Amputation, health, healthcare, health promotion, rehabilitation, rehab, musculoskeletal physiotherapy, physiotherapy, physio, sports physiotherapy, para athlete, para athletes, amputee.

1. Dr. Mumux Mirani
M.P.T. Sports

2.  Amputation - Removal of the limb through a
part of the bone.
 Or all of a limb
 Or some other outgrowth of the body.
 Disarticulation – removal of the limb through
the joint.

3.  Lower limb Amputation are more common than upper
limb amputation.
But,
 Upper limb amputation causes greater functional loss
because it is used more commonly.

5. Amputation → considered to be a
treatment of last resort when other methods like,
revascularization or reattachment have failed or
not suitable.

6.  Age – common in 50 to 70 years of age.
 Sex – 75% men, 25 % women
 Limbs – 85% through lower limbs, 15% through upper
limb.

7.  TRAUMA:
◦ Compound fracture
◦ Blood vessel rupture
◦ Stab / Gunshot injuries
◦ Compression injuries
◦ Severe burns
◦ Cold injuries

8. When trauma is the cause the aim of
the amputation is to restore maximum length
with good soft tissue covering.

9. ◦ VASCULAR DISEASE: When it is associated with
smoking.
 Diabetes
 Atherosclerosis
 Buerger’s disease.
◦ INFECTIONS
◦ TUMORS

10.  NEUROLOGICAL DISORDERS
◦ Anesthetic limb
◦ Eg. Complete plexus avulsion.

11.  CONGENITAL DEFORMITY:
◦ Partial / Full absence of limb
◦ Amputation for cosmetic reason.
 Eg. Extra digit.

15. 1. PARTIAL TOE:
1. Excision of any of one or more toes.

16. 2. TOE DISARTICULATION:
Disarticulation at the metatarsal phalangeal
joint.

17.  3. PARTIAL FOOT / RAY RESECTION:
 Resection of the 3rd, 4th, 5th metatarsals and digits.

18.  4. TRANSMETATARSAL.:
◦ Amputation through the midsection of all metatarsals.

19.  5. SYME’S
AMPUTATION:
 Ankle disarticulation
with attachment of
heel pad to distal end
of tibia.
 May include removal
of malleoli and distal
tibial/fibular flares.

20.  6. LONG TRANSTIBIAL [BELOW KNEE]
 More than 50% tibial length.
 7. TRANSTIBIAL [BELOW KNEE]:
 Between 20 and 50% of tibial length.
 8. SHORT TRANSTIBIAL:
◦ Less than 20% tibial length.

22.  9. KNEE DISARTICULATION:
 Amputation through the knee joint, femur intact.

23.  10. LONG TRANSFEMORAL
[ABOVE KNEE]:
 More than 60% femoral
length.

24.  11. TRANSFEMORL [ABOVE KNEE]:
 Between 35 and 60% femoral length.
 12. SHORT TRANSFEMORAL [ABOVE KNEE]:
 Less than 35% femoral length.

25.  13. HIP DISARTICULATION:
◦ Amputation through hip joint, pelvis intact.

26.  14. HEMIPELVECTOMY:
 Resection of lower half of the pelvis.

27.  15. HEMICORPORECTOMY:
 Amputation both lower limbs and pelvis below
L4-L5 level.

28.  Type of surgery depends upon the status of extremity at
the time of amputation.
 The surgeon must remove the part of the limb that must
be eliminated, allow for primary or secondary wound
healing.
 Construct the residual limb for optimal prosthetic fitting
and function.

29.  Conservation of residual limb length and uncomplicated
wound healing.
 Skin flaps are as broad as possible.
 Scar should be pliable, painless and non adherent.
 For transfemoral and transtibial amputation, equal
length anterior and posterior flaps are used, placing the
scar at the end of the bone.

30.  Long posterior flaps are often used in dysvascular
transtibial amputation because the posterior tissue have
a better blood supply than anterior skin.
 Care must be taken to ensure that the scar does not
become adherent to the bone.

31.  The skew flaps is an angular medial- lateral incision
that places the scar away from bony prominences, a
problem with the long posterior flaps.
 Stabilization of major muscles allows for maximum
retention of function.
 Muscle stabilization may be achieved by myofascial
closure, myoplasty, myodesis or tenodesis.

