The document provides information about amputation, including definitions, types, causes, indications, and management. It discusses the epidemiology of amputation globally and regionally. It describes the diagnostic evaluation and various types of amputations, including closed and open amputations. Post-operative care involves pain management, wound care, exercise and rehabilitation to improve mobility and self-care abilities. Nursing focuses on managing pain, promoting mobility and self-esteem, and preventing complications like infection.

1. Supervised by: Presenter:
Prof. Dr.Ram Sharan Mehta Sushila Hamal
Medical Surgical Nursing M.Sc. Nursing 1st year
BPKIHS BPKIHS

2. At the end of this session, the participant will be
able to;
 Introduce amputation
 State the epidemiology and incidence
 Describe the causes of amputation
 List down the indication of amputation
 Explain the types of amputation

3.  State the diagnostic evaluation
 List out the principle of amputation
 List the complication of amputation
 Explain management (pharmacological ,nursing
management , rehabilitation)

4. Introduction:
The word amputation is derived from the Latin
word amputare, “to cut away”. An amputation
usually refers to the removal of the whole or part
of an arm/hand or leg/foot.
Amputation is a procedure where a part of the
limb is removed through one or more bones.
It should be distinguished from disarticulation
where a part is removed through a joint.

5. Amputation should only be considered if
the limb is non-viable (gangrenous or
grossly ischemic, dangerous malignancy or
infection), or non-functional .
Amputation is always a last resort and it
will not be done unless it is absolutely
necessary for a person’s health.

6.  In 2017, 57.7 million people were living with limb
amputation due to traumatic causes worldwide. (GBD 2017)
 Leading traumatic causes of limb amputation were falls
(36.2%), road injuries (15.7%), other transportation injuries
(11.2%), and mechanical forces (10.4%).
 Approximately 150000 patients per year undergo a lower
extremity amputation in the United States.
 The most common leading causes to amputation are diabetes
mellitus, peripheral vascular disease, neuropathy and trauma.
(Cesar S. Molina 2022)

7.  In India every year 23,500 amputees are added to the
amputee population in India, of which 20,200 are males
and 3,300 are females.
 There was a 54.1% increase in major amputations noted
in the pandemic period more than the pre pandemic period.
(COVID19 Pandemic in South India, 2021)
 In Nepal the average age of amputees was 33 years (7 to
90 years) 22% female and 78 % were males. 53 % were
between 20 to 40 years.
 Most common level of amputation was below knee
amputation (60.33%) followed by above knee (33.6 %)
and through knee amputation (6%). Only 46 % of all
amputees used a prosthesis. (BBMed,2019)

8. Age:
 Common in 50-75 yrs of age
Sex:
 Appro.75% in male 25% in female
Involvement of limb:
 85% in lower limb 25% in upper limb
Age VS Indication
 Children- congenital anomalies
 Young adults- Injuries
 Elderly- Peripheral vascular disease (DM)

9.  Circulatory disorders : Diabetic foot infection or
gangrene
 Neoplasm: Cancerous bone or soft tissue tumors
 Trauma
 Deformities : Deformities of digits and/or limbs, Extra
digits and/or limbs
 Infection: Bone infection (osteomyelitis)
 Legal punishment: Amputation is used as a legal
punishment in a number of countries, among them Iran,
Yemen, Saudi Arabia, Sudan, and Islamic regions of
Nigeria

10. The Seven d’s for amputation are as follows.
 A dead limb: e.g. vascular gangrene.
 A dying limb: e.g. TAO, frost bite, Burn etc.
 A destroyed limb: e.g. crush injury.
 A denervated limb: e.g. hereditary sensory neuropathy,
brachial plexus injury.
 A dangerous limb: e.g. malignant bone tumor, gas gangrene.
 A deformed limb: abnormalities in growth and development
 A damned nuisance: loss of function, gross deformity,
deformities of digits/limbs

11. Guillotine or Open Amputation:
 An amputation after which the stump is left unsutured
(without skin flap closure) for several weeks while debrid-
ement and antibiotic therapy are carried out.
 Closing the stump before the wound is free from bacteria
or debris increases the risk of infection and compromises
healing.

