Amputation.doc

8/22/2019 Amputation.doc

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AMPUTATIONS

GENERAL

Amputation of the limb is one of oldest surgial proedures pratised e!en in

prehistori times" E!er# $ar in histor# has meant thousands of limbs lost in thebattle or remo!ed after in%ur#" &ith the ad!anes in anaesthesia' blood transfusion

and asepti tehni(ue' more and li!es ha!e been sa!ed' lea!ing more and more

sur!i!ors $ith loss of limbs" The phenomenal inrease in the road traffi aidents

all o!er the $orld has also enormousl# inreased the number of amputations of

limbs" Till reentl#' the main aim of amputation $as to sa!e life b# remo!al of a

badl# damaged limb or b# eradiation of a malignant disease" )ollo$ing

amputations' some t#pe of artifiial limb fitting had been pratised e!en in anient

times" The ma*imum restoration of the lost funtion of the limb has beome possible

b# the reent ad!anes in artifiial limb fabriation and fitting"

Amputation surger# is no longer a rude ablational surger# but a refinedreonstruti!e proedure' to prepare the stump not onl# for its motor funtions of

loomotion or prehension but for e!en sensor# feed ba+ and osmesis" ,ene' it is

essential that a surgeon amputating a limb and fashioning the stump must ha!e a

good +no$ledge of the prostheti proedures a!ailable and $or+ in lose

oordination as a team $ith the prostheti tehniian and the ph#siotherapist"

Amputation is defined as the surgial remo!al of a part or $hole of a limb"

IN-I.ATIONS

The ablation of a limb is an e*treme step and an irre!ersible operation ande!er# are should be ta+en to see that an amputation is done onl# $hen absolutel#

indiated" Amputation should be onsidered onl# if the limb is dead /gengrenous0'

d#ing /grossl# ishaemi0' dangerous /due to malignan#0' or dud /useless limb0"

The ommon indiations for amputation in our ountr# are1

2" Traumati onditions1 .rush in%uries to the limb"

3" 4asular onditions1 Ishaemi onditions of the limb"

i0 Thromboangiitis obliterans /5uerger6s -isease0ii0 Arterioslerosis1 Senile and -iabeti

iii0 Gangrene1 -r# and Moist"

7" Neoplasti onditions1 Malignant tumours of bone or soft tissue

/Osteosaroma

s#no!iosaroma0


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8" Infeti!e onditions1

2" Lepros#1 &hen the leg is totall# useless and grossl# destro#ed

3" Atinom#oosis of the foot or hand

7" )ilarial elephantiasis"

9" .ongenital onditions1 &hen the limb is grossl# deformed and useless"

Traumati onditions

In transport and industrial aidents' the limbs $ith se!ere rush in%uries and

total loss of blood suppl# often re(uire amputation as a life sa!ing measure" &hen

threat to life is not serious' a period of onser!ati!e management of the sho+ ma#

e!en restore ollateral irulation in the limb' help in a!oiding amputation or

minimising the segment to be remo!ed" Emergen# repair of torn blood !essels b#

the !asular surgeon an ma+e limbs !iable and e!en help to a!oid amputation"

4asular onditions

Thromboangiitis obliterans /5uerger6s disease0 is !er# ommon in South India"

&hen all efforts to relie!e the e*ruiating pain in the patient' ontrol infetion and

to pre!ent gengrene of the limb fail' the patient $ill ha!e to be treated b#

amputation at appropriate le!els" The a!erage age of the amputee in India is muh

lo$er than in the &est $here the predominant indiation is the !asular

insuffiien# in the geriatri age group" All t#pes of gangrene are indiations for

amputations"

Tumours

Osteosaroma and soft tissue saromas in hildren and hondrosaroma and

melanomas in the older age group are the ommon indiations for amputation" The

introdution of ne$er methods of hemotherap# and immunotherap# ha!e

impro!ed the prognosis and sur!i!al rate' in man# ases of malignant tumours"

-eformities

.ases of gross ongenital deformities of limbs li+e phoomelia $here orretion

is impossible' ha!e to be treated $ith amputation and prostheti fitting"

T:PES O) AMPUTATIONS

2" Guillotine Amputation

This is an emergen# amputation done as a life sa!ing measure" This is done in

ases of gross rush in%uries of the limb" It is also indiated in ases of gas gangrene'

$hen a rapid remo!al of the dangerousl# infeted part is a life sa!ing proedure" In


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guillotine amputation' the inision is irular around the limb at the site of bone

setion and all the tissues are ut at the same le!el and the $ound is left open to

pro!ide free drainage"

3" .lassial Amputation

These are planned amputations $here regular s+in flaps are raised and the

$ound is losed after ablation of the limb"

7" Re!ision Amputation

Re!ision amputations are done1

a0 As a seond stage in guillotine amputation"

b0 Those $ith !er# unsatisfator# stumps follo$ing a pre!ious amputation"

SELE.TION O) LE4ELS O) AMPUTATION

The lassial sites of amputation of limbs $ere determined on the basis of the

follo$ing onsiderations"

2" The disease proess for $hih the amputation $as done to eradiate the

patholog#"

3" The !asular suppl# to the s+in flaps"

