[SEMINAR 2]
Amputation
OUTLINE: Sites of Amputation: UE
I. AMPUTAtion
II. Sites of Amputation: UE
III. Sites of Amputation: LE
IV. Atbp.
REFERENCES:
• Tx2 Trans (Batch 2019), O’Sullivan, ConcePTs
Amputation
• Defined as the surgical removal of a limb or extremity through continuity of
the bone
• Removal of a body extremity by trauma or surgery
• Indications for amputation:
• Gangrene as a complication of PVD or DM
• Improve function/cosmesis due to Congenital deformities
• Badly damaged limbs from 3rd deg. Burns
ETIOLOGY
• Acquired Amputation due to:
• Vascular complication
• major cause of LE amputation
AMPUTATION THROUGH FINGERS (RAY AMPUTATION)
• usually from diabetes
• Thumb
• Trauma
• Most functionally critical digit
• 2nd leading cause
• Important in grasp, vital in pinch
• usually from MVA, war, and gunshot
• 50% of hand function is lost when thumb is amputated
• Tumor or CA or neoplasm
• partial or complete, results in loss of palmer grip, side-to-side
• Infections
pinch, and tip-to-tip pinch
• Thermal Injury
• Index and middle finger
• PNI
• Most important in all 3 functions because of their proximity to the
• Surgical Process
thumb
• Special type of amputation is the discretions of the attending surgeon
• Strongest and most stable
• Approach is to save as much length as possible
• Consideration for the level of amputation include: AMPUTATION ABOUT THE WRIST
• Viability of soft tissues and blood supply • Advantages
• Amount of skin coverage with adequate sensation • Pronation and supination are preserved
• Feasibility for the prosthetic fitting and function • Greater stump adaptability (not as cumbersome/uncomfortable
compared to above the elbow amputations)
TYPES OF SURGICAL PROCESS
• Retains wrist flexion and extension if the amputation is done through
• Equal length anterior and posterior flaps the carpals
• For most transfemoral and transtibial amputations w/o vascular • Amputation through the carpals (midcarpal amputation)
problems • Easily performed since radiocarpal is not invaded
• Long posterior flaps • Rounded to a smooth contour and covered with palmar skin
• Transtibial w/ compromised circulation (posterior tissues have better • Retains natural wrist flexion
blood supply)
• Skew flap AMPUTATION THROUGH THE LOWER THIRD OF THE FOREARM
• Angular medial–lateral incision • Poor since the skin is thin and underlying soft tissue are largely tendons
• Believed by some surgeons to be a better approach for individuals and fascia
with severely compromised distal circulation • Poor since the circulation is not good; the stump is frequently cold, tender
• Myoplasty – muscle to muscle closure and cyanotic
• Myofascial – muscle to fascia closure • 2° skin breakdown is common
• Myodesis – muscle attached to periosteum or bone
• Tenodesis – tendon attached to bone AMPUTATION AT THE JUNCTION OF THE MIDDLE AND THE LOWER
THIRD OF THE FOREARM
• Ideal transradio-ulnar stump (functionally and cosmetically)
• Ideal length: 7”-8’ from the up of the olecranon process to the end of the
stump
• Circulation is good in this area
• Full elbow flexion is very possible
Transcribed by: Colmo, J. and Sotelo, A.