12. Fig:Open amputation

13.  Closed Amputation :
Amputation in which flaps are made from skin
and subcutaneous tissue and sutured over the
bone end of the stump; called also flap
amputation.

14. Fig:Close amputation

15.  Forequarter amputation: Scapula + lateral 2 /3
of clavicle + amputation of whole upper limb
 Shoulder disarticulation: Removal through the
glenohumeral joint
 Above elbow amputation: Through the arm
 Elbow disarticulation: Through the elbow joint.

16.  Below elbow amputation: Through the forearm
bones
 Wrist disarticulation: Through the radiocarpal
joint
 Ray amputation: Removal of a finger with
respective metacarpal from carpometacarpal joint
 Krukenburg's amputation: Making 'forceps'
with two forearm bones

18. Fig: Krukenburg amputation

19. Fig: Ray amputation

20.  Hindquarter amputation: Whole of the lower
limb with one side amputation of the Ilium being
removed
 Hip disarticulation: Through the hip joint
 Above knee amputation: Through the femur
 Knee disarticulation : Through the knee joint

21.  Below knee amputation: Through the tibia-fibula
 Syme's amputation : Through the ankle joint
 Chopart's amputation: Through talonavicular
joint
 Lisfranc's amputation: Through intertarsal joints

23. Fig:Syme’s amputation

24. Fig: Chopart amputation

25. Fig: Lisfranc’s amputation

27.  History collection
 Physical examination
 The diagnostic assessments include the usual
preoperative blood studies and radiographs to
determine the level of amputation.

28.  Arteriography may be done to determine the level of
blood flow in the extremity.
 Doppler studies are used to measure blood flow
viscosity.
 Transcutaneous oxygen level may also be measured.

29.  Tourniquet is always used except in a case of vascular
disease.
 Flaps are marked properly before the skin incision is
made.
 Designing equal antero-posterior flaps is desirable.
 The procedure should aim at designing an ideal
stump.
 Skin division is the farthest, followed by fascia,
muscle and the bone.

30.  Sharp spikes of bone are trimmed and made round.
 Skin flap: good skin coverage is important to helps in
preventing from edema or swelling . Skin should be
mobile and sensitive.
 Method of muscle suture:
1. Myodesis: muscle is suture to bone through drill holes
2. Myoplasty: The muscle is sutured to other muscle
and then placed over the end of the bone .

31.  The major vessels are to be perfectly ligated.
 Tourniquet is always released before closure
and hemostasis achieved.
 Wound always closed over a drain.
 Regular stump exercises are to be done to
prevent joint contractures
 Level of amputation: efforts should be made to
preserve all the possible limb length, keeping
in mind the prosthesis to be fit.

32.  Haematoma
 Infection
 Skin flap necrosis
 Deformities of the joints
 Neuroma
 Pantom sensation

33.  Phantom sensation are feelings that the amputated
part is still present. Although these sensation are
often referred to as phantom pain , not all of the
sensation are painful.
 The patient may describe unusual sensations, such
as numbness,, warmth, cold, itching as well as a
feeling that the extremity is present, crushed,
cramped, or twisted in an abnormal position

34.  Phantom sensation are caused by intact peripheral nerves
proximal to the amputation site that carried messages
between the brain and the now amputated part.
 Amputees may experience phantom limb pain soon after
surgery or 2 to 3 months after amputation. It occurs
more frequently in above-knee amputations. Phantom
sensations diminish over time. It gradually decreases
over the next 2 years.

35.  Pain is usually burning, cramping, squeezing, or
shooting in nature.
 May occur in large number of clients.
 It is thought to be caused by combination of
physiologic and psychological components.
 Phantom pain occurs most often in clients who had
pain in the limb before the amputation.
 Distraction techniques and activity are helpful.

