2. Definition
O Cutting of the extremity or part of the
extremity through the bone
While ………..
O Cutting of the extremity extremity or part
of the extremity through the joint is
disarticulation
3. indications
O Amputation can be regarded as a
treatment and not tragedy
O indications :-
1. Dead ( or dying ) limb
2. Dangerous limb
3. Damn nuisance limb
Injury is the most common cause of
amputation
4. Indication according age
Congenial anomaly usually in children
Crush injury at any age
Peripheral vascular disease and infections
at elderly
5. Dead or dying limb
1. Peripheral
vascular disease
( 90% )
2. Sever
traumatized limb
3. Burns
4. Frostbite
7. Damn nuisance
Remaining the limb is more worse than
having no limb at all …. Because of :-
1. Pain
2. Gross malformation
3. Recurrent sepsis
4. Sever loss of function
8. Varieties of amputations
Provisional
amputation
O When primary healing is unlikely
O The limb amputate as distal as the causal
factor will allow
O Skin flap suture loosely over a pack
O Re-amputation perform when stump
condition is favorable
9. Definitive end-
bearing
O When weight is taken through the end of
the stump
O The scar must not be terminal
O Bone end must be solid (cut near the joint)
O Example through knee , syme’s
12. O The “ sites of election
”are determined by :-
1. the demand of the prosthetic design
2. local function e.g bellow the most distal
palpable arterial pulsation
13. Too short a stump
slips out from the prosthesis
Too long a stump
painful , ulcerate , complicates the
incorporation of the joint in the prosthesis
Now a day the skill of orthotiest make
amputation possible at any level
16. O Skin flaps are cut so that there
combined length equals one & half the
width of the limb at the site of the
amputation
O Equal flaps are for upper limb & trans-
femoral amputations , long posterior
flap for bellow – knee
17. O Muscle cut at distal level from the level of
the bone proposed
OMyoplasty …. When the
muscles sutured together over the bone
18. O A raw nerve end should not bear weight
Divide the nerve proximal to
the bone cut
19. O Saw is used to make the bone ends
smooth , and for beveling the tibia
interiorly
O Fibula is cut 3 cm shorter
20. O Remove the tourniquet and stop bleeding
O Suture the skin without tension
O Apply suction drain
O Bandage the stump tightly
21. Aftercare
O Evacuate the hematoma as soon
O Elastic bandaging the stump for shrinkage
O Exercise the muscles
O Keep joints mobile
O Advice using the prosthesis
23. upper limb amputations
O Interscapulo - thoracic amputation which
is known as fore-quarter amputation
O Disarticulation of the shoulder
O Transhumeral amputation
O Elbow disarticulation
O Transradial amputation
O Wrist disarticulation
O Amputations in the hand
24.
25. Lower limb amputations
O Hemipelvectomy
O Disarticulation through the hip
joint
O Transfemoral ( at least 12 cm )
O Around the knee ( Stokes –Gritti
)
O Through knee
O Transtibial ( 14 cm )
O Above the ankle ( Syme’s )
O Boyd’s amputation in which
there is calcaneo tibial fusion .
O Mid-tarsal joint ( chopart )
O Tarsometatarsal joint ( lisfranc )
O Ray excision of entire toe.
31. Psychological rejection
O Proper preoperative preparation
O Psychological therapy
O Group therapy
O Motivation
O Recall pervious similar condition
32. Early stump complications
1. Secondary hemorrhage
2. Breakdown of the skin
flaps (may be due to
ischemia or excessive
suture tension )
3. Gas gangrene
33. Late stump complications
Skin
O eczema
O purulent lumps
O fissuring & ulceration
O infected epidermoid cyst
O Squamouse cell carcinoma
O Verrucous hyperplasia
34. O A superficial skin defect can usually be
closed adequately with a Split –thickness
skin graft (STSG).
O Full –thickness defect over bony
prominence is better handled with full –
thickness coverage (either with local flap,
pedicle flap, or free island flap).
O Physical therapy can enhance wound
healing and reduce associated
complication (such as development of
hypertrophic scar) through using low level
laser therapy (LLLT) (Helium neon laser
therapy and or Gl-Al-Ars), with following
treatment protocol
35. Muscle ..
O If excessive muscle left , it will produce
unstable , loose cushion
O If loose muscle left, it will give conical
stump appearance and poorly fitting
prosthesis
O So, muscle condition is highly interesting
to get better fitting prosthesis furthermore
better control in residual limb
37. Nerve .
O Painful neuromas attached to the scar
O So, nerves should be retracted during
surgery
O Nerve ends should be non weight bering
areas in the prosthesis
O Irritation of nerve ends would precipitate
phantom pain
38. Pain
neuropathic pain variable from prepheral
tingling to severe intense burning pain
Phantom
Causalgia
Telescoping
A feeling that the
amputated limb still present
Intense burning pain and
sensitivity
Due to division of peripheral
nerves
Feeling of shrinking of
amputee limb
39. Pain managment
O Good preoperative preparation and early
psychological acceptance
O Good surgical procedure (nerves should
be retracted above level of suture)
O Post operative care
psychological therapy
medical treatment for neuropathic pain
physiotherapy (electrical stimulation,
TENS, hydrotherapy)
nerve block
sympathectomy
40. .
Joint
O the joint above the site of amputation
may become stiff or deformed
O Deformities are fixed flexion & fixed
abduction in above knee ….. Fixed flexion
in bellow knee amputations .
O Fore-foot amputation may be complicated
by equineus deformity.
O Contracture
O Lax joint
41. Bones
O terminal bone spur may cause pain &
infection
O Stump bone fracture may result from
sever osteoporosis
O Protrusion
O Periosteal exostosis
O deformity
42. Rehabilitation
It is a program designated by rehabilitation
team to restore maximal function capacity of
the amputee
With respecting of his disability limitation
43. Proper evaluation
Cause of amputation
Type of amputation
Level of amputation
Final stump
Socio economic level
General condition
Comorbid diseases
Patient expectation
44. 1- presurgical stage
In elective amputation prior to surgery
psycological consultation is highly
recommended to allow early acceptance
and avoid post operative complication
Proper evaluation to socio economic level
Evaluation General condition and comorbid
diseases
Family education and support
45. 2- early post operative
rehabilitation
Target
1- rapid uncomplicated wound healing
2- short stay hospital
3- early patient acceptance
4- pain management
5- minimal scaring and proper stump out
come.
48. Description
O Lying supine: make
sure that hips and
knees are straight,
the patients should
lie on a firm surface
and avoid pillows
under the residual
limb. The legs
should be held
close together.
49. O Lying prone; pillow should be avoided
under the hip and the hip should be kept
straight, and the leg close together. The
patients should lie prone or on wither side
for up to 15 minutes, four times a day.
This position will extended the hip and
knee
50. O Side lying; the hip should be
kept in a neutral position. The
patient should not sleep with
large pillow between the legs
or under the back .Pillow in
these positions enhance hip
flexion and abduction.
O Sitting: when sitting patients
should use a sliding board or
other firm surface under the
residual limb to promote knee
extension.
51. Stump care
Post operative rigid
dressing (PORD)
Ace wrap (circular,
figer of eight, spiral)
Elastic stock
53. O Full ROM to all joints by daily prone
lying o avoid hip and knee
contracture
O Elevation of amputee limb for long
period can precipitate joint flexion
deformity
so, should be avoided
O PNF and biofeed back are highly
effective in combating joint
contracture due to muscle
imbalance
55. O The exercises program is designed individually
and includes ROM, exercises, isometric,
isotonic, and endurance activities, and these
dependent largely on
(i)-Postoperative healing.
(ii)-Postoperative pain
(iii)-Post-surgical dressing.
O This exercise should not produce more than
mild discomfort and put less stress on suture
line, otherwise stop exercises.
O The hip extensor, abductors and knee extensor
and flexors are particularly important for
prosthetic ambulation.
56. O Strengthening exercise for upper extremity
muscles of shoulder depressor, elbow extensor,
wrist extensor, and hand flexor should
encouraged, with general strengthening
program for trunk and abdominal muscles.
O The program should emphasize active or active
assistive ROM of the joint (s) proximal to the
amputation, at 1st to 2nd day postoperative.
O Active motion of all proximal joints through the
full ROM should be obtained by 10 -14 days
following amputation unless grafting procedure
precludes exercising.
57. These exercises help to
O (i)-Reduce edema, and promote healing.
O (ii)-Maintain joint ROM,
O (iii)-Prevent contracture and correct
existing contracture
O (iv)-Allow early mobility self care and
O (v)-Maintain muscle strength, and
kinesthetic sense of residual and phantom
limb, which can later be used in prosthetic
training
60. O Need expert doctor to select proper
prosthesis
O Patient must be
motivated , intelligent and respect
prosthesis
Learn patient how to do on and off
61. Daily patient protocol
O Daily exercise for remaining limb
O Daily stump hygiene (clean, dry and
soothing).
O Strengthen exercise to sound limb
O Basic Prosthesis Care
oiling and maintenance
65. Characteristics of amputated
limb which can functional well
in prosthesis
O Pain free
O Well padded by soft tissue
O Non adherent scar
O Cylindrical shape
O Greatest bone length
O Normal sensation
66. Ideal prosthesis
1. Fits comfortably
2. Function well
3. Looks presentable
4. Fit as soon after the operation
67. O In the upper limb the distal portion is
detachable & can be replaced
O In lower limb weight can be transmitted
through the greater trochanter , tibial
tuberocity , patellar tendon , upper tibia or
soft tissues
O Electrically powered limb is present now
68.
69. 4- follow up stage
Regular follow up visits
stump complication
residual limb muscle and joint state
prosthesis maintenance
pain management
occupational and psychological support
71. Class 1
O Full restortion of
functional capacity
O Return to work
O Sport practice
O Do well with
prosthesis
72. Class 2
O Partial restoration of
functional capacity
O Modify his work
O Stop sport
O Get benefit with
prosthesis
73. Class 3
O Self care plus
O Can care himself and
his family
O Can walk short
distance
O Cannot carry load
O Get benefit with
prosthesis
74. Class 4
O Self care minus
O Can hardly care himself
O Cannot walk short distance
O Cannot go out alone
O Get benefit with prosthesis
75. Class 5 Class 6
O In small amputed
part like a finger
O No movement
gained
O Cosmotic plus
O In wholly amputee
limb with bad
general condition
O Not fit for prosthesis
O Do well with WC or
bed
