What is amputationWhat is amputation

• intentional surgical removal of a limb or intentional surgical removal of a limb or body part. It is performed to remove body part. It is performed to remove diseased tissue or relieve diseased tissue or relieve painpain. .

• Most amputations involve small body Most amputations involve small body parts such as a finger, rather than an parts such as a finger, rather than an entire limbentire limb

• About About 65,00065,000 amputations are amputations are performed in the United States each performed in the United States each year. year.

Why perform amputation?Why perform amputation?

• Amputation is performed for the Amputation is performed for the following reasons:following reasons:• to remove tissue that no longer has to remove tissue that no longer has

an adequate blood supplyan adequate blood supply• to remove malignant tumorsto remove malignant tumors• because of severe trauma to the body because of severe trauma to the body

partpart

• The blood supply to an extremity can The blood supply to an extremity can be cut off because of injury to the be cut off because of injury to the blood vessel, hardening of the blood vessel, hardening of the arteries, arteries, arterial embolismarterial embolism, impaired , impaired circulation as a complication of circulation as a complication of diabetes mellitusdiabetes mellitus, repeated severe , repeated severe infection that leads to infection that leads to gangrenegangrene, , severe frostbite, severe frostbite, Raynaud's diseaseRaynaud's disease, , or or Buerger's diseaseBuerger's disease. .

What is acquired What is acquired amputation?amputation?

• The loss of part or The loss of part or all of extremity as all of extremity as a direct result of a direct result of trauma or by trauma or by surgery.surgery.

What is congenital What is congenital amputation?amputation?

• The absence of part or all of an The absence of part or all of an extremity at birth.extremity at birth.

What is elective What is elective amputation?amputation?

• This is performed when the hand This is performed when the hand or entire limb has no sensation and or entire limb has no sensation and function as a result of brachial function as a result of brachial plexus injury.plexus injury.

What is an open What is an open amputation?amputation?

• Amputation in which the surface of Amputation in which the surface of the wound is not covered with skin the wound is not covered with skin but left unclosed. This is done to but left unclosed. This is done to control infection.control infection.

What is closed What is closed amputation?amputation?

• Usually a final or definitive Usually a final or definitive amputation performed to create a amputation performed to create a stump that can be used effectively stump that can be used effectively with a prosthesis.with a prosthesis.

What is minor What is minor amputation?amputation?

• Amputation Amputation through of distal through of distal to the metacarpus to the metacarpus or to the or to the metatarsus.metatarsus.

What is major What is major amputation?amputation?

• Amputation proximal to the Amputation proximal to the metacarpal or metatarsal bones.metacarpal or metatarsal bones.

What is a disarticulation?What is a disarticulation?

• Amputation performed through a Amputation performed through a jointjoint

What are the causes of What are the causes of amputation?amputation?

• 11stst year of life year of life

Congenital deficienciesCongenital deficiencies• 1 to 10 years of age.1 to 10 years of age.

Motor vehicular accidents, tumor and Motor vehicular accidents, tumor and trauma.trauma.

• 10 to 20 years of age10 to 20 years of age

Malignancy is the most common cause.Malignancy is the most common cause.• 55 years of age55 years of age

Peripheral vascular diseasePeripheral vascular disease

• The right arm is more frequently The right arm is more frequently involved in work related injuries.involved in work related injuries.

Lower Extremity Lower Extremity AmputationAmputation

• The major cause of LE amputation id The major cause of LE amputation id peripheral vascular accidentperipheral vascular accident

• The most common cause of PVD is The most common cause of PVD is atherosclerosisatherosclerosis

• After PVD the second leading cause is After PVD the second leading cause is traumatrauma

• This is followed by tumors (Osteogenic This is followed by tumors (Osteogenic sarcoma) and last by congenital cases.sarcoma) and last by congenital cases.

Congenital AmputationsCongenital Amputations

Causes:Causes:• Intrauterine developmentIntrauterine development• HereditaryHereditary• Teratogenic agentsTeratogenic agents• Maternal diabetesMaternal diabetes

What are the classification of What are the classification of congenital amputation?congenital amputation?