37. There are numerous theories about the causes of
phantom limb pain including peripheral, central and
spinal theories:
 Peripheral Theories
 Remaining nerves in the stump grow to form
neuromas, which generate impulses. These impulses
are perceived as pain in the limb which has been
removed.
 After changes in the severity of phantom limb pain
were noted in different temperatures, another theory
says that cooling of the nerve endings increases the
rate of firing of the nerve impulses, which are
perceived by the patient as phantom limb pain

38. Central Theories
 Melzack proposed that the body is represented in the
brain by a matrix of neurons. Sensory experiences
create a unique neuromatrix, which is imprinted on the
brain. When the limb is removed, the neuromatrix tries
to reorganise, but the neurosignature remains due to the
chronic pain experienced prior to the amputation. This
causes phantom limb pain after amputation.
Spinal Theories
 When peripheral nerves are cut during amputation,
there is a loss of sensory input from the area below the
level of amputation. This reduction in neurochemicals
alters the pain pathway in the dorsal horn

39. 39

41.  The extremity of limb left after amputation.
 The distal end of a limb left after AMPUTATION; called
residual limb.

42.  In below-knee amputations: 10.0–12.5 cm from the Tibial
tuberosity.
 In above-knee amputations: 22.5–25.0 cm from the
greater trochanter.
 In above and below elbow amputations: 20.0 cm from the
Acromion process and the Olecranon process respectively.
 These stump lengths recommended, are not constant.
 The length varies depending on the length of the limb. It is
useful in determining the length of prosthesis

43.  Conical shape
 Ideal length
 Good muscle power
 Non-adherent scar
 No fixed deformity
 Absence of neuroma
 Bone well covered by
muscles
 Muscular and not
flabby
 Free of infection

44. Stump care
 Keep the skin on the surface of stump clean to reduce
the risk of it becoming irritated or infected.
 Gently wash your stump at least once a day (more
frequently in hot weather) with mild unscented soap
and warm water, and dry it carefully.
 If you have a prosthetic limb, you should also regularly
clean the socket using soap and warm water.

45.  When taking a bath, avoid leaving your stump
submerged in water for long periods because the water
will soften the skin on your stump, making it more
vulnerable to injury.
 Skin becomes dry, use a moisturizing cream before
bedtime or when wearing your prosthesis.
 Wearing one or more socks around their stump helps
absorb sweat and reduces skin irritation.

46.  The size of your stump may change as the swelling goes
down, so the number of socks you need to use may vary.
Socks should be changed every day.
Check your stump carefully every day for signs of
infection, such as:
 warm, red and tender skin
 discharge of fluid or pus
 increasing swelling

47. Pharmacological management
Nursing management
Rehabilitation

48. Medications that may be used to help relieve pain include:
 Non-steroidal anti-inflammatory drugs (NSAIDs): such
as ibuprofen
 Anticonvulsants : such as carbamazepine or gabapentin
 Antidepressants : such as amitriptyline or nortriptyline
(these medications work directly on the nerves in your leg)
 Opioids : such as codeine or morphine
 Corticosteroid

49. Pre-operative management:
 Before surgery, the nurse must evaluate: the neurovascular
and functional status of the extremity through history and
physical assessment.
 If the patient has experienced a traumatic amputation, the
nurse assesses the function and condition of the residual limb.
The circulatory status and function of the unaffected extremity.
 Build the patient's strength by implementing muscular exercise

50. Exercises for the unaffected limbs.
 Improve the patient's nutritional status by encouraging a
balanced diet high in vitamins and minerals and with adequate
protein to enhance wound healing.
 Maintain adequate hydration.
 Follow the physician's orders for therapeutic measures used
to stabilize any chronic medical conditions such as diabetes,
hypertension, that may interfere with surgery or rehabilitation.