32.  In most transtibial and transfemoral amputation, a
combination of myoplasty [muscle to muscle closure]
and myofascial closure is used to ensure that the
muscles are properly stabilized and do not slide over the
end of the bone.
 Myodesis [muscle attached to periosteum or bone] is
employed particularly in transtibial amputations.

33.  Tenodesis [tendon attached to bone] may be used for
muscle stabilization.
 Severe peripheral nerves from neuromas [collection of
nerve bundles] in the residual limb.
 The neuroma must be well surrounded by soft tissue so
as not cause pain and interfere with prosthetic wear.

34.  Neuromas that form close to scar tissue or bone
generally cause pain and may require later resection or
revision.
 Hemostasis is achieved by ligating major veins and
arteries.
 Care must be taken not to compromise circulation to
distal tissues, particularly the skin flaps.

35.  Bones are sectioned at a length to allow wound closure
without excessive redundant tissue at the end of the
residual limb without placing incision under great
tension..
 Sharp bone are smoothed and rounded; in transtibial
amputation, the anterior portion of the distal tibia is
beveled to reduce the pressure between the end of the
bone and the prosthetic socket.

36.  Tissue layers are approximated under normal
physiological tension and incision is closed.
 In traumatic amputation, the surgeon attempts to save as
much bone length and viable skin as possible and
preserve proximal joints while providing for appropriate
healing of tissue without secondary complications such
as infection.

37.  In potentially “dirty” [involving foreign body]
amputations, the incision may be left open with the
proximal joint immobilized in a functional position for
5 to 9 days to prevent invasive infections.
 Secondary closure also allows the surgeon to shape the
residual limb appropriately for prosthetic rehabilitation.

38.  Infection : internal or external sources.
 Individual with contaminated wounds from injury,
infected foot ulcer or other causes are at greater risk of
infection.
 Smoking is a major deterrent to wound healing.
 Severity of the vascular problems
 Diabetes

39.  Renal disease
 Other physiological problems such as cardiac disease.

40.  It mainly includes,
 Post surgical cardiopulmonary and general
physiological function
 Ability to be mobile
 The condition of the remaining LE.
 Her feeling about the amputation

41.  Patient demographics
 Family and social data
 Preamputation status
 Work
 Activity level
 Independence
 Financial status

42.  Causes of amputation
◦ Disease
◦ Tumor
◦ Trauma
◦ Congenital

43.  Associated disease or symptoms:
◦ Neuropathy
◦ Visual disturbance
◦ Cardiopulmonary disease
◦ Renal failure
◦ Congenital anomalies.

44.  Skin examination:
◦ Scar [healed, adherent, invaginated , flat]
◦ Other lesions [size, shape, open, scar tissue]
◦ Moisture [moist, dry, scaly]
◦ Sensation [absent, diminished, hyperesthesia]
◦ Graft [location, type and healing]
◦ Dermatological lesions [psoriasis, eczema, cysts]

45.  Residual limb length:
◦ Bone length
 Transtibial limbs measured from medial tibial
plateau
 Transfemoral limbs measured from ischial
tuberosity or greater trochanter.

46.  Residual limb shape:
◦ Cylindrical
◦ Conical
◦ Bulbous end
 Abnormalities :
◦ Dog ear
◦ Adductor roll

48.  Emotional status:
 Acceptance
 Body images

49.  Vascularity : [both limb if amputation cause is
vascularity]
◦ Pulses
 Femoral
 Popliteal
 Dorsalis pedis
 Posterior tibial

50. ◦ Color : red or cyanotic
◦ Temperature
◦ Edema
 Circumference measurement
 Water displacement

51. ◦ Pain
 Type
 Location
 Duration
 Intensity
◦ Trophic changes

52.  Range of Motion:
◦ Residual limb [Specific for remaining joints]
◦ Other lower extremity [gross for major joints]

53.  Muscle Strength:
◦ Residual limb [specific for major muscle group]
◦ Other extremities [gross for necessary function]

54.  Neurological:
 Pain
 Phantom pain
 Differentiate between sensation or pain
 Neuroma
 Incisional
 From other causes

55.  Functional Patient:
 Transfers [bed to chair, to toilet, to car]
 Mobility [necessary support, supervision]
 Home/ family situation, supervision, caregiver
 Activities of daily living [bathing , dressing]
 Instrumental activities of daily living [cooking,
cleaning]

56.  Circumference measurement of the residual limb are
taken as soon as the dressing will allow.
 Circumference measurement of the transtibial or symes
residual limb are started at the medial tibial plateau and
taken every 5 to 8 cm depending on the length of the
limb.

