This document provides information on amputations of the lower limb. It discusses the indications for amputation including peripheral vascular disease, trauma, burns, frostbite, infections, and tumors. It covers the surgical principles of amputation including determination of amputation level, techniques, postoperative care, and complications. It also provides specifics on transtibial (below knee) amputation techniques for both ischemic and nonischemic limbs.
The document discusses the history and principles of amputations. It covers indications for amputations including peripheral vascular disease, trauma, infections and tumors. Key points include determining the appropriate amputation level by balancing function versus complications, and employing techniques like rigid dressings and early prosthesis to aid healing and rehabilitation. The goal of amputation is to remove non-viable tissue while preserving maximum function through prosthetics.
1. Fracture is a break in the structural continuity of bone that can be caused by trauma or pathology. Fractures are classified based on etiology, communication, and shape.
2. Evaluation of fractures involves history, physical exam, and imaging studies like x-rays. Treatment depends on the fracture type but generally involves reduction, immobilization, and rehabilitation.
3. Complications of fractures include infection, malunion, nonunion, and impaired function. Open fractures require emergent irrigation, debridement, and antibiotic treatment to prevent infection.
This document summarizes key information about amputation:
1. Amputation may be necessary due to trauma, ischemia, infection, tumors or congenital anomalies. Factors like peripheral neuropathy increase risk of amputation for diabetics.
2. The level of amputation is determined based on factors like skin perfusion and oxygen levels, with the goal of ensuring wound healing and a functional residual limb.
3. The surgical procedure involves dividing muscles below the intended bone cut, handling nerves to prevent neuromas, and shaping the bone for a smooth contour. Rigid dressings aid rehabilitation.
4. Rehabilitation progresses from non-weight bearing to partial weight bearing as healing is documented. Complications can
Appraoch to patient with polytrauma and Damage control orthopedicsKaushal Kafle
A brief approach to patient with polytrauma, physiological response of body with trauma, the trimodal mortality, golden hour, lethal triad of trauma, two hit hypothesis, inflammatory mediators, prehospital care, primary survey, secondary survey, ABCDE approach, Adjucts are included. Besides thc concept of Damage control orthopedics, trend in fracture management , evolution , principle, indication , surgical stratergies, advantage, limitation, definitive fixation and EAC and ETC are included in breif.
This document provides information on amputations of the lower limb. It discusses the indications for amputation including peripheral vascular disease, trauma, burns, frostbite, infections, and tumors. It covers the surgical principles of amputation including determination of amputation level, techniques, postoperative care, and complications. It also provides specifics on transtibial (below knee) amputation techniques for both ischemic and nonischemic limbs.
The document discusses the history and principles of amputations. It covers indications for amputations including peripheral vascular disease, trauma, infections and tumors. Key points include determining the appropriate amputation level by balancing function versus complications, and employing techniques like rigid dressings and early prosthesis to aid healing and rehabilitation. The goal of amputation is to remove non-viable tissue while preserving maximum function through prosthetics.
1. Fracture is a break in the structural continuity of bone that can be caused by trauma or pathology. Fractures are classified based on etiology, communication, and shape.
2. Evaluation of fractures involves history, physical exam, and imaging studies like x-rays. Treatment depends on the fracture type but generally involves reduction, immobilization, and rehabilitation.
3. Complications of fractures include infection, malunion, nonunion, and impaired function. Open fractures require emergent irrigation, debridement, and antibiotic treatment to prevent infection.
This document summarizes key information about amputation:
1. Amputation may be necessary due to trauma, ischemia, infection, tumors or congenital anomalies. Factors like peripheral neuropathy increase risk of amputation for diabetics.
2. The level of amputation is determined based on factors like skin perfusion and oxygen levels, with the goal of ensuring wound healing and a functional residual limb.
3. The surgical procedure involves dividing muscles below the intended bone cut, handling nerves to prevent neuromas, and shaping the bone for a smooth contour. Rigid dressings aid rehabilitation.