51.  If ordered, arrange preoperative counseling with the
physical therapist.
 If a mobilization aid such as a walker or crutches is to be
used postoperatively, it is easier to provide instruction in
the preoperative period.
 The physical therapist will also inform the patient about
his postoperative rehabilitation program.
 If authorized by the physician, schedule a visit from the
prosthetic specialist

52.  . This may help to alleviate some of the patient's anxieties
about the fitting and wear of prosthetic devices.
 Hemodynamic evaluation is performed through testing:
angiography, arterial blood flow
 Cultural and sensitivity test of draining wounds: to assist in
control of infection preoperatively
 Evaluation of any concurrent health problems (eg:
dehydration, anemia)

53. NURSING DIAGNOSIS :
 Acute pain related to amputation.
 Impaired physical mobility related to loss of
extremity.
 Situational Low Self-Esteem related to loss of body
part/change in functional abilities.
 Disturbed body image related to amputation of body
part
 Impaired skin integrity related to surgical amputation

54.  Self-care deficit: feeding, bathing/hygiene,
dressing/grooming, or toileting, related to loss of
extremity .
 Risk for Infection related to post-operative
procedure.
 Risk for disturbed sensory perception: phantom
limb pain related to amputation .
 Risk for anticipatory and/or dysfunctional
grieving related to loss of body part .

55. Nursing diagnosis:
 Acute pain related to amputation
Nursing intervention:
 Assess the level of pain, intensity and duration.
 Keep patient in comfort position .
 Keep stump elevated .
 Measure stump size in every shift.
 Provide patient with diversional therapy.
 Administer analgesic as prescribed and patients need.

56. Nursing diagnosis:
 Impaired Physical Mobility related to loss of extremity
Expected outcome:
 Client will demonstrate techniques/behaviors that
enable resumption of activities
Nursing intervention:
 Demonstrate and assist with transfer techniques and use
of mobility aid like crutches/walker
 Provide stump care on a routine basis

57.  Rewrap stump immediately with an elastic
bandage, elevate if “immediate or early” cast is
accidentally dislodged. Prepare for reapplication
of the cast.
 Encourage active and isometric exercises for
unaffected limbs.
 Provide trochanter rolls as indicated.
 Assist with ambulation.

58. Nursing diagnosis:
 Situational Low Self-Esteem related to loss of body
part/change in functional abilities.
Expected outcome:
 Client will develop realistic plans for adapting to new
role/role modifications.
Nursing intervention:
 Assess and consider patients preparation for and view of
amputation.
 Help the amputee cope with his altered body image.

59.  Encourage expression of fears, negative feelings and grief
over the loss of body part.
 Provide psychological support to patient.
 Ascertain individual strengths and identify previous
positive coping behaviors.
 Encourage and provide for a visit by another amputee
especially one who is successfully rehabilitating.
 Note withdrawn behavior, negative self talk, use of denial.

60. Nursing diagnosis:
 Risk for Infection related to post-operative procedure.
Expected outcome:
 Achieve timely wound healing; be free of purulent drainage
or erythema, and be afebrile.
Nursing intervention:
 Monitor vital signs, clean the wound and give tetanus
prophylaxis and antibiotics as order
 Flush the wound with sterile saline solution, apply a sterile
pressure dressing.

61.  Maintain aseptic technique when changing dressing
and caring for the wound.
 Inspect dressings and wound, note characteristics of
drainage, and send for culture and sensitivity.
 Maintain patency and routinely empty drainage device.
 Expose stump to air; wash with mild soap and water
after dressing are discontinued.
 Administer antibiotics as indicated.

62. Nursing diagnosis:
 Risk for Ineffective Tissue Perfusion related to reduced arterial/venous
blood flow.
Expected outcome:
 Client will maintain adequate tissue perfusion as evidenced by
palpable peripheral pulses, warm/dry skin, and timely wound healing.
Nursing intervention:
 Monitor vital signs, palpate peripheral pulse,assess neurovascular
function
 Inspect dressings and drainage device ,noting amount and
characteristics of drainage.

63.  Apply direct pressure to the bleeding site if
hemorrhage occurs.
 If the patient experience throbbing after the stump is
wrapped the bandage may be too tight.
 Check the bandage regularly
 Report persistent or unusual pain in the operative site.
 Evaluate for homan’s signs
 Monitor PT and activated partial thromboplastin time.
 Encourage and assist with early ambulation.
 Administer low dose anticoagulant as indicated.

64. PROSTHESIS:
 Prosthetics is a unit of rehabilitation medicine dealing
with the replacement of whole or a part of a missing
extremity with an artificial device.

65. Commonly used prosthesis are:
 Above knee amputation: Quadrilateral socket
prosthesis
 Below knee amputation: Patellar tendon bearing
prosthesis
 Syme’s amputation: Canadian syme’s prosthesis
 Partial foot amputation: Shoe fillers

66. Fig:Quadrilateral and patellar tendon bearing prosthesis

67. Fig: Canadian syme’s
prosthesis
Fig:Shoes fillers

68. Fig: Above elbow
amputation
Fig:Below elbow amputation

69. Prosthesis care:
 Remove sweat and dirt from the prosthesis socket daily
by wiping the inside of the socket with damp soapy
cloth and dry thoroughly.
 Never attempt to adjust or mechanically alter the
prosthesis. If problems develop, consult the prosthesist.
 Schedule a yearly appointment with the prosthesist.

70.  A Functional Outcome Study was conducted on, “Lower
Extremity Amputations Around the Knee Joint” in
2019. A complete enumeration method was used, and all
the amputees between 2005 and 2017 were included in the
study. Of the 520 amputees, 275 trauma related amputees
were available for interview. Structured questionnaire and
SF-36 was used for the general information and functional
outcome respectively. Telephone conversation was done to
know the functional outcome and some of the participants
were called to our center for the face to face interview.

71.  Only above knee, through knee and the below knee
amputation cases were included in the study. Of the 275
study participants 214 were male, 166 had below knee,
92 had above knee and 17 had through knee amputation.
 The result showed that the average age of amputees was
33 years (7 to 90 years) 22% female and 78 % were
males. 53 % were between 20 to 40 years.
 Most common level of amputation was below knee
amputation (60.33%) followed by above knee (33.6 %)
and through knee amputation (6%). Only 46 % of all
amputees used a prosthesis. Main reason for not using
prosthesis was no access and poor economic status.
Main complain among the prosthesis user was difficulty
in walking for long distance.

72.  78% of prosthesis users were involved in farming whereas
13% had their own business. 65% amputees belonged to
literate group.
 The study concluded that trauma was found to be the most
common cause of amputation around the knees. More than
half the patients were not using prosthesis. Amputees using
prosthesis, had better physical and mental health functional
outcomes.
(Nitesh K Karn, Ishor Pradhan, Bibek Banskota. B & B Hospital,
Gwarko, Lalitpur, Nepal and Hospital and Rehabilitation Centre for
Disabled Children (HRDC), Janagal, Kavre, Nepal in 2019)

73.  Shenoy, RM..(2014) Essentials of ORTHOPEDICS 2nd ed.
Nepal: Jaypee Brothers medical publishers (p) Ltd.
 Maheshwari ,J. and Mhaskar V. (2015) Essential
orthopaedics. 5th edition, India: Jaypee
 Brunner and suddharth’s , (2009). Textbook of Medical –
surgical Nursing ,.11th edition. India: Wolters Kluwer
 http://hrdcnepal.org/Content/EditorImages/files/06_%20Dr_
%20Nitesh%20Lower%20Extremities%20Amputation.pdf

74.  Järnhammer A, Andersson B, Wagle PR, Magnusson L.
Living as a person using a lower-limb prosthesis in Nepal.
Disabil Rehabil. 2018 Jun;40(12):1426-1433. doi:
10.1080/09638288.2017.1300331. Epub 2017 Mar 21.
PMID: 28320228.
 Viswanathan V, Nachimuthu S. Major Lower-Limb
Amputation During the COVID Pandemic in South India. Int
J Low Extrem Wounds. 2021 May 28:15347346211020985.
doi: 10.1177/ 15347346211020985. Epub ahead of print.
PMID: 34047626.
 Retrieved on Amputation causes, types of amputation and
amputation complications (healthjade.net)