57.  Length of the residual limb is measured from the medial
tibial plateau to the end of the bone.
 For transfemoral circumference taken from the ischial
tuberosity or greater trochanter and taken every 8 to 10
cm.
 Length is measured from the ischial tuberosity or the
greater trochanter to the end of the bone.

58.  Phantom is the sensation of the limb that is no longer
there.
 It occurs initially immediately after surgery and is
described as a tingling, numbness, itching or pressure
sensation.
 The distal part of the extremity is most frequently felt
although, on occasion, the person will feel the whole
extremity.

60.  The sensation is responsive to external stimuli such as
bandaging or rigid dressing; it may dissipate over time
or person may be have the sensation throughout life.
 It is important for the patient to understand that the
feeling is quite normal.
 It usually not interfere with prosthetic rehabilitation.

61.  It is important to differentiate phantom pain from non
painful phantom sensation, residual limb pain and non
residual limb pain.
 Phantom pain – cramping or squeezing sensation or
shooting or burning pain.
◦ It may be localized / diffuse
◦ May be continuous or intermittent and triggered by
some external stimuli.

62.  In the presence of trigger points, injection with steroids
or local anesthesia will reduce the pain temporarily.
 Non invasive pain such as,
◦ TENS
◦ Icing
◦ Ultrasound
◦ Massage
◦ Biofeedback
◦ Guided imagery

63.  Initial reaction to the loss of limb is usually grief and
depressive.
 If the amputation was traumatic, the immediate reaction
may include disbelief.
 Person may experience insomnia, restlessness, difficulty
in concentrating.

64.  In early stages, person’s grief may alternate with feeling
of hopelessness, despondency, bitterness and anger.
 Socially the patient may feel lonely, isolated and object
of pity.

65.  Long term adjustment depends to a great extent on,
 Individual’s basic personality
 Structure
 Sense of accomplishment
 Place in the family
 Community
 World

67.  Persons not fitted with a rigid dressing or a temporary
prosthesis use elastic wrap or shrinkers to reduce the
size of the residual limbs.
 Removable rigid dressing for use with transtibial
amputation are available and may be alternative to the
elastic wrap.

68.  Edema :
◦ Edema in the residual limb is often difficult to control
owing to complication of diabetes, cardiovascular
disease or hypertension.
◦ Inntermittent compression unit also can be used to
reduce edema on the temporary basis.

69. Intermittent
compression unit.

70.  Transfemoral and transtibial sleeves are commercially
available.
 Proper hygiene and skin care are important.
 Once the incision is healed and sutures removed, the
person can bath normally.
 Residual limb must be kept clean and dry.

71.  Individual with dry skin may use good skin lotion.
 Care must be taken to avoid abrasions, cuts and other
skin problems.
 Friction massage in which layers of skin, subcutaneous
tissue can be used to prevent or mobilize the scar tissue.
 Massage is done gently after the wound is healed and
when no infection is present.

72.  It is also used to help decrease hypersensitivity of the
residual limb to touch and pressure.
 Patient is taught to inspect the residual limb with a hand
held mirror each night to make sure that there is no
sores or impending problems, especially in the area not
readily visible.

73.  If the person has diminished sensation, careful
inspection is important.
 Because the residual limb tends to become a bit
edematous after bathing as a reaction to the warm water,
nightly bathing is recommended. [this will help to
minimize swelling and allows the natural skin oils to be
replaced overnight ]

74.  The elastic bandage, shrinker or removable rigid
dressing is reapplied after bathing.
 Skin of the residual limb may be affected by variety of
dermatological problems such as eczema, psoriasis or
radiation burns.