• AmeliaAmelia

Complete absence of the entire upper Complete absence of the entire upper extremity or lower extremity.extremity or lower extremity.

• Hemimelia or MeromeliaHemimelia or Meromelia

Partial limb absencePartial limb absence• Acheiria Acheiria

Terminal transverse hemimelia, wrist Terminal transverse hemimelia, wrist levellevel

Amelia Hemimelia

• AdactyliaAdactylia

Absent digitAbsent digit• ApodiaApodia

Absent footAbsent foot• PhocomeliaPhocomelia

Transverse total humeral radial , Transverse total humeral radial , ulnar deficiencyulnar deficiency

Franz and O’Rahilly Franz and O’Rahilly ClassificationClassification

• Terminal Terminal

Complete loss of the distal end of an extremityComplete loss of the distal end of an extremity• IntercalaryIntercalary

Absence of intermediate parts with preserved Absence of intermediate parts with preserved proximal and distal component of the limb.proximal and distal component of the limb.

• Transverse/HorizontalTransverse/Horizontal

Absence of all skeletal elements distal to the Absence of all skeletal elements distal to the deficiency along a designed transverse axis. deficiency along a designed transverse axis.

PercentagesPercentages

Above ElbowAbove Elbow

0% - Shoulder Disarticulation0% - Shoulder Disarticulation

0-30% - Humeral Neck0-30% - Humeral Neck

30-50% - Short Above Elbow30-50% - Short Above Elbow

50-90% - Long Above Elbow50-90% - Long Above Elbow

Below Elbow Below Elbow

0-35% very short below elbow0-35% very short below elbow

35-55% short below elbow 35-55% short below elbow

55-90% long below elbow55-90% long below elbow

90-100% wrist disarticulation90-100% wrist disarticulation

Percentages for Above and Percentages for Above and Below Knee Levels Below Knee Levels

• DelisaDelisa• <33% short above knee or below <33% short above knee or below

knee stump.knee stump.• 33-36% medium length below 33-36% medium length below

knee or above knee stump.knee or above knee stump.• >66% long above knee or below >66% long above knee or below

knee stump.knee stump.

• SullivanSullivan• TranstibialTranstibial

>50% of tibial length – long below >50% of tibial length – long below knee knee

20-50% - below20-50% - below

<20% of tibial length – short below <20% of tibial length – short below kneeknee

What contractures are common for What contractures are common for lower extremity amputations?lower extremity amputations?

• For below knee amputeesFor below knee amputees

Knee flexion contracturesKnee flexion contractures• For above knee amputeesFor above knee amputees

Hip abduction and flexionHip abduction and flexion

Symes AmputationSymes Amputation

• An amputation at the ankle with An amputation at the ankle with removal of the malleoli and formation of removal of the malleoli and formation of a heel flap. a heel flap.

• The Symes amputation can be one of The Symes amputation can be one of the best amputation of the lower the best amputation of the lower extremity.  extremity.  • When it is done right, it creates an excellent When it is done right, it creates an excellent

end-bearing stump and  allows for a end-bearing stump and  allows for a functionally most satisfactory prosthesis.  functionally most satisfactory prosthesis. 

• The talus and calcaneus were The talus and calcaneus were removed.removed.

• The level of the amputation in The level of the amputation in generally at the distal tibia and generally at the distal tibia and fibula 0.6cm proximal to the fibula 0.6cm proximal to the periphery of the ankle joint and periphery of the ankle joint and passing through the dome of the passing through the dome of the ankle centrally.  ankle centrally. 

ChopartChopart

• This is an amputation where the This is an amputation where the talus and calcaneus are preserved.talus and calcaneus are preserved.

• forefoot/midfoot level procedure forefoot/midfoot level procedure and suffers from gait disturbances and suffers from gait disturbances during walking.  during walking. 

• prone to form an equinus prone to form an equinus deformitydeformity

Lisfranc AmputationLisfranc Amputation

• Amputations proximal to the Amputations proximal to the transmetatarsal level often result transmetatarsal level often result in considerable gait problems in considerable gait problems during walking.  This is secondary during walking.  This is secondary to the loss of support and push-off. to the loss of support and push-off.    

Transmetatarsal AmputationTransmetatarsal Amputation

• The transmetatarsal amputation is more The transmetatarsal amputation is more disabling than simple toe amputations, disabling than simple toe amputations, but as in the toe amputations there is no but as in the toe amputations there is no need for a prosthesis other than a shoe need for a prosthesis other than a shoe filler.   The loss of push-off in the absence filler.   The loss of push-off in the absence of a positive fulcrum in the ball of the of a positive fulcrum in the ball of the foot is chiefly responsible for impairment foot is chiefly responsible for impairment of gait.  The more proximal the of gait.  The more proximal the amputation, the more disability is amputation, the more disability is present.  present. 

What is Phantom Pain?What is Phantom Pain?

• This is a normal sensation This is a normal sensation occurrence after amputation of a occurrence after amputation of a limb. The part amputated is still limb. The part amputated is still present.present.

What are the Types of What are the Types of Phantom Pain?Phantom Pain?

• Cramping (most common)Cramping (most common)• Electric shockElectric shock• BurningBurning• Squeezing and wrenchingSqueezing and wrenching

What are the Steps for What are the Steps for Prosthetic Management?Prosthetic Management?

• PreprostheticPreprosthetic• Pre-OperativePre-Operative• OperativeOperative• Post-OperativePost-Operative• Prosthetic Fitting and TrainingProsthetic Fitting and Training• Prosthetic Follow-Up CareProsthetic Follow-Up Care

• PreoperativePreoperative• Evaluation and AssessmentEvaluation and Assessment• Emotional CounselingEmotional Counseling• Therapy CounselingTherapy Counseling

• Operative ManagementOperative Management• The cardinal rule is to preserve as The cardinal rule is to preserve as

much as length as possible.much as length as possible.• Avoid the following level:Avoid the following level:

• HindfootHindfoot• Distal 1/3 of the legDistal 1/3 of the leg• Supracondylar of femurSupracondylar of femur

• Muscles are just distal to the level of Muscles are just distal to the level of intended bone section.intended bone section.

• Bone must be bevelled and should be Bone must be bevelled and should be covered with a good padding of the covered with a good padding of the tissue.tissue.

• Nerves should be pulled before cutting Nerves should be pulled before cutting to retract.to retract.

• Blood vessels (major blood vessels are Blood vessels (major blood vessels are ligated the smaller ones are cauterized).ligated the smaller ones are cauterized).

• Skin closureSkin closure• Above knee amputee-fish mouth or Above knee amputee-fish mouth or

middle flap.middle flap.• Below knee amputee-posterior Below knee amputee-posterior

flap/anterior suture.flap/anterior suture.

• Post-Operative ManagementPost-Operative Management• Healing of woundsHealing of wounds• Pain controlPain control• Preparation for prosthetic fittingPreparation for prosthetic fitting• Maintenance of range of motionMaintenance of range of motion• Independent mobilityIndependent mobility• Independent self-careIndependent self-care

What muscles need to be What muscles need to be strengthened for crutch walking?strengthened for crutch walking?

• Shoulder depressorsShoulder depressors• Shoulder adductorsShoulder adductors• Flexor, extensor and abductor of the Flexor, extensor and abductor of the

armarm• Extensor of the forearm at the elbow.Extensor of the forearm at the elbow.• Wrist extensorWrist extensor• Finger and thumb flexors.Finger and thumb flexors.

• Post-Operative DressingPost-Operative Dressing• RigidRigid

• Made of Plaster of ParisMade of Plaster of Paris• Change every 5-10 days.Change every 5-10 days.

• AdvantagesAdvantages• Limits post-operative edemaLimits post-operative edema• Allows for early ambulationAllows for early ambulation• Reduces length of time for shrinkingReduces length of time for shrinking

• DisadvantagesDisadvantages• Requires careful applicationRequires careful application• Requires close supervisionRequires close supervision• Does not allow early wound Does not allow early wound

inspectioninspection

• Semi-RigidSemi-Rigid• The Unna Paste DressingThe Unna Paste Dressing

• A compound of zinc oxide, gelatin, glycerin A compound of zinc oxide, gelatin, glycerin and calamine maybe applied in the and calamine maybe applied in the operating room.operating room.

• AdvantageAdvantage• Better control of edemaBetter control of edema

• DisadvantageDisadvantage• May loosen easilyMay loosen easily

• Soft DressingSoft Dressing• Oldest method of post-surgical Oldest method of post-surgical

managementmanagement

of residual limb.of residual limb.

• AdvantageAdvantage• InexpensiveInexpensive• Lightweight and readily availableLightweight and readily available• Easily laundered Easily laundered

• DisadvantageDisadvantage• Poor control of edemaPoor control of edema• Requires skill of applicationRequires skill of application• Need frequent reapplicationNeed frequent reapplication• Can slip and form a torniquetCan slip and form a torniquet

What are the appropriate sizes of What are the appropriate sizes of bandages for amputees?bandages for amputees?

• For above knee amputees two 6 For above knee amputees two 6 inches bandages sewn together inches bandages sewn together and one 4 inch bandage.and one 4 inch bandage.

• For below knee amputee two 4 For below knee amputee two 4 inch elastic bandage can be used.inch elastic bandage can be used.

What is the golden age of What is the golden age of prosthetic fitting?prosthetic fitting?

• It is the first 30 days following the It is the first 30 days following the amputation.amputation.

• ActivitiesActivities• Learn to put prosthesisLearn to put prosthesis• WeightshiftingWeightshifting• Progressive ambulation between parallel Progressive ambulation between parallel

barsbars• Walker-crutches-cane-unassisted on flat Walker-crutches-cane-unassisted on flat

surfaces.surfaces.

• Uneven terrain-stairs-ramps-curbsUneven terrain-stairs-ramps-curbs• Falling and getting-upFalling and getting-up• Transfer activities.Transfer activities.

What are the different energy What are the different energy expenditures for amputees?expenditures for amputees?

• Single BKASingle BKA 9-28% 9-28%• Double BKADouble BKA 41-100% 41-100%• Single AKASingle AKA 40-65% 40-65%• Double AKADouble AKA 150% 150%• Single AKA and BKASingle AKA and BKA 75% 75%• Unilateral hemipelvectomy Unilateral hemipelvectomy

with prosthesiswith prosthesis 125% 125%

What are the different energy What are the different energy expenditures for amputees?expenditures for amputees?

• Single BKASingle BKA• Double BKADouble BKA • Single AKASingle AKA • Double AKADouble AKA • Single AKA and BKASingle AKA and BKA • Unilateral hemipelvectomy Unilateral hemipelvectomy with prosthesiswith prosthesis• Crutch ambulation without prosthesis Crutch ambulation without prosthesis

• Wheelchair Wheelchair

What are the functional What are the functional classifications of amputees?classifications of amputees?

• Class 1 Full RestorationClass 1 Full Restoration• The individuals is functionally The individuals is functionally

equivalent to normalequivalent to normal

• Class 2 Partial RestorationClass 2 Partial Restoration• The artificial limb is completely The artificial limb is completely

functional. The person is able to work functional. The person is able to work and engage in sports but on a and engage in sports but on a selective basis.selective basis.

• Class IIIClass III• Self-Care PlusSelf-Care Plus

The individual is disabled and has The individual is disabled and has physical limitation, requires frequent physical limitation, requires frequent adjustment of prosthesis.adjustment of prosthesis.

• Class IVClass IV• Self-Care MinusSelf-Care Minus Needs help from others because he is Needs help from others because he is

severely disabled. Cannot go up and severely disabled. Cannot go up and down the stairs without assistance.down the stairs without assistance.

• Class VClass V• Cosmetic PlusCosmetic Plus

The amputee is better off without a The amputee is better off without a prosthesisprosthesis

• Class VIClass VI• Not feasible. Only a wheelchair is Not feasible. Only a wheelchair is

prescribed.prescribed.