amputation 2008 version 4

8/10/2019 Amputation 2008 Version 4

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Amputation



What is acquired amputation?

The loss of part or all

of extremity as a

direct result of trauma

or by surgery.



What is congenital amputation?

The absence of part or all of an extremity

at birth.



What is elective amputation?

This is performed when the hand or entire

limb has no sensation and function as a

result of brachial plexus injury.



What is an open amputation?

Amputation in which the surface of the

wound is not covered with skin but left

unclosed. This is done to control infection.



What is closed amputation?

Usually a final or definitive amputation

performed to create a stump that can be

used effectively with a prosthesis.



What is minor amputation?

Amputation through of

distal to the

metacarpus or to the

metatarsus.



What is major amputation?

Amputation proximal to the metacarpal or

metatarsal bones.



What is a disarticulation?

Amputation performed through a joint



What are the causes of amputation?

1st

year of lifeCongenital deficiencies

1 to 10 years of age.

Motor vehicular accidents, tumor and trauma.10 to 20 years of age

Malignancy is the most common cause.

55 years of age

Peripheral vascular disease



The right arm is more frequently involved

in work related injuries.



Lower Extremity Amputation

The major cause of LE amputation idperipheral vascular accident

The most common cause of PVD is

atherosclerosis After PVD the second leading cause is

trauma

This is followed by tumors (Osteogenicsarcoma) and last by congenital cases.



Congenital Amputations

Causes:

Intrauterine development

Hereditary

Teratogenic agents

Maternal diabetes



What are the classification of

congenital amputation?

Amelia

Complete absence of the entire upper

extremity or lower extremity.

Hemimelia or Meromelia

Partial limb absence

AcheiriaTerminal transverse hemimelia, wrist level



Adactylia

Absent digit

Apodia Absent foot

Phocomelia

Transverse total humeral radial , ulnardeficiency



Franz and O’Rahilly Classification

Terminal

Complete loss of the distal end of an

extremity

Intercalary

Absence of intermediate parts with preserved

proximal and distal component of the limb.

Transverse/Horizontal

Absence of all skeletal elements distal to the

deficiency along a designed transverse axis.



How is acquired amputation

classified?

UE Measurement of Amputation

Above Elbow Stumps

Normal LengthTip of acromion process to lateral

epicondyle

Stump LengthTip of acromion process to end of stump



Bilateral Upper Extremity Amputations

Normal Upper Arm Length

Patient’s height x 0.19 Normal Forearm Length

Patient’s height x 0.21



Percentages

Above Elbow

0% - Shoulder Disarticulation

0-30% - Humeral Neck30-50% - Short Above Elbow

50-90% - Long Above Elbow



Below Elbow

0-35% very short below elbow

35-55% short below elbow55-90% long below elbow

90-100% wrist disarticulation



What is forequarter amputation?

shoulder disarticulation amputation in

which the shoulder blade and collar bone

are removed



Lower extremity Amputation

Above knee

Normal Length

Ischial tuberosity or the greater

trochanter to lateral tibial plateau.

Stump Length

Ischial tuberosity or the greater

trochanter to end of stump.



`

Below knee

Stump Length

From medial tibial plateau to end ofbone

Normal Length

From medial tibial plateau to medialmalleolus



What is a hip disarticulation?

Hip disarticulation is the surgical removal

of the entire lower limb at the hip level. A

traditional hip disarticulation is done by

separating the ball from the socket of thehip joint, while a modified version retains a

small portion of the proximal (upper) femur

to improve the contours of the hipdisarticulation for sitting.



What is a transpelvic amputation?

Transpelvic amputation is the removal of

the entire lower limb, plus a portion of the

pelvic bones. It occurs in a skeletal zone

that can include, from the socket on theoutside to the spinal column in the middle,

the acetabulum, ischium, rami, ilium and

sacrum.



What is a Lisfranc amputation?

Partial amputation of the foot at the

tarsometatarsal joint, with the sole being

preserved to make the flap. The technique

was used to treat forefoot gangrene fromfrostbite. Lisfranc was widely known for his

ability to amputate a foot in less than a

minute.



What is a Syme Amputation?

