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AMPUTATION

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DEFINITION: Amputation is a procedure where a part of the limb is removed through one or more bones. Disarticulation is removal of the limb through the joint.

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INDICATIONS FOR AMPUTATION Indications Common causes Trauma Peripheral vascular insufficiency Less common causes Malignant tumours Nerve injuries & Infections Congenital anomalies Extreme heat & cold

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COMMON CAUSES: 1)Trauma :Trauma due to road traffic accidents, industrial accidents etc. are common causes. Attempts are always made to save the limb as far as possible. But when there is extensive loss of tissue and disruption of blood supply, amputation is performed. 2)Peripheral vascular insufficiency : Irreversible loss of vascularity to a limb due to diseases like diabetes, Bergers disease, atherosclerosis, embolism, arterial thrombosis, arteriovenous aneurysms or trauma etc. are indications for amputation.

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LESS COMMON CAUSES 1)Malignant tumours : Amputation is considered for extensive malignancy. This is done to prevent recurrence. 2)Nerve injuries & infections : Anaesthetic limb often develops ulceration, infection & severe tissue damage. When ulceration & infection persists, and fail to respond to the medical treatment, amputation is performed. Some infections like gas gangrene, chronic infections like osteomyelitis etc. may also need amputation.

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3) Congenital anomalies : accessory thumb, congenital absence of bones etc. requires amputation. 4) Extreme heat or cold : Injuries following electrical burns, accidental burns as well as exposure of the limb to extreme cold conditions may need amputation. Thermal injuries may sometimes lead to extensive tissue destruction & deformities. Prolonged exposure of the limb to extreme cold conditions results in blockage of blood circulation leading to gangrene.

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Closed Amputation Open Amputation TYPES OF AMPUTATION

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In this type of amputation, the stump is closed primarily by retaining skin and muscles at least 5 cm distal to the bone end to facilitate closing of the stump.

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LEVELS OF AMPUTATION In a limb an amputation is carried out at a level which will give the stump an optimum length to facilitate subsequent prosthetic fitting. The level of amputation is determined by the viability of the tissues. It is,however, important that the stump should be well healed and non tender. A joint must always be preserved whenever possible.

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UPPER LIMB AMPUTATIONS

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FORE QUARTER AMPUTATION It is carried out proximal to the shoulder joint. Scapula + lateral 2/3 of clavicle + whole of upper limb

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SHOULDER DISARTICULATION Removal through the gleno-humeral joint.

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ABOVE ELBOW AMPUTATION It is an Amputation through the Arm. A 20 cm long stump as measured from the tip of acromion is ideal.

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ELBOW DISARTICULATION It is an Amputation through the elbow.

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BELOW ELBOW AMPUTATION It is an Amputation through the forearm bone. The optimum length of stump is 20 cm as measured from the tip of olecranon with minimum length of 7.5. cm.

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KRUKENBERG AMPUTATION This is a below elbow amputation done usually on both sides. Here the forearm is split between the radius and ulna. This can be used like a fork and it provides a pincer grip. a below elbow prosthesis or a hook prosthesis can be put over the stump to lift the heavy objects

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WRIST DISARTICULATION It is an Amputation through the radio-carpal joint.

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METACARPOPHALANGEAL DISARTICULATION

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PHALANGEAL AMPUTATION

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LOWER LIMB AMPUTATIONS

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HEMIPELVECTOMY Hindquarter Amputation or complete hip amputation. Whole of the lower limb with one side of the ilium removed.

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HIP DISARTICULATION Complete hip amputation It implies amputation through trochanters and femoral neck

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ABOVE KNEE AMPUTATION 1)Short AK : 3-4 inches below ischial tuberosity 2)Middle AK : 10-12 inches below ischial tuberosity 3)Supracondylar amputation

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KNEE DISARTICULATION Complete leg amputation This gives an excellent end bearing stump. Large end bearing surface of the distal femur is naturally suited for weight bearing and prosthesis will be stable.

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BELOW KNEE AMPUTATION The optimum length of the below- knee stump is 14 cm from the tibial tubercle.

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SYMES AMPUTATION Amputation just above the ankle joint.