75.  Treatment may includes,
 Ultraviolet irradiation
 Whirlpool bath
 Medication

76.  In case of dysvascular disease ultraviolet is used.
 The whirlpool bath not used as it increase circulation
and edema in the part under treatment.
 The advantage of whirlpool as a cleaning agent for skin
problems, infected wounds or incidence of delayed
healing must be balanced against its disadvantage.

77.  Patient tend to wrap their own residual limb in a
circular manner, often creating a tourniquet which may
compromise healing and may cause the development of
a bulbous end.

78.  An effective bandage should be,
◦ Smooth
◦ Wrinkle free
◦ Emphasizes angular turns
◦ Provides pressure distally
◦ Encourage proximal joint extension.

79.  The end of bandages are fastened with tape, safety pins
or Velcro rather than clips, which can cut the skin and
do not anchor well.
 A system of wrapping that uses mostly angular or figure
of eight turns.

80.  The transtibial Bandage:
 Two 4 inch bandages are usually enough to wrap
most transtibial residual limb.
 Very large residual limbs may require three
bandages.
 Elastic wrap does not provide as much as a rigid
dressing, the postsurgical edema must be reduced as
much as possible.

81.  Therefore a firm, even pressure against soft tissue is
desirable.
 First bandage is started at either the medial or lateral
tibial condyle.
 Brought diagonally over the anterior surface of the limb
to the distal end.
 The bandage is continued diagonally over the posterior
surface then back over the beginning turns as an anchor.

82.  At this point, there is a choice, the bandage may be
brought directly over the beginning point as indicated or
it may be brought across the front of the residual limb
in an X design.
 Second bandage is wrapped like the first, except that it
is started at the opposite tibial condyle from first
bandage.

83.  The Transfemoral Bandage:
 For most residual limbs two 6 inch and one 4 inch
bandage can be used together end to end taking care
not to create a heavy seam.
 The 6 inch bandages are used first.
 The first bandage is started in the groin and brought
diagonally over the anterior surface to the distal
lateral corner, around the end of the residual limb.

86. ◦ Diagonally up the posterior side to the iliac crest and
around the hips in a spica..
◦ The bandage is started medially so that the hip wrap
[spica] will encourage extension.
◦ The second 6 inch bandage is wrapped like a first but
is started a bit more laterally.
◦ Any areas not covered with the first bandage must be
covered at this time.

87.  The transtibial shrinker is rolled over the residual limb
to mid thigh and is designed to be self suspending.
 Shrinkers are easier to apply than elastic bandage and
may be better alternatives.
 Specially for transfemoral residual limb.
 Shrinkers are more expensive to use than elastic wrap.
 Initial cost is greater, then new shrinkers of small size
must to be purchased as the limb volume decresed.

88.  Shrinkers may not be used until the incision has healed
and sutures have been removed.

89.  Most deterrent to functional prosthetic rehabilitation is
contracture of the hip and knee.
 Contracture can develop as a result of,
◦ Muscle imbalance or fascial tightness
◦ Loss of plantar stimulation in extension
◦ Faulty positioning.

91. ◦ Prolonged sitting
◦ Placing residual limb on pillow.
Patient should understand the
importance of proper positioning and regular
exercise in preparing for eventual prosthetic fit and
ambulation.

92.  Transtibial amputation:
◦ Full ROM in hip and knee
◦ Particularly in extension.
◦ While sitting patient can keep knee extended by using
posterior splint or board attached to the wheelchair.

93. Quadriceps setting

95. Prone Hamstring Curls
Pillow squeeze

97.  Transfemoral amputation:
◦ Full ROM in the hip particularly in extension and
adduction.
◦ Prolonged sitting to be avoided.
◦ Some time each day should be spent in prone position.
◦ Elevation of transfemoral or transtibial residual limb
amputation can lead to development of hip flexion
contracture, that should be avoided.

98.  Mild contracture may respond to manual mobilization
and active exercise
 Moderate to severe contracture by manual stretching,
specially hip flexion contracture.
 Holding the extremity in a stretched position with
weight for considerable length of time.

99.  Hold relax
 Knee contracture may
reduced by fitting the
patient with a patellar
tendon bearing [PTB]
prosthesis aligned in a
manner that places the
hamstring on stretch with
each step.