4. Rehabilitation progresses from non-weight bearing to partial weight bearing as healing is documented. Complications can
Appraoch to patient with polytrauma and Damage control orthopedicsKaushal Kafle
A brief approach to patient with polytrauma, physiological response of body with trauma, the trimodal mortality, golden hour, lethal triad of trauma, two hit hypothesis, inflammatory mediators, prehospital care, primary survey, secondary survey, ABCDE approach, Adjucts are included. Besides thc concept of Damage control orthopedics, trend in fracture management , evolution , principle, indication , surgical stratergies, advantage, limitation, definitive fixation and EAC and ETC are included in breif.
Postoperative spinal infections can occur after both instrumented and non-instrumented spinal procedures. Risk factors include obesity, malnutrition, diabetes, smoking, surgical complexity, blood loss over 1L, and revision surgery. Superficial infections present with erythema and drainage while deep infections cause pain, fever, and neurological deficits. Evaluation includes labs like ESR, CRP, and blood/wound cultures as well as imaging like MRI, CT, or bone scan. Common pathogens are Staphylococcus and MRSA. Treatment involves antibiotics targeted to culture results as well as surgical debridement of infected tissues. Adjuvant techniques like vacuum-assisted closure can aid in wound management and closure. Strict prevention methods including antibiotic
This document provides an overview of amputation and rehabilitation. It discusses the history and definitions of amputation, as well as pre-operative preparations and evaluations. The document outlines different types and levels of amputations for both upper and lower limbs. Key principles of amputation surgery are described, including goals for post-operative care and rehabilitation. Specific considerations for upper limb amputations are also covered.
A mangled extremity refers to severe limb injury where viability is questionable. Emergent management prioritizes life-saving care. The decision to salvage or amputate is complex, considering scoring systems, nerve function, bone/joint integrity, and patient factors. If salvaged, options include debridement, fixation, flaps, and bone reconstruction. Amputation may provide better function than some salvaged limbs, especially with vascular/major injuries. The child's growth is also a key consideration.
This document outlines the principles of amputation, including definitions, indications, classifications, pre-operative preparations, operative techniques, post-operative care, complications, rehabilitation, prosthetics, and follow-up. It notes that amputation involves removing a limb or part of a limb by trauma, constriction or surgery. The pre-operative assessment determines the appropriate level of amputation based on factors like blood supply. The surgery involves dividing muscles and bones above the intended level and creating skin flaps for coverage. Post-operative care focuses on rehabilitation, residual limb shaping, and prosthetic fitting to maximize patient function and independence.
1) A 25-year-old man presented with an open tibia/fibula fracture and underwent irrigation, debridement, and fixation with a tibial nail. However, a week later pseudomonas was cultured from the wound and the nail was removed for further debridement and soft tissue reconstruction.
2) The evidence on antibiotic prophylaxis and timing of debridement for open fractures is limited but suggests antibiotics should be given within 3 hours and debridement can generally be done within 24 hours without increased risk of infection.
3) Classification systems like Gustillo and MESS can help determine prognosis but have limitations and are best applied by experienced surgeons after initial debridement.
AMPUTATION:
“Surgical removal of limb or part of the limb through a bone or multiple bones”
DISARTICULATION:
“Surgical removal of hole limb or part of the limb through a joint”
This document provides an overview of nonunion fractures, including definitions, classifications, etiology, evaluation, and treatment principles. It defines nonunion as a fracture that has not healed after 9 months and has not shown progression for 3 months. Nonunions are classified as hypervascular (hypertrophic, oligotrophic) or avascular (atrophic, pseudarthrosis). Treatment may involve debridement, plating, intramedullary nailing, bone grafting, BMPs, or electrical stimulation depending on the type and location of the nonunion. The goals are to achieve stability, stimulate healing, correct any deformity, and allow early mobilization.
1. Amputation is the complete removal of an injured or deformed body part. It is one of the oldest surgical procedures. The main indications are peripheral vascular disease, trauma, burns, infections, tumors, and frostbite.
2. The appropriate level of amputation depends on factors like the zone of injury, adequate margins in tumor cases, circulation status, soft tissue envelope, and bone/joint condition. More distal amputations allow better function but more proximal ones reduce complications.
3. Surgical techniques aim to provide good blood supply, muscle attachments, nerve handling and bone shaping to allow for an effective prosthesis. Hemostasis, wound closure and drain placement are also important considerations.