7" The re(uirements of limb fitting proedures and tehni(ues a!ailable at

that time"

Radiograph# of the part is done to see the e*tent of the malignant disease" Insome ases arteriograph# ma# be used to assess the !asularit# of the limb and le!el

of !iabilit#"

Modern ad!anes in the tehnolog# of limb fitting has made possible

satisfator# limb fitting to stumps of an# length and hene one should not sti+ to

the lassial le!els too rigidl# and sarifie parts of limbs $hih ould be sa!ed"

LE4ELS O) AMPUTATION

a0 In the lo$er limb

b0 In the upper limb

A0 The le!els of amputation in the lo$er limbs are as gi!en belo$"

2" ,ind (uarter amputation"

3" ,ip disartiulation"

7"" Abo!e +nee amputation"

8" Through +nee disartiulation"


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9" 5elo$ +nee amputation"

;" S#me6s amputation"


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amputations' the funtions to be restored are $eight bearing and loomotion and

sensor# feedba+" The $eight bearing ould be a0 end bearing' b0 side bearing or 0

pro*imal bearing" The modern method of total ontat so+et has made $eight

bearing more omfortable to patients" The ph#siologial method of $eight

transmission is through the terminal ends of bones" ,ene' artifiial limbs $ith

$eight bearing through the alaneum' lo$er end of tibia or lo$er end of femur' aremore ph#siologial" The S#me6s amputation and +nee disartiulation are beoming

inreasingl# popular' from the point of !ie$ of limb fitting"

A good stump should be neither too long nor too short" It should ha!e good

musle po$er $ith full mo!ement in the pro*imal %oint and a health# non adherent

sar" It should ha!e a flesh# end $ith no bon# spurs" The are of the stump onsists

of1

a0 Stump bandaging $ith repe bandage to impro!e its shape for limb fitting"

b0 Stump e*erises to impro!e its motor po$er and mo!ements in the pro*imal

%oint"0 Stump h#giene to maintain the s+in and sar in good ondition"

The amputation ma# be the end of the management of the patholog# but it is

the beginning of the phase of retraining of the stump for prostheti fitting and

funtional restoration"

.OMPLI.ATIONS O) AMPUTATION

Treatment of .ompliations

Immediate1 a0 Infetionb0 Seondar# haemorrhage

0 S+in sloghing

These are pre!entable b# ontrol of infetion and proper tehni(ue in suturing"

Late1 a0 Stump Neuroma

b0 Phantom Limb

0 .ontratures

Infetion must be !igorousl# ontrolled as it ma# lead to sloughing of the edges

of the flaps or e!en osteomyilitis $ith se(uestrum formation" Se!ere infetion anlead to separation of a ring sequestrumfrom the tip of the setioned bone" This also

ends in pu+ered and adherent sar $hih is painful $hih interferes $ith proper

limb fitting"

Neuroma1 This is the de!elopment of a bulbous s$elling at the ut ner!e end" It

is tender and auses pain on $eight bearing" Pain ma# be relie!ed b# loal

h#droortisone in%etion or in some ases b# ultrasoni therap#"


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Phantom Limb1 In this ondition the patient feels that the limb is still present

and he ma# feel e!en pain in some areas in the non e*istent foot or toes" It usuall#

lears up $ith assurane' analgesis' stump e*erises and regularit# in the use of

prosthesis"

AMPUTATION IN .,IL-REN

The speial feature of amputations in hildren is the gro$th potential of the

bone in the stump" In ases of belo$ +nee or abo!e elbo$ amputation in hildren'

the bone in the stump ontains thegrowing epiphyseal plateof the upper end of tibia

and the upper end of humerus respeti!el#" In the #ears follo$ing the amputation'

the gro$th of the bone ontinues" If the stump is o!ered snugl# $ith the s+in flap'

the subse(uent gro$th of the bone $ill streth the s+in in the tip of the stump and

the bone ma# e!en tend to protrude" This $ill need a revision amputationto e*ise

the e*ess bone" One must remember to lea!e the s+in flaps a bit flabb# so that it

$ill fit snugl# $hen the bone gro$th ours" In the lo$er limb' disartiulation

through +nee is preferable to the abo!e +nee amputation through the femur' asthere $ill be gro$th of the stump proportionate $ith the gro$th of the hild"

PROST,ETI. )ITTING AN- RE,A5ILITATION

The responsibilit# of the surgeon does not end $ith the healing of the $ound

but must inlude the restoration of loomotion b# orret limb fitting and re

eduation" The limb must fit the amputee not onl# ph#siall# but also

ph#siologiall#" It must be integrated emotionall# $ith the patient and be soiall#

aeptable"

The medial man6s responsibilit# does not end e!en $ith the fitting of thesuitable prosthesis" The ph#siian should aept the philosoph# that his onern for

the patient should ontinue till the amputee is !oationall# and eonomiall#

rehabilitated" ,is in!ol!ement and guidane should ontinue $ith the !oluntar#

soial $or+ and emplo#ment agenies to assist the handiapped amputee to get

integrated as a self reliant and dignified member of the soiet#"

5ONE GRA)TING

5one grafting is the proedure of transplanting bone from a donor area to a

reipient area" Suh a grafting of bone tissue on a prepared bