This document discusses pain management, skin disorders, and psychological consequences related to amputation. It covers different types of pain experienced after amputation like immediate postoperative pain and phantom limb pain. Skin issues from poor hygiene, infections, and reactions to the prosthetic are examined. Management of pain, skin conditions, and the important role of psychology in adapting to life with an amputation are summarized.

2.  Pain Management
 Skin Disorders and Their Management
 Psychological Consequences of Amputation

3.  Amputation is just the beginning and not the end of a
treatment! The amputation surgeon and prosthetist have
joined together to become the lifelong advisors to the
amputee who will wear an artificial limb for the rest of
his life.
 A dermatologist is capable of rendering valuable aid to
not only the amputee but also other members of the
rehabilitation team, for he is familiar with the problems
of the skin that can result from the wearing of an
artificial limb.

5.  Post-amputation Limb pain is often the result of
surgical trauma, wound healing complications, tissue
loading effects, local scarring, and central neuropathic
phenomenon. Limb pain may be categorized as
immediate post-operative pain, extrinsic residual limb
pain, intrinsic residual limb pain, and phantom limb
pain. Unfortunately, most authors have not
discriminated carefully between residual limb pain
and phantom limb pain which makes the literature
confusing as to the incidence and prevalence of each
of these postamputation pain problems.

6.  Immediate postoperative pain is almost always present
following amputation and is the direct result of the
surgical trauma to bone, nerve, and soft tissue.
 Postoperative pain can be expected to resolve within
three weeks or less, as with pain following any major
surgical procedure
 This pain is often described as sharp, is localized to the
surgical site, is usually self limiting, and resolves as the
edema decreases and the surgical wound heals.

7.  Management
› In the immediate postoperative period the primary method
of pain control is medication utilizing intravenous or
epidural delivery of pain medication via patient controlled
analgesia.
› The patient is commonly transitioned to oral analgesic
medication by post-operative day 3 or 4.
› The adjunctive measures for edema include elastic wraps,
elastic stump socks, semi-rigid dressings, and rigid plaster
casts.

8.  Extrinsic residual limb pain is usually mechanical in
origin related to the prosthetic socket or other prosthetic
components.

9.  Intrinsic residual limb pain is often due to
› underlying disease process
› surgical trauma
› bone abnormality
› local scar
› neuroma
› central neuropathic phenomenon.

10.  Residual limb pain may result from infection,
ischemia, tumor recurrence, joint dysfunction, or
stress fractures.
› The pain is often described as generalized and
usually requires medical or surgical intervention.

11.  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 vascularization of the muscles and skin.

12.  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
spicule.
 Management
› The pain is often managed by socket modifications to offload
pressure over painful areas. When prosthetic modification is not
satisfactory surgical intervention is usually required.

13.  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
› Initial treatment usually includes prosthetic
modifications to reduce loading of pressure sensitive
areas through a better distributed load or reduced
shear force on adjacent tissues.
› Treatment may also include injections as well as
medication intervention. Surgical intervention rarely
provides adequate relief for intrinsic residual limb
pain secondary to scar formation.

14.  Neuromas at the surgical site are the most common
etiology of intrinsic residual limb pain.
 Neuromas result of the normal nerve re-growth during
the healing process.
 Treatment
› Medical intervention for limb pain resulting from neuromas have
utilized nonsteroidal anti-inflammatory drugs, tricyclic anti-
depressants, and anti-convulsants with limited success.

15.  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).

16.  The phantom limb is the perceived presence of the
amputated body part.
 Phantom limb experience was first referenced by
d'Ambroise Pare, a 16th century military surgeon for
Napoleon, in 1551.
 Silas Weir Mitchell, a Civil War surgeon, was the first to
use the term phantom limb pain in a scientific report in
1871.

18.  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.

19.  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, and
persistence of infected 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.

20.  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.

24.  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.

26.  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.

27.  A number of authors have described the appearance of
multiple cysts, frequently called post-traumatic
epidermoid cysts, in the skin of amputees' stumps in
association with the wearing of an artificial limb.

29.  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.

34.  An irritated cutaneous papilloma can be snipped off and
the base cauterized.

35.  Chronic ulcers of the stump may result from bacterial
infection or from poor cutaneous nutrition secondary to
edema or to an underlying vascular disorder. In some
instances localized pressure from a poorly fitting
prosthesis can produce erosion followed by ulceration.

36.  Amputation surgeons, prosthetists, and engineers are applied
scientists from whom great technical assistance is expected.
Through their efforts, we have made great strides in our knowledge
and technical ability to produce the finest of prostheses, but their
skills must be combined with the contributions of the dermatologist
in the solution of the many skin problems of the amputee.

38.  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.

39.  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

40.  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.

41.  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.