Bilateral hip fractures are rare and usually result from high-energy trauma. This case report describes a 40-year old male who sustained simultaneous bilateral intertrochanteric hip fractures after his lower body was crushed in a motor vehicle accident. He underwent staged surgical fixation of the fractures with dynamic hip screws. Postoperative recovery was uncomplicated. While bilateral hip fractures pose risks, early surgical treatment and careful monitoring can lead to good functional outcomes even in active patients.
This document summarizes key points about musculoskeletal trauma presented by Dr. Mohit Garg. It discusses resuscitation of patients with extremity injuries, including controlling hemorrhage from injuries like arterial bleeding, traumatic amputations, bilateral femoral fractures, and crush syndrome. It also covers assessment and management of open fractures, vascular injuries, compartment syndrome, and neurological injuries. Physical examination involves identifying life-threatening and limb-threatening injuries by looking for deformities, feeling for areas of tenderness, and evaluating circulation and sensation. X-rays may be needed but not if there is vascular compromise or risk of skin breakdown.
This document discusses open fractures and mangled extremities. It covers the goals of treatment which are to preserve life, limb and function while preventing infection and restoring stability and soft tissue coverage. Open fractures require urgent assessment and debridement to remove non-viable tissue which can be aided by lavage and the use of tourniquets. Skeletal stabilization is also important. Scores can help determine if limb salvage is possible or if amputation is required based on the extent of soft tissue and bone damage. Proper antibiotic use, wound coverage and further reconstruction are also outlined.
This document discusses the management of polytraumatized patients presenting to the emergency department. It defines polytrauma as two or more significant injuries to two or more organ systems. The management involves a multidisciplinary team performing a primary survey to address life threats, secondary survey to identify all injuries, and definitive treatment tailored to the patient's condition. Complications can include shock, sepsis, multiple organ dysfunction syndrome, and death if not properly managed. Special considerations are given to polytrauma in children, elderly, and pregnant patients.
This document provides information on spine and extremity injuries, including fractures, compartment syndrome, traumatic amputations, and spinal injuries. It describes the types, clinical features, investigations, management principles, and complications of these conditions. Fractures are classified as open or closed. Compartment syndrome results from increased pressure compromising circulation. Amputations require urgent wound care and resuscitation. Spinal injuries can damage the vertebrae and spinal cord, and require immobilization, imaging, and multidisciplinary management.
management priorities in high energy trauma
Define the terms of fracture, dislocation and Subluxation
Identify the clinical and radiological pictures of fractures
Classify the different types of fractures
general principles of fracture management
Principles of open fracture management
This document provides information about amputation indications, surgical principles, and post-operative care. It discusses various types of amputations for both lower and upper limbs. The main indications for amputation include peripheral vascular disease, trauma, malignancy, infection, burns, and frostbite. The surgical principles focus on choosing an amputation level for optimal function, creating adequate skin and muscle flaps, and hemostasis. Post-operative care involves pain management, rigid dressings, physiotherapy, and prosthetic training to prevent complications like infection, contractures, and phantom limb pain.
Surgical Approaches around Hip and Knee Kushal.pptxKushalKhanal10
The document discusses various surgical approaches for the hip and knee. It describes the Smith-Petersen and anterior approaches for the hip which provide good exposure of the anterior joint while preserving vascularity. The anterolateral approach combines exposure of the acetabulum and femoral shaft safely. Posterior and lateral approaches are also discussed. For the knee, the document outlines the anteromedial, subvastus, midvastus, medial, lateral, posterior and posteromedial approaches indicating their indications and risks to structures. Approaches to the tibial plateau and distal femur are also summarized.
1. Reconstruction of forehead and scalp defects poses unique challenges due to the visibility of these areas and their complex 3D anatomy. Successful reconstruction requires replacing like tissue and avoiding interference with other treatments.
2. Reconstructive options are tailored based on defect analysis and the patient's needs/anatomy. Local flaps and skin grafts are used for smaller defects while regional and microsurgical flaps are needed for larger or complex defects.
3. Postoperative care involves monitoring for complications like infection, dehiscence, or flap failure. Secondary procedures may be required to refine hairlines, release dog ears, or address functional issues over time.