100.  It includes,
 Strengthening
 Balance
 Co-ordination activities

101.  The postsurgical dressing
 Degree of post operative pain
 Healing of the incision
 Will determine when resistive exercises for the
involved extremity can started.
 Strengthening of hip extensors and abductors, knee
extensors and flexors are important for prosthetic
ambulation.

102.  General strengthening program that includes,
 Trunk exercises
 All other extremities strengthening
 Proprioceptive neuromuscular exercises are also
beneficial.
 Isometric exercises.

103. ◦ For back exercise ask the patient to lift the buttock off
the table in a bridging movement.
◦ Young patient with traumatic amputation does not
usually lose a great deal of muscle strength.
◦ Older or sedentary people may need to develop good
strength, coordination, and cardiopulmonary
endurance for late ambulation.

104.  Patient should progress from bed to mat activities using
exercises that emphasize coordinated functional
mobility.
 The postoperative status will be determined to a great
extent by the preoperative activity level, length of time
of disability and other medical problems.

105.  Started from supine to sit
◦ Sit to stand etc..
◦ Care must be taken during early bed and transfer
movement to protect the residual limb from any
trauma.
◦ Patient advised not to push on or slide the residual
limb against the bed or chair.

106.  Also ask not to spend too much time in any one position
to prevent the development of joint contracture or skin
breakdown.
 Sitting and standing balance activities.
 Particularly in old patient who may be afraid of falling.

107.  Upper extremity strengthening exercises with weight or
elastic bands are important in preparation for crutch
walking.
 Shoulder depressors and elbow extensors are necessary
to improve the ability to lift the body in ambulation.

108.  Walking is an excellent exercise and necessary for
independent in daily life.
 Gait training can start early in the post operative phase.
 Person with a unilateral LE amputation can become
quite independent using a 3 point gait pattern on crutch.
 Walking with crutches without a prosthesis requires a
greater expenditure of energy than walking with a
prosthesis.

109.  The individual who can ambulate with crutches will
develop a greater degree of general fitness than the
person who can learn to use crutches will not have
difficulty in learning to use prosthesis.
 It may take considerable time for an older person to
learn to use crutches, but the benefits are worth the
efforts.

110.  Cardiovascular endurance is necessary for effective
prosthesis ambulation, particularly at the transfemoral
level.
 Walking with walker is physiologically and
psychologically more beneficial than sitting in a
wheelchair, but it should be used only if the person
cannot be used on stair.

111.  A walker encourage a step to gait pattern whereas
efficient prosthesis use require a step through gait
pattern.
 A reciprocal walker is not safe during the postsurgical
period when the individual is using a 3 point gait
pattern.

112.  A temporary prosthesis includes a socket designed and
constructed according to regular prosthesis principles
and attached to some form of pylon, a foot and some
type of suspension.

115.  Advantage to using a temporary prosthesis;
 It shrinks the residual limb more effectively than the
elastic wrap.
 It allows early bipedal ambulation.
 Many older people can walk safely with a temporary
prosthesis and a cane who otherwise would not be
ambulatory during the postsurgical period.

116.  Many temporary socket today are made of light
thermoplastic material that can be formed over a
positive cast of the residual limb.
 The prosthesis is worn with a wool sock of appropriate
thickness.
 When the residual limb has shrunk so that three wool
sock are needed to maintain socket fit and new socket
needs to be constructed.

117.  Prosthetic component such as feet of various sizes,
suspension straps, knee joint and pylon are now
generally available.
 The temporary transfemoral prosthesis should
incorporate a well-designed socket, articulated knee
joint, foot and pylon.
 Suspension may be accomplished with silesian bandage
or pelvis band.

118.  It is an integral and ongoing part of the rehabilitation
program.
 Information on the,
 Care of residual limb
 Proper care of uninvolved extremity
 Positioning
 Exercises
 Diet.

119.  The education program includes,
 A discussion of the disease process, the
physiological effects of the symptoms.
 Life style changes to reduce risk factors
 Information for benefits of exercises
 LE cleanliness
 Proper foot care

120.  Proper shoe fitting
 Methods of edema control
 The use of exercise program to improve circulatory
status.
 Edema, pain and changes in skin color or
temperature may indicate impending problems.

