A brief introduction to Amputation...

1. Ammarah Sabzwari

2. 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. • Circulatory Disorders
• Neoplasm
• Trauma
• Deformities
• Infections
• Athletic Performance
• Legal Punishment
• Snake bite

4. 1. Leg Amputation
2. Arm Amputation
3. Face Amputation
4. Breast Amputation
5. Genital Amputation
6. Self Amputation

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

6. “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. “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 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. • 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

11. • 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

13. • 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.

14. • Emotional Support and Encouragement
• Opportunity to express
• Occupational and social rehabilitation

15. • Neurovascular and functional status of
extremity
• Circulatory status and function of unaffected
limb
• Signs and Symptoms of infection(culture
required)
• Nutritional status
• Current medications

17.  Closed amputation can be done by two ways.
1. Myodesis
2. Myoplasty
Also called Fish Mouth Technique.

18.  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.

20.  Long posterior flap technique
 Skewed flap technique

21.  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.

24.  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.

26. • 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

27. • Begin controlled weight bearing
• Accomplish functional activities
• Facilitate psychological adjustment to the
lost limb

28. • 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

29. • 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

30. • 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.

31. • 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.

32. 1. 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.
2. 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.

34. 3. 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.
4. 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.

35. 5. 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.

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

37. “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.”

38. • 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.

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

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

42.  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.

43.  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

44.  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.

45. 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.

46.  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.

47. 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.

48.  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

49.  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.

50. The phantom limb is the perceived
presence of the amputated body part.

52.  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.

53.  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.

54.  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.

56.  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.

58.  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.

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

60.  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.

62.  Psoriasis
 Blisters
 Tumors
 Chronic ulcers

64.  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.

65.  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.

66.  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

67. 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.

68. 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.

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

70. 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.

71. 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.