Successful management of Polytrauma must achieve the following goals, 1- Keep someone alive that would be dead without you 2- Prioritize treatment to prevent killing someone 3- Treat extremity injuries to return the patient to a functional life. The Priorities are 1- Life threatening, 2- Limb threatening, 3- Function threatening. The question about the best strategy in the management Polytrauma and the choice between an Early Total Care (ETC) vs. Damage Control Orthopedics (DCO) will be answered in this presentation.
1. Amputation is the surgical removal of a limb or part of a limb and is commonly performed due to trauma, vascular disease, tumors, infections, or other conditions.
2. The goals of amputation are to preserve functional residual limb length while providing well-healed, non-tender soft tissue reconstruction.
3. Major types of amputations include below knee amputations, above knee amputations, and forequarter (shoulder) amputations. Each type has specific surgical and rehabilitation considerations.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
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Postoperative spinal infections can occur after both instrumented and non-instrumented spinal procedures. Risk factors include obesity, malnutrition, diabetes, smoking, surgical complexity, blood loss over 1L, and revision surgery. Superficial infections present with erythema and drainage while deep infections cause pain, fever, and neurological deficits. Evaluation includes labs like ESR, CRP, and blood/wound cultures as well as imaging like MRI, CT, or bone scan. Common pathogens are Staphylococcus and MRSA. Treatment involves antibiotics targeted to culture results as well as surgical debridement of infected tissues. Adjuvant techniques like vacuum-assisted closure can aid in wound management and closure. Strict prevention methods including antibiotic
This document provides an overview of amputation and rehabilitation. It discusses the history and definitions of amputation, as well as pre-operative preparations and evaluations. The document outlines different types and levels of amputations for both upper and lower limbs. Key principles of amputation surgery are described, including goals for post-operative care and rehabilitation. Specific considerations for upper limb amputations are also covered.
A mangled extremity refers to severe limb injury where viability is questionable. Emergent management prioritizes life-saving care. The decision to salvage or amputate is complex, considering scoring systems, nerve function, bone/joint integrity, and patient factors. If salvaged, options include debridement, fixation, flaps, and bone reconstruction. Amputation may provide better function than some salvaged limbs, especially with vascular/major injuries. The child's growth is also a key consideration.
This document outlines the principles of amputation, including definitions, indications, classifications, pre-operative preparations, operative techniques, post-operative care, complications, rehabilitation, prosthetics, and follow-up. It notes that amputation involves removing a limb or part of a limb by trauma, constriction or surgery. The pre-operative assessment determines the appropriate level of amputation based on factors like blood supply. The surgery involves dividing muscles and bones above the intended level and creating skin flaps for coverage. Post-operative care focuses on rehabilitation, residual limb shaping, and prosthetic fitting to maximize patient function and independence.
1) A 25-year-old man presented with an open tibia/fibula fracture and underwent irrigation, debridement, and fixation with a tibial nail. However, a week later pseudomonas was cultured from the wound and the nail was removed for further debridement and soft tissue reconstruction.
2) The evidence on antibiotic prophylaxis and timing of debridement for open fractures is limited but suggests antibiotics should be given within 3 hours and debridement can generally be done within 24 hours without increased risk of infection.
3) Classification systems like Gustillo and MESS can help determine prognosis but have limitations and are best applied by experienced surgeons after initial debridement.
AMPUTATION:
“Surgical removal of limb or part of the limb through a bone or multiple bones”
DISARTICULATION:
“Surgical removal of hole limb or part of the limb through a joint”
This document provides an overview of nonunion fractures, including definitions, classifications, etiology, evaluation, and treatment principles. It defines nonunion as a fracture that has not healed after 9 months and has not shown progression for 3 months. Nonunions are classified as hypervascular (hypertrophic, oligotrophic) or avascular (atrophic, pseudarthrosis). Treatment may involve debridement, plating, intramedullary nailing, bone grafting, BMPs, or electrical stimulation depending on the type and location of the nonunion. The goals are to achieve stability, stimulate healing, correct any deformity, and allow early mobilization.
1. Amputation is the complete removal of an injured or deformed body part. It is one of the oldest surgical procedures. The main indications are peripheral vascular disease, trauma, burns, infections, tumors, and frostbite.