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Topic: Amputation
FOREARM AMPUTATION ABOVE THE IDEAL LEVEL • Balance and weight are distributed in direct proportion to the
• Forearm/elbow flexion may be normal but can be impaired in either its extent and location of loss
range or strength
AMPUTATION THROUGH THE METATARSALS AND ANKLE JOINT
AMPUTATION THROUGH THE HUMERUS
• Disarticulation through the elbow joint
• At the level of the humero-ulnar and humero-radial joint
• Retains near normal rotation of the shoulder
• Transcondylar amputation
• Amputation of the wound through the epicondyles (long above the
elbow stump)
• Hard to fit with a prosthesis
• Through the supracondylar amputation
• Still considered a long above the elbow stump
AMPUTATION ABOVE THE SUPRACONDYLAR AREA
• Ideal Transhumeral stump
• Ideal length 8” from the acromion process to the end of the stump
• Syme’s amputation
• Most functional stump
• Transmalleolar amputation
AMPUTATION ABOUT THE SHOULDER • Designed for weight bearing at the end of the stump
• A functional prosthesis cannot be worn: (worn only for cosmesis: • Provides stability for prosthesis; may be used w/o prosthesis
impractical) • Boyd’s amputation
• 2 possible levels • Weight bearing over calcaneus following removal of the remaining
• Through the surgical neck of the humerus bones of the foot and calcaneotibial arthrodesis
• Disarticulation at the scapulohumeral joint • Vasconecelos amputation
• Done if use of an artificial limb is not anticipated
Sites of Amputation: LE • Midtarsal amputation combined with tibiotalar and subtalar arthrodesis
and section of the inferior surface of the calcaneus
• Pirogoff’s amputation
• Principles of arthrodesis of the tibia to the calcaneus after the latter
has been rotated forward and upward 90° (anterversion)
• Unsuccessful for prosthetic fitting due to its irregular shape
• Lisfranc’s amputation
• Disarticulation of the foot through the tarsometatarsal jont
• Falls into moderate equinus deformity
• Like the Pirigoff’s amputation, it is unsuccessful for prosthetic use
• Chopart’s amputation
• Through the transverse tarsal joint (talonavicular/calcaneocuboid)
• Intended for endbearing
• Prosthetic fitting not possible
AMPUTATION THROUGH THE LOWER LEG
• Ideal shape for transtibio-fibular: Cylindrical
FOOT AMPUTATIONS
• Balance bet. muscle and bony support is lost
• Toes
• Function in tip-toeing
• Amputation results in loss of push-off • Through the lower 3rd of the leg
• Big/great toe • Unsatisfactory adaptation of the stump to the prosthesis
• Has supporting role in stance • Amputation through the middle third
• Fulfills vital function in gait: principal weight bearing element in • Ideal length for a transtibio-fibular amputation
the final phase of heel-off
• 6” (5-7”) from the medial tibial plateau/tibial tubercle to the end of the
• When amputated, the loss is felt more during rapid walking or stump
running
• Quads tend to weaken (vastus med.) since hams tend to pull the
• Lesser Toes stump
• Stabilizes the foot by widening the base of support during
squatting and tip-toeing AMPUTATION THROUGH THE THIGH
• Assists the great toe in push-off in the proximal phalanx results • Ideal shape for transtibio-femoral: Conical
in hallux valgus deformity
• Metatarsal (Ray amputation)
Transcribed by: Colmo, J. and Sotelo, A.
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Topic: Amputation
• Gritti-Stokes amputation Below Elbow
Percentage of Normal Classification
0 – 34% Very Short B/E
35 – 54% Short B/E
55 – 99% Long B/E
100% Wrist Disarticulation
• Measurement
Transhumeral Stump – Normal measurement: from tip of acromion
• Removes condyles w/ 10° bevel, patella anchored inside the end of process to lateral epicondyle
the femur creating an end-bearing stump Transradio-ulnar Stump – normal measurement: from medial
epicondyle to ulnar styloid
• Similar to Syme’s amputation (provides weight bearing and can
withstand excessive strain)
• Utilized sectioned patella fused to the femur at or about the level of
the adductor tubercle
• Ischial bearing amputation
• Ideal for transfemoral amputation
• Ideal length: 10-12” from greater trochanter to the end of the stump
• Illopsoas and gluteus med are unaffected
• Gluteus max abd adductor magnus reduced in volume and werpa
AMPUTATION THROUGH THE THIGH ABOVE THE IDEAL LEVEL
• The shorter the stump, the greater the difficulty in maintaining and
activating the prosthesis B. Lower Extremity
• Greater tendency for contractures • Developed by Task Force on Standardization of Prosthetics-Orthotics
• When the stump is only 3-4” below ischial tuberosity abd adductor tendon Terminology (p.6)
insertion, it is impossible to retain the stump w/in the socket of the • If unilateral:
prosthesis
AMPUTATION ABOUT THE HIP
• Amputation through the trochanters, femoral neck, and hip disarticulation
• Needs to be fitted with a tilt-table type of prosthesis
HINDQUARTER AMPUTATION
• Done only on cases where there is a malignant tumor
• Removal of the pelvis by disarticulation of the symphysis pubis and section
of the posterior portion of the ilium near the SI joint
HEMICORPORECTOMY
• Removal of the entire lower extremity through the last 2 lumbar vertebrae (L
4-5), sacrum, coccyx, half of pelvis
• Involves in the creation of an artificial bladder and rectum • Measurement
Transfemoral stump – normal measurement: Perineum to medial
Levels of Amputation femoral condyle
A. Upper Extremity Transtibio-fibular Stump – Normal measurement: Medial tibial
• If unilateral: plateau to medial malleolus
Above Elbow
%___= length of residual limb x100%
Percentage from Normal Classification length of sound limb
Levels of Impairment
0% Shoulder Disarticulation UE % of impairment
0 – 29% Humeral Neck 1. Thumb 22
2. Index finger 14
30 – 49% Short A/E 3. middle finger 11
4. ring/little finger 5
50 – 89% Standard or Long A/E 6. Wrist 54
6. elbow 57
90– 100% Elbow Disarticulation 7. shoulder 60
8. forequarter 70
BELOW ELBOW AMPUTATI 9. all fingers except thumb 32
Transcribed by: Colmo, J. and Sotelo, A.
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Topic: Amputation
3. Burning, agonizing discomfort – most severe, felt
LE % of impairment throughout the stump and phantom limb.
1. Big toe 5 4. Squeezing, wrenching type
2. other toes 2 (each) 4. Skin problems
3. Chopart’s amputation 21 5. Bone development problem
4. Syme’s amputation 28 • Amputation before 6y/o, no bonedevelopment problems.
6. Scoliosis
Energy Requirements: • Wheelchair dependent.
7. Neuroma
• Pain at the end of the nerve.
8. Psychologic problems
9. Contractures
• Hip flexion/Hip abduction contracture – most common contracture
for Transfemoral amputation
• Knee Flexion contracture - most common for transtibio-fibular
amputation.
10. Edema
Functional Classification of Amputees (UE/LE) Factors to Consider for a Successful Rehabilitation
1. Good and I deal Stump
• Conical – Ideal shape for Transfemoral amputation
• Cylyndrical – Transtibio-fibular amputation
• Not too long or short
• No Dog Ears, painless, mobile, no wound.
• No contractures and edema
• Possess good ms tone
• Can stand pressure when weight is placed,
2. Functional well-fitted prosthesis
3. Proper prosthetic training.
4. Sound Psychological adjustment
A. Pt must be able to accept his limitations
General Factors which affect an amputee with a prosthesis
1. Body build
2. Sex
3. Age
4. Occupation/money
5. Desire/motivation
6. Cooperation
6. need
PT management (LE amputation)
1. Pre-operative Stage
a) Provide psychological support
b) Strengthen crutch walking ms
Problems for Amputees c) Isometrics of affected extremity
1. Phantom Sensation d) Maintain ROM and strength of unaffected extremities and joints
• Pt perceives the amputated limb as still complete (normal occurrence) proximal to affected area
• Not experienced by pts with congenital limb deficiencies or by pts e) Maintain good respiratory function
amputated before the age of 4 f) Maintain independence in ADLs (bed mob)
2. Post-Operative Stage
• Phantom sensation may assist pt in use of prosthesis
a) Prevent infection of stump, respiratory problems and contractures
• Telescoping phenomenon of phantom sensation – after
b) Maintain ROM and strength of unaffected joints
amputation, pt feels extremity is complete but as days go by, it
c) Strengthen Stump ms ( Isometrics -> PREs)
gradually shortens until it is no longer felt. ( it is d/t this phenomenon
d) Develop coordination to the stump
that prosthetic training should be started early.)
e) Prom9ote good stump healing
2. Stump Pain
f) Restore balance
• Pain on stump itself Management – commences day 1 post-op
• May be d’t an unprotected neuroma, that is being pressed upon a) Proper bed positioning – elevate stump to decrease edema
3. Phantom Pain b) Breathing exercises
• Sensation of pain on the absent limb, accompanied by strong c) If medically fit, may start with sitting and balance exercises and
paresthesias. transfers
• May be constant or intermittent. d) Stump Isometrics -> AAROM -> AROM -> PREs (PREs are given
• Types after sutures are removed.)
1. Cramping – most common e) Trunk strengthening exercises Rolling, bridging, sit ups
2. Electric - Shock like discomfort. Lasts a few seconds, f) Coordination exercises
lancinating/ episodic neuritic type of pain g) Strengthening of crutch walking muscles
Transcribed by: Colmo, J. and Sotelo, A.
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Topic: Amputation
h) Training inside/outside // bars
i) Bandaging: re-applied 3-4 hours regularly (for shinking, shaping and A/K PRESSURE TOLERANT AREAS
support. GLIDe
j) HMP/IRR (Wound healing)
k) Psychological support G – Gluteals
l) Ward instructions: Exercise , bandaging L – Lateral side of residual limb
m) Rigid/ plaster of paris for immediate healing / dressing I – Ischial Tuberosity
3. Pre-prosthetic stage (From removal of the suture and ends before prosthetic De – Distal End of stump
fitting)
• In addition to post-op management the ff. are added
A. Ambulation training A/K PRESSURE RELIEF AREAS
B. Desensitization training – Start with Partial WB, TENS, Raindrop GRASH
massage
C. Shadow walking – Stimulates normal walking even if extremity is G – Gluteus Maximus
amputated R – Rectus Femoris
D. Crutch ambulation – Stimulate hip extension to prevent hip flexion A – Adductor Longus Tendon
contractures S – Sciatic Nerve
4. Prosthetic training H – Hamstring Tendon
• Starts when pt already has a prosthesis; ends when pt can uses
prosthesis proficiently
•
Additional Goals
A. Develop balance with prosthesis on
B. Ambulate with ease using prosthesis
C. Maintain good posture
Management
• Balance exercise with prosthesis worn
• Gait training
• ADL training
-Stairs, Ramps, uneven surfaces, obstacles
Prosthetic fitting
• LE – done 8-12 weeks post surgery
• UE – done 5-6 weeks post surgery
IPPF (Intermittent Post-operative Prosthetic Fitting)
• Advantages
-Reduces hospitalization time
-Rapid Stump Healing
-Avoids effect of prolonged bedrest
-psychological benefits from early ambulation
-Controls post-op edema
Pressure Areas (LE)
B/K PRESSURE SENSITIVE AREAS
PAFA
P – Peroneal Nerve
A – Anterior Tibia
F – Fibular Head & Neck
A – Anterior Tibial Crest
B/K PRESSURE TOLERANT AREAS
PTMD
P – Patellar Tendon
T – Tibular & Fibular Shafts
M – Medial Tibial Plateau
D – Distal end of stump
A/K PRESSURE SENSITIVE AREAS
PDP
P – Pubic Symphysis
D – Distolateral end of Femur
P – Perineal Area
Transcribed by: Colmo, J. and Sotelo, A.
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Topic: Amputation
Transcribed by: Colmo, J. and Sotelo, A.
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