121.  Intermittent claudication during activity indicates the
need to stop at least temporarily.
 The collateral circulation of the remaining extremity is
developed slowly through a progressive program of
exercises and ambulation.
 It is important to remember that too much activity may
be as harmful as too little.

122.  All individual with bilateral amputations need a
wheelchair on a permanent basis.
 The chair should be as narrow as possible with
removable desk arms and removable legs.
 Amputee wheelchair with offset rear wheels and no legs
rests are not recommended.

123.  The post surgical program includes mat activities
designed to help the person regain a sense of body
position and balance, upper extremity and residual limb
strengthening exercises and ROM exercises.
 Functional mobility training should stress independence
in bed mobility, transfers, and wheel chair use.
 The patient should be encouraged to sleep prone if
possible or at least spend some time in the prone
position each day.

124.  The ambulatory potential of patients with bilateral
transfemoral amputation is uncertain, particularly
among older adults.
 Some individuals may be fitted with bilateral
transfemoral temporary prosthesis for use in
cardiovascular training but continue to use a wheelchair
for functional activities.

125.  Person with bilateral transfemoral amputations can be
fitted with shortened prosthesis called, ‘Stubbies’.
 Stubby prosthesis have regular socket, no articulated
knee joint or shank and modified rocker bottoms turned
backward to prevent the person from falling backward.
 It allows the individual with bilateral transfemoral
amputation to acquire erect balance.

127.  Also allows to participate in ambulatory activities
quickly and with only moderate expenditure of energy.

128.  There is no general rue that can safely be applied to all
patient in making the decision making process but the
fact that the individual wants a prosthesis is not enough.
 The prosthesis should be,
 Lightweight prosthesis
 Stance control knees
 Hydraulic mechanism
 Energy conserving feet

129.  Transtibial Level:
 Flexion contracture, scars, poorly shaped residual
limbs and adherent skin are not contraindicated for
fitting with today’s prosthetic component.
 Circulatory problems in nonamputed extremity,
unless so severe as to preclude any ambulation are
indication for fitting at earliest possible time because
bipedal ambulation reduces stress on the remaining
extremity.

130.  Individual who were not ambulatory prior to surgery for
reason other than the problems leading to the
amputation will probably not be ambulatory with an
amputation.
 Individual who were nonambulatory and debilitated
because of infection, lack of diabetic control and ulcers
will probably regain the necessary strength and
coordination for ambulation after the disease limb has
been removed.

131.  Transfemoral Levels:
 The physiological demands of walking with a
transfemoral prosthesis are considerably higher than
walking with a transtibial prosthesis and not all
individual have the necessary balance, strength and
energy reserves.

132. ◦ The person’s level of activity and participation in the
postsurgical program helps in determinig potential for
prosthetic ambulation.
◦ The temporary prosthesis is a good examination tool.
◦ Individual amputed at hip levels are younger and learn
to use a prosthesis relatively easily.
◦ Radiation therapy often burns the skin making fitting
impossible until the skin has healed.

133.  Patient undergoing chemotherapy may be ill, lose
weight and have the energy to participate in a prosthetic
training program.
 If the person has lost considerable weight, fitting may
have to be delayed because it is difficult to adjust a
prosthesis for increase in weight.

134.  Young, agile individuals are generally good candidate
for prosthetic fitting regardless of amputation.
 Most older individuals with bilateral transfemoral
amputations have considerable difficulty learning to use
two prosthesis.

135.  Patient with one transfemoral and one transtibial
amputation generally can learn to use two prosthesis if
the first amputation was at the transfemoral level and if
the person successfully used a transfemoral prosthesis
before losing the other leg.

136.  The person who has lost portion of both LEs needs
more strength, better coordination, better balance and
greater cardiopulmonary reserves than the person who
has lost a portion of one LE.
 Obesity makes fitting of bilateral prosthesis more
difficult.

137.  Bilateral transfemoral amputation, energy requirement
are still quite high and even younger individual with
bilateral transfemoral amputation may need to use a
wheelchair some of the time.

138.  Training includes,
 All transfers
 Wheelchair mobility
 ADL.
 Sitting balance
 Moving safely in and out of wheelchair
 Activities to support as independent a lifestyle as the
person’s physical and psychological condition
allows