2. The appropriate level of amputation depends on factors like the zone of injury, adequate margins in tumor cases, circulation status, soft tissue envelope, and bone/joint condition. More distal amputations allow better function but more proximal ones reduce complications.
3. Surgical techniques aim to provide good blood supply, muscle attachments, nerve handling and bone shaping to allow for an effective prosthesis. Hemostasis, wound closure and drain placement are also important considerations.
Bilateral hip fractures are rare and usually result from high-energy trauma. This case report describes a 40-year old male who sustained simultaneous bilateral intertrochanteric hip fractures after his lower body was crushed in a motor vehicle accident. He underwent staged surgical fixation of the fractures with dynamic hip screws. Postoperative recovery was uncomplicated. While bilateral hip fractures pose risks, early surgical treatment and careful monitoring can lead to good functional outcomes even in active patients.
This document summarizes key points about musculoskeletal trauma presented by Dr. Mohit Garg. It discusses resuscitation of patients with extremity injuries, including controlling hemorrhage from injuries like arterial bleeding, traumatic amputations, bilateral femoral fractures, and crush syndrome. It also covers assessment and management of open fractures, vascular injuries, compartment syndrome, and neurological injuries. Physical examination involves identifying life-threatening and limb-threatening injuries by looking for deformities, feeling for areas of tenderness, and evaluating circulation and sensation. X-rays may be needed but not if there is vascular compromise or risk of skin breakdown.
This document discusses open fractures and mangled extremities. It covers the goals of treatment which are to preserve life, limb and function while preventing infection and restoring stability and soft tissue coverage. Open fractures require urgent assessment and debridement to remove non-viable tissue which can be aided by lavage and the use of tourniquets. Skeletal stabilization is also important. Scores can help determine if limb salvage is possible or if amputation is required based on the extent of soft tissue and bone damage. Proper antibiotic use, wound coverage and further reconstruction are also outlined.
This document discusses the management of polytraumatized patients presenting to the emergency department. It defines polytrauma as two or more significant injuries to two or more organ systems. The management involves a multidisciplinary team performing a primary survey to address life threats, secondary survey to identify all injuries, and definitive treatment tailored to the patient's condition. Complications can include shock, sepsis, multiple organ dysfunction syndrome, and death if not properly managed. Special considerations are given to polytrauma in children, elderly, and pregnant patients.
This document provides information on spine and extremity injuries, including fractures, compartment syndrome, traumatic amputations, and spinal injuries. It describes the types, clinical features, investigations, management principles, and complications of these conditions. Fractures are classified as open or closed. Compartment syndrome results from increased pressure compromising circulation. Amputations require urgent wound care and resuscitation. Spinal injuries can damage the vertebrae and spinal cord, and require immobilization, imaging, and multidisciplinary management.
management priorities in high energy trauma
Define the terms of fracture, dislocation and Subluxation
Identify the clinical and radiological pictures of fractures
Classify the different types of fractures
general principles of fracture management
Principles of open fracture management
This document provides information about amputation indications, surgical principles, and post-operative care. It discusses various types of amputations for both lower and upper limbs. The main indications for amputation include peripheral vascular disease, trauma, malignancy, infection, burns, and frostbite. The surgical principles focus on choosing an amputation level for optimal function, creating adequate skin and muscle flaps, and hemostasis. Post-operative care involves pain management, rigid dressings, physiotherapy, and prosthetic training to prevent complications like infection, contractures, and phantom limb pain.
Surgical Approaches around Hip and Knee Kushal.pptxKushalKhanal10
The document discusses various surgical approaches for the hip and knee. It describes the Smith-Petersen and anterior approaches for the hip which provide good exposure of the anterior joint while preserving vascularity. The anterolateral approach combines exposure of the acetabulum and femoral shaft safely. Posterior and lateral approaches are also discussed. For the knee, the document outlines the anteromedial, subvastus, midvastus, medial, lateral, posterior and posteromedial approaches indicating their indications and risks to structures. Approaches to the tibial plateau and distal femur are also summarized.
1. Reconstruction of forehead and scalp defects poses unique challenges due to the visibility of these areas and their complex 3D anatomy. Successful reconstruction requires replacing like tissue and avoiding interference with other treatments.
2. Reconstructive options are tailored based on defect analysis and the patient's needs/anatomy. Local flaps and skin grafts are used for smaller defects while regional and microsurgical flaps are needed for larger or complex defects.
3. Postoperative care involves monitoring for complications like infection, dehiscence, or flap failure. Secondary procedures may be required to refine hairlines, release dog ears, or address functional issues over time.
Successful management of Polytrauma must achieve the following goals, 1- Keep someone alive that would be dead without you 2- Prioritize treatment to prevent killing someone 3- Treat extremity injuries to return the patient to a functional life. The Priorities are 1- Life threatening, 2- Limb threatening, 3- Function threatening. The question about the best strategy in the management Polytrauma and the choice between an Early Total Care (ETC) vs. Damage Control Orthopedics (DCO) will be answered in this presentation.
1. Amputation is the surgical removal of a limb or part of a limb and is commonly performed due to trauma, vascular disease, tumors, infections, or other conditions.
2. The goals of amputation are to preserve functional residual limb length while providing well-healed, non-tender soft tissue reconstruction.
3. Major types of amputations include below knee amputations, above knee amputations, and forequarter (shoulder) amputations. Each type has specific surgical and rehabilitation considerations.
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These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
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These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
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To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
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3. Introduction
Amputation
- Surgical removal of limb or part of the limb
through a bone or multiple bones
Disarticulation
- Surgical removal of whole limb or part of the
limb through a joint
4. • Most ancient of surgical procedure
• Crude procedure
• Associated with high complications and mortality rate
• Improved surgical technique, post-operative rehabilitation and greatly
improved prosthetic design
• “Amputation should not be viewed as a failure of treatment but
rather as the first step toward a patient’s return to a more
comfortable and productive life”
7. Types of Amputation
• Provisional amputation
-Unlikely primary healing
-Amputated as distal as possible
-Skin flap loosely sutured
-Reamputation later
• Definitive end-bearing amputation
-Stump bear weight or pressure
-Scar: not terminal
-Bone end: solid, not hollow
-e.g. Syme amputation
8. • Definitive non-end bearing amputation:
-Commonest variety
-All upper limb and most lower limb amputation
-Scar: terminal
• Open Amputation:
-Skin:not closed over the end of the stump
-Always followed by secondary closure,reamputation,revision or
plastic repair
-Indications: infection or contaminated severe traumatic wound
10. • Dead like/Damned nuisance:
-Gross malformation
-Recurrent sepsis
-Severe loss of infection
-Severe pain
• Only Absolute indication: Irreversible Ischemia
11. Peripheral Vascular Disease
• M/C indication in 50 to 75 years
• Half associated with DM
• Risk Factors: Peripheral neuropathy, prior stroke, prior major
amputation, smoking, poor glucose control
• Vascular Surgery consultation for possible revascularization
• Pre-op optimization:
-Infection control
-Medical control
-Wound Complications: S.albumin <3.5 gm/dl/ TLC <1500 cells/ml
12. • Level of Amputation:
• Evaluation: Cognitive function,balance,strength and motivation level
• Energy required for walking is inversely proportionate to the length of
remaining limb
• Ambulatory Patient: Most distal level offering reasonable chance of
healing to maximize function
• Non-ambulatory Patient: Transfemoral amputation or knee
disarticulation
13. Trauma
• MC in younger patient
• Male>Female
• Absolute indication: Irrepairable vascular injury in ischaemic limb
• Salvage vs Amputation:
-Patient’s pre-injury status
-injury factors (soft tissue injury, location, contamination and
physiological status)
-patient’s wish and available resources
• Salvaging severely injured limb: Metabolic overload and secondary organ
failure
15. Educating the patient
• Protracted treatment course limb salvage vs immediate amputation
and prosthetic fitting.
• Multiple admission & operations on affected and non affected areas.
• External fixation with its complication
• Chronic pain and drug addiction
• Isolation from family, friend and unemployment
• End result of Salvage:
-Unsuccessful---> Amputation
-Successful---> Functionless or chronically painful
16. Early amputation and prosthetic fitting
• Decrease morbidity
• Fewer operation
• Shorter hospital stay
• Decreased hospital cost
• Shorter rehab
• Earlier return to work.
• Treatment outcome and course predictable.