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ANKLE DISARTICULATION Complete tarsal amputation

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CHOPART DISARTICULATION Partial Tarsal Amputation

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LISFRANCS AMPUTATION Complete Metatarsal Amputation through tarsometatarsal joint

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TRANSMETATARSAL AMPUTATION Partial Metatarsal Amputation through the metatarsal bones

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TOE AMPUTATION Complete phalangeal amputation

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COMPLICATIONS 1)Hematomas : This delays the wound healing and acts as a culture media for the growth of the organisms 2)Infections : This is more common in peripheral vascular disease and diabetics. 3)Necrosis of the skin flaps are usually due to insufficient circulation and require revision amputation.

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4)Contractures : This is largely preventable by positioning the stump properly. Flexion contractures of hip and knee are very common. 5)Neuromas form always at the end of a cutaneous nerve and any pain from a neuroma is usually caused by traction on a nerve when it is embedded within the scar tissue. 6)Abnormality of residual limb : dog ear appearance

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7) Phantom sensation : This is a pseudo feeling of the presence of the amputated limb. It could be of a painless or a painful variety. The reasons why someone will still perceive the amputed body part are as follows : Firstly, the nerves have been severed, causing injury to nerve tissue, and thus pain messages are sent to the brain. Secondly, the brain has an area of tissue dedicated to that part & will expect sensory information. This area of brain is not removed during limb amputation & still tries to process information which is perceived as pain.

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Treatment method consists of reassurance, ultrasound therapy, TENS, percussion, cryotherapy, steroid injections, exploration of the neuroma, etc.

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PHYSIOTHERAPY AIMS Physiotherapy involves continuous assessment of patient, needs & ability, in order to set treatment plan. Ideally the person should achieve : 1)Independent self caring 2)Independent indoor mobility 3)Independent outdoor mobility 4)Ability to get into/ out of any means of transportation 5)Return to leisure/hobbies/work/society

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(I) THE PREOPERATIVE STAGE (a)ASSESSMENT : The ROM, muscle power, condition of the skin & status of circulation should be evaluated. The status of hearing & vision plays an important role in training so it should be assessed. Aspects such as age, sex, occupation, general physical status etc. should be taken into consideration. The underlying condition for amputation should be considered as it may be associated with future complications e.g. atherosclerosis, diabetes, trauma, tumour etc.

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Assessment of the psychological status is extremely important. The patient will undergo a grief process associated with loss. it produces great psychological trauma leading to depression. It can lead to loss of confidence, loss of function, loss of lifestyle, income, status and loss of independence. The physiotherapist should talk to the patient, to understand their fear & hopes, to gain their confidence and work together to set goals.

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(b) TRAINING : The preoperative training involves : 1)Prevention of thrombosis by maintaining circulation through movements. 2)Prevention of chest complications by deep breathing, coughing & PD. 3)Preserve mobility of the joints. 4)Improve mobility of trunk, pelvis & shoulder girdle. 5)Teach method to be adopted for mobility & limb positioning in bed. 6)Teach techniques of transfers, monitoring the wheelchair, single limb standing and balancing.

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7) It is necessary to explain the patient all necessary aspects of balance, equilibrium, standing and walking techniques he is supposed to adapt later on. This can be done by showing the video of a similar patient using a prosthesis. 8) The patient should be educated and be made aware of possible complications, care of pressure points & phantom sensation. 9)Lastly various exercises such as active exercises, resisted exercises, progressive resisted exercises & various techniques to improve endurance are taught.

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(II) EARLY POSTOPERATIVE STAGE a)Prevention of contracture & deformities : Shoulder - adduction and rotation contracture Elbow- flexion contracture Hip- flexion and abduction contracture Knee- flexion contracture Ankle- plantar or equinus Bilateral amputee are more prone to develop hip and knee contracture due to decreased mobility.

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Methods of prevention of contracture: 1)Early identification- the early sign of developing contracture is a tight feeling with pain at end range of passive antagonist movement. Immediate sessions of repetitive sustained stretches manually should be started. 2)Postural guidance- the posture which keeps the tightness prone area stretched should be emphasized. Moreover posture promoting development of contracture should be discouraged. 3)Use of traction sustained sessions of gentle traction to stretch the contracture developing areas 4)Use of corrective splint- velcrostraps & broadcuffs can be extremely useful.

