1. Amputation involves cutting through bone or joint to remove part or all of a limb. It is usually done as a treatment for a dead, dangerous, or severely problematic limb. 2. Several factors determine the appropriate level of amputation, including the patient's age, underlying condition, and goals for mobility. 3. Proper rehabilitation following amputation, including exercises, stump care, desensitization, and eventually prosthesis training, can help patients regain function and mobility. Complications are minimized with a coordinated post-op care plan.

1. Amputation of
extremities
Professor doctor
Seif Elden M. A. Farag
Professor of Physical Medicine, Rheumatology and
Renabilitatiom

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

6. Dangerous limb
1. Malignant tumors
2. Lethal sepsis
3. Crush injury
leading to crush
syndrome

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

10. Definitive non-end-
bearing
O Commonest variety
O All upper limb & most lower limb
amputations are come under this type
O The scar can be terminal

11. Amputation
s at the
sites of

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

14. Principles
of technique

15. O Tourniquet is
used unless
there is vascular
insufficiency

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

22. Level of amputation

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

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.

27. OStump is the
terminal segment of
the limb remaining
after the amputation

28. Types of the stump
Conical
Bullous
cylindrical

30. Complication
s of the
amputation

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

36. Artery… poor vascularity gives
O cold
O blue color stump
O liable to ulcerate

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.

46. 6- control oedema
7- maintain muscle stregnth
8- desensitization
9- avoid joint contructure

47. Patient positioning

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

52. Desensitization
program
By
O Circular massage
O Gentile tapping and
friction
O Brush with soft cloth

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

54. Daily exercise is a cardinal
protocol

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

58. O Physical and
occupational
therapy to restore
patient mobility and
one limb ADL

59. 3- Prescription and
ambulation stage

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

62. Perambulation exercise
program

63. parellel bar ambulation
activities
Turning
&
Returning
Stepping
Forward
Backward
Standing
Push up
Hip
Hiking
Lateral
Weight
Shift
Anterior
Posterior
Weight
Shift
Standing
Balance
Parallel
Bar
Activities

64. prosthes
is

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

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

70. Functional classification of the
amputee

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

76. thanks