Advances in limb salvage surgery have been paralleled by
advances made in amputation surgery and prosthetic design
17. Decision making
• Patient views:
• Cosmesis
• Function
• Body image
• Handling uncertainty
• Dealing with prolong immobilization
• Accepting social isolation
• Bearing financial burden
The “correct” decision are based on the patient as a whole, not solely on extent of injury
18. Thermal or Electrical Burn
• Initial presentation: Full extent of tissue damage
may not be apparent
• Early aggressive debridement
• Fasciotomy when indicated
• Early amputation:
-Decrease risk of infection ( local and systemic)
-Myoglobin induced renal failure and death
19. Frostbite
• Risk groups:
-High attitude climbers, skiers
-Alcoholic, schizophrenic and homeless
• Delayed for 2 to 6 months:
-For clear demarcation of viable tissue
-Recovery of deep tissue
• Indication of early surgery: removal of circumferentially constricting
eschar
• Premature surgery: greater loss and increased risk of infection
20. Infection:Acute
• Open amputation:
-Acute or chronic infection unresponsive to antibiotics and surgical
debridement
-Wound closed loosely
-Infusion of antibiotics irrigants
• Acute setting: infection by gas forming organisms
• Clostridial myonecrosis: Emergency open amputation one joint above
the affected compartment is life saving measure
Any contaminated wound that is closed without appropriate debridement is at high risk for the
development of gas gangrene
21. Infection :Chronic
• Individual basis
• Systemic effect of refractory infection may justify amputation.
• Disability reaching a point- pt. better served by amputation and
prosthetic fitting
-Nonhealing trophic ulcer
-Chronic osteomyelitis
-Infected nonunion
-Chronic draining sinus:squamous cell carcinoma
22. Tumor
• Limb salvage:
-Acute complication: extensive procedure, greater risk of infection,
wound dehiscence, flap necrosis, blood loss, DVT
-Long term complication: Periprosthetic #, prosthetic loosening or
dislocation, nonunion of graft host junction, allograft #, LLD and late
infection
• Amputation for malignancy:technically demanding
-Nonstandard flaps, bone graft, prosthetic augmentation
Patient with salvage limb is likely to need multiple operation for treatment of complications
and 1/3rd ultimately require amputation
23. Location
• UL: salvage even with sacrifice of major nerve
• Proximal femoral and pelvic lesion: resection and
local reconstruction better function than hip
disarticulation or hemipelvectomy.
• Sarcomas around ankle and foot: amputation +
prosthesis
• Sarcomas around knee: individualized
-Wide resection with prosthetic knee
replacement
-Wide resection with allograft arthrodesis
-Transfemoral amputation
24. Indications for Amputation
• Palliative measure for metastatic disease
• Refractory pain-radiation, chemotherapy, standard surgical treatment
• Recurrent pathological fracture
• Massive necrosis,
• Fungation
• Infection
• Vascular compromise
The ultimate decision must be taken by patient based on long term goals and lifestyle
Although cure is not goal, improve pain and functional status for remaining month of life
25. Surgical Principles of amputation
• Determination of amputation level:
• Increased function with more distal level of amputation
• Decreased complication rate with a proximal level of amputation
• For LL :
• Chief concern- Ambulation: most distal level
• No ambulatory potential :wound healing with decreased
perioperative morbidity
26. Determining most distal level of amputation
• Preop clinical assessment: Skin color, hair growth, skin temperature
• Skin perfusion pressure
• Thermography/laser doppler flowmetry
• Transcutaneous oxygen measurement
28. Hemostasis
• Torniquet use- except severely ischaemic status
• Major blood vessels- isolated and doubly ligated
• Torniquet deflation before closure
• Drain: 48 to 72 hour
29. Nerves
• Neuroma formation: Unevitable
• Painful :If in position of repeated trauma
• Normal physiological stimuli: painful.
• Best way: isolated, gently pulled and divided with sharp knife
• Avoid: strong tension, crush
• Large nerve: ligated as often contain relatively large arteries
30. Bone
• Bony prominence:
-Rasped for smooth contour
-Resected if not well padded by soft tissue:
-Anterior aspect of tibia
-Lateral aspect of femur
-Radial styloid
• Periosteum:
-Excessive striping contraindicated :ring sequestra / bony
overgrowth
31. Open amputation
• Goal: To prevent or eliminate infection
• Indication:
-Infected wound
-Severe traumatic wounds with
extensive destruction of tissue
- Gross contaminated traumatic wounds
• Require:
-Repeated debridement
-Appropriate antibiotics use
-Vacuum assisted closure
-At least 2 operations to construct satisfactory stump
32. IDEAL STUMP
• Ideal length – for prosthesis fitting
• Ideal shape – Conical & smooth
• Good muscle power
• Joint should be supple
• Non adherent scar
• No fixed deformity
• Adequate muscle padding
• Absence of neuroma
• Free from infection
• Adequate blood supply
34. Amputation in Children: Principle
• Congenital limb deficiency :60%
• Acquired conditions: 40%
• Preserve length (70% of the growth of the femur occurs at the distal
growth plate)
• Preserve important growth plates
• Perform disarticulation rather than transosseous amputation whenever
possible
• Preserve the knee joint whenever possible
• Stabilize and normalize the proximal portion of the limb, and
• Be prepared to deal with issues in addition to limb deficiency in children
with other clinically important conditions
35. Post operative care
• Multidisciplinary team
• Precaution: Antibiotics, DVT prophylaxis,
pulmonary hygiene, pain management
• Treatment of stump
• Conventional soft dressing
• Rigid dressing
36. Rigid Dressing
• POP: Weight bearing is not planned immediately
• Advantages:
-Prevent edema
-Protect wound from bed trauma
-Enhance wound healing
-Decreased postoperative pain
-Allow early mobilization from bed to chair and ambulation with support
-Prevent knee flexion contracture in transtibial amputations
-Decreased hospital stay
-Earlier definitive prosthetic fitting
37. Physiotherapy
• Start as soon tolerated.
• Muscle setting exercise – exercise to mobilize joints
• Bed to chair – Day 1
• Parallel bars – walker/crutches
• Cast changed weekly/ additional stump sock
• When volume appear unchanged from previous one week
• Prosthetist may apply the first prosthesis
40. Infection
• Most common in Peripheral vascular disease with DM
• Deep infection:
-Immediate debridement & irrigation
-Open wound management
• Antibiotics usage a/c to C&S
• Smith and Burgess method: central 1/3rd
closed and the remainder of the wound packed open
41. Wound Necrosis
• Preop evaluation:
-Transcutaneous oxygen studies,
- S. albumin(<3.5 gm/dl)
- TLC(<1500 cells/ml)
- Avoid tobacco use(2.5 fold rise)
• Nutritional Supplementation
• Management:
• <1cm: conservative with open wound management
• >1cm: local debridement + nutritional support
• Sever necrosis with poor coverage: wedge resection+hyperbaric
oxygen+TENS
42. Contracture
• Mild/Moderate:
-Proper positioning of the stump
-Gentle passive stretching
-Strengthening the muscles controlling the joint
-Prosthetic modification
• Severe:
-Surgical release of the contracted structures
-Wedging cast application
43. Pain
• Post op Pain:
-Multimodal analgesia
-Effective postoperative analgesia:
-Promote function
-Psychological well being
-Minimize developing chronic pain
44. Chronic Pain
• Residual limb pain
-Poorly fitting prosthesis
-Painful neuroma
• Management:
-Socket modification
-Simple neuroma excision or more proximal neurectomy
-Sealing the epidural sleeve
• Phantom limb sensation
-Present in almost all patient
-Educate patient regarding these sensation
-Disappear over a year by a phenomenon called “ Telescoping”
48. Prosthesis
• Prosthesis are devices used to replace a missing limb and to restore or
provide function.
• Features of Ideal Prosthesis:
-Perform its function
-Be easy to maintain, don and doff,
-Be comfortable to bear
-Preferably light weight, durable and cosmetic to look at
49. Component of prosthesis
-Socket made of plastic or resin
-Body of prosthesis
-Harness / suspension system
-Control system
-Terminal device: Hand , Foot
50. Upper limb Prosthesis Components
- Socket
- Suspension system
- Elbow unit for A/E
- Forearm
- Wrist unit
- Terminal device: Hand/hook
- Power Transmission system