An amputation at the ankle with removal of

the malleoli and formation of a heel flap.



What is the ideal stump size?

Above knee amputee

10 cm or 3 to 4 inches above the knee joint.

Below knee

8 to 18 cm or 5 to 7 inches below medial

tibial plateau.



Percentages for Above and Below

Knee Levels

Delisa

<33% short above knee or below knee

stump.

33-66% medium length below knee or

above knee stump.

>66% long above knee or below knee

stump.



Sullivan

Transtibial

>50% of tibial length – long below knee20-50% - below

<20% of tibial length – short below knee



What contractures are common for

lower extremity amputations?

For below knee amputees

Knee flexion contractures

For above knee amputeesHip abduction and flexion



What is Phantom Pain?

This is a normal sensation occurrence

after amputation of a limb. The part

amputated is still present.



What are the Types of Phantom

Pain?

Cramping (most common)

Electric shock

Burning

Squeezing and wrenching



What are the Steps for Prosthetic

Management?

Preprosthetic

Pre-Operative

Operative

Post-Operative

Prosthetic Fitting and Training

Prosthetic Follow-Up Care



Preoperative

Evaluation and Assessment

Emotional Counseling

Therapy Counseling



Operative Management

The cardinal rule is to preserve as much as

length as possible.

Avoid the following level:• Hindfoot

• Distal 1/3 of the leg

• Supracondylar of femur



Muscles are just distal to the level of

intended bone section.

Bone must be bevelled and should be

covered with a good padding of the tissue.

Nerves should be pulled before cutting to

retract.

Blood vessels (major blood vessels are

ligated the smaller ones are cauterized).



Skin closure

Above knee amputee-fish mouth or middle

flap.

Below knee amputee-posterior flap/anteriorsuture.



Post-Operative Management

Healing of wounds

Pain control

Preparation for prosthetic fitting

Maintenance of range of motion

Independent mobility

Independent self-care

Wh t l d t b



What muscles need to be

strengthened for crutch walking?

Shoulder depressors

Shoulder adductors

Flexor, extensor and abductor of the arm

Extensor of the forearm at the elbow.

Wrist extensor

Finger and thumb flexors.



Post-Operative Dressing

Rigid

• Made of Plaster of Paris

• Change every 5-10 days.

Advantages

Limits post-operative edema

Allows for early ambulationReduces length of time for shrinking



Disadvantages

Requires careful application

Requires close supervision

Does not allow early wound inspection



Semi-Rigid

The Unna Paste Dressing

• A compound of zinc oxide, gelatin, glycerin and

calamine maybe applied in the operating room.

Advantage

Better control of edema

DisadvantageMay loosen easily



Soft Dressing

Oldest method of post-surgical management

of residual limb.

Advantage

Inexpensive

Lightweight and readily available

Easily laundered



Disadvantage

Poor control of edema

Requires skill of application

Need frequent reapplication

Can slip and form a torniquet

What are the appropriate si es of



What are the appropriate sizes of

bandages for amputees?

For above knee amputees two 6 inches

bandages sewn together and one 4 inch

bandage.

For below knee amputee two 4 inch elastic

bandage can be used.

What is the golden age of



What is the golden age of

prosthetic fitting?

It is the first 30 days following the

amputation.

Activities

Learn to put prosthesis

Weightshifting

Progressive ambulation between parallel bars

Walker-crutches-cane-unassisted on flat

surfaces.



Crutch ambulation without

prosthesis 50%

Wheelchair 9%

What are the functional



What are the functional

classifications of amputees?

Class 1 Full Restoration

The individuals is functionally equivalent to

normal

Class 2 Partial RestorationThe artificial limb is completely functional. The

person is able to work and engage in sports

but on a selective basis.



Class IIISelf-Care Plus

The individual is disabled and has physical

limitation, requires frequent adjustment ofprosthesis.

Class IV

Self-Care Minus

Needs help from others because he isseverely disabled. Cannot go up and downthe stairs without assistance.



Class V

Cosmetic Plus

The amputee is better off without a prosthesis

Class VI

Not feasible. Only a wheelchair is prescribed.



End of Lecture

amputation 2008 version 4

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