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The common practise of using a pillow under the thigh or the knee although relieves the pressure over the end of the stump and gives comfort; it is the commonest cause of soft tissue contracture. Hip flexion contracture should be prevented by session of prone lying initiated as soon as possible. Long periods of sitting and soft mattresses can predispose to development of flexion contracture so it should be avoided. Repeated sustained isometrics of extensors and repeated periods of prone lying can prevent development of hip flexion contracture.

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b) Maintenance of strength and mobility: The patient should be encouraged to move in bed by pushing up the body on the arms. This push up exercise strengthens the muscles which may be necessary for using ambulation aid later on especially in bilateral amputee. Vigorous strengthening exercises should be given. Bed activities like bridging, rolling etc. can be useful to initiate bed mobility.

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MANAGEMENT OF STUMP Improper management of stump is one of the major causes of delayed rehabilitation. Stump oedema delays prosthetic fitting and ambulation. Causes of stump oedema: 1)Surgical trauma itself 2)Incorrect bandaging of stump 3)Incorrect stump positioning 4)Uncontrolled diabetes 5)Atherosclerotic disease

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MEASURES TO CONTROL STUMP OEDEMA 1)Limb in elevation with bandage 2)Resistive exercises to the stump and other joints 3)Stump bandaging : It plays an important role in conditioning and shaping the stump by reducing oedema. An elastocrepe bandage of 4 to 6 inches is necessary. Bandage should be taken out during exercise.

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4) Stump hygiene : regular washing of stump with warm disinfected soap water and thorough drying. 5) Exercise : After 3-4 days of surgery active assisted exercises should be started in a small ROM. Assisted hip flexion, abduction and adduction movements can be performed in back rest sitting. Frequent periods of prone lying with attempted hip extension with strong and sustained contraction of gluteus maximus are valuable. Repeated sustained isometrics for muscles of stump especially two joint muscles which originate above the joint proximal to the amputation.

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6)Massage : repeated tapping can help restore the tone of muscles. 7) Stimulation: ES with the stump in elevation can improve the muscle tone and reduce oedema. 8)Pressure : exposing the stump to pressure by gradual training of bearing weight on the terminal weight bearing area of the stump. Crawling or knee walking on a mattress placed over a bed with hard top is ideal as a pressure bearing technique for above knee or through knee amputation.

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(III) MOBILITY STAGE This is stage of mobilization and restoration of functional independence. It starts with crutch walking as early as possible. The normal alignment of pelvis and the reciprocal movement of the stump should be maintained during walking. It has been observed that usually patients tend to walk on crutches holding the stump in flexion which needs immediate attention.

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Elderly patients may need initial ambulation practice in parallel bars.

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Functional training with crutches should be given to all hemipelvectomy, hip disarticulation and above knee amputees. Resistive mat activities using PNF techniques offer easy and stable mobility.

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MOBILISATION & STRENGTHENING EXERCISE Mobilisation of the body segment proximal to the amputation and strengthening of adjacent muscle group need special emphasis. PNF techniques, PRE and strong endurance exercises to the specific muscle groups are needed to facilitate effective body functions with the prosthesis.

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The muscle groups to be concentrated are: a)Disarticulation of the arm : Shoulder elevators, depressors, protractors and retractors. Mobility exercise to the neck and trunk are also important. b)Above-elbow amputation : Flexors, abductors and extensors of the shoulder. Scapular elevators and retractors on the normal side. c)Below-elbow amputation : Elbow flexors, extensors, pronators and supinators of the forearm with mobilization of the trunk.

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d)Hip disarticulation : Pelvic rotators and elevators e)Above-knee amputation : Hip extensors, abductors, flexors and shoulder girdle muscles f)Below-knee amputation : Knee extensors and flexors, hip abductors and extensors g)Symes amputation : Same as in below-knee amputation

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ROM exercises: full Rom exercises are regularly given to the joint proximal to the stump and other joints susceptible for contracture. Gait training: it should be carried out in patient with lower limb amputations.

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