely except in end bearing amputations where it is cut parallel to the ground.Bone edges are rounded off with a file.Tibia in below knee to be rounded postereo medially .Bone dust irrigated out.

12. Nerves – During initial wound care both nerve and tendon length should be preserved as much as possible to allow for future reconstruction, ends to be tagged with non absorbable suture.During definitive surgery nerves are isolated pulled down gently , sectioned and allowed to retract above saw line.Large nerves to be ligated before division.

13. Open amputation stump Stump is left open , to prevent infection hence is indicated in infections and severe traumatic wounds. Done in two stages – First we remove the necrotic tissue and fashion a stump followed by second stage of secondary closure/ reamputation /revision or plastic repair.

14. Complications of stump 1. IMMIDIATE PROBLEMS Immediate post operative bleed Superficial infections- need debridement and antibiotics .Stitch abscess can develop about cotton or silk if wound sutured under tention , can also lead to a draining sinus.If the bone infection area is evident then a sequestrectomy is performed.In case of anaerobic infections where conservative management fails the area is opened and an open amputation is done at a higher level.

15. Ulceration- due to inaccurate skin approximation ,infection,hemmorhages,drain that has been left for too long and tight closure.Treated by elevation,rest and hot packs until infection is controlled and surrounding skin appears normal.Then scar is completely excised down to the base with exposure of normal appearing bleeding tissue. Stump length – A short limb is not effective as a lever in moving the prosthesis and frequently falls out of socket.Also prone to contractures.the stump in children should be kept long because growth lags behind in the amputated stump.Projecting bone and massive redundant muscle mass leads to abnormally shaped stump which is not suitable for prosthesis.

16. Inadequate circulation within stump leads to breakdown of tissue and infection. Stump pain most commonly caused by involvement of nerve trunks.neuromas should be avoided, if encountered should be excised.likewise a nerve incarcerated in scar tissueshould be cut,freed and allowed to retract. Phantom limb – Patients perceive a sensation as thought the lost portion of limb is still present which gradually disappear with time. Phantom pain – If the above condition become painfull and annoying.It might require use of analgesics.

17. Hyperasthesia of stump Stump edema – when prosthetic socket becomes ill fitting because stump has shrunk or patient has lost weight proximal tightness of socket develops and leads to terminal stump edema Blisters,swelling and pain due to pressure sores due to poorly fitted prosthesis. Bony overgrowth – The femur or tibial bone ends in children grows excessively during prosthesis usage and actually protudes through skin and might need resection later.Bone spurs can be formed due to retained tags of periosteum.

18. Late complications Prosthetic fit – As stump matures there is progressive decrease in soft tissue mass with resulting increasing bony prominence .The prosthesis becomes loose leading to pain and pressure changes.These can be overcome with increasing the number of stump socks but eventually a new socket is required. Dermatitis and skin problems – seborrheic dermatitis, folliculitis and painful nodular cysts in adductor region in above knee amputee due to pressure of socket brim are common.

19. Post surgical rehabilitation/stump care Primary goals are to control pain,edema,prevention of contractures,stump shaping and return to the optimum level of activity. COMPRESSION DRESSING- with elastic compression and rigid plaster to be used until maximum shrinkage of wound takes place. The amputee must be instructed not to lie on a overly soft matress and use a pillow under the limb. Transtibial amputee must not sit or lie with limb hanging from the bed and should sit on a wheelchair with knee extended on a padded board. Must lie prone for 15 minutes daily to avoid hip flexion contractures . Early mobilisation should be encouraged Standing on parallel bars and upper body exercises to be started as early as possible.

20. Sutures removed in 14 days,drain on day 2. Poorly applied bandage can cause circumferential constriction with distal edema resulting in a dumbbell-shaped stump. Elastic shrinkers are used these days for stump shrinkage with advantages of good skin tolerance,providing pressure gradient from distal to proximal end and easy application. The conventional prosthesis is fitted a minimum of 8-12 weeks after surgery.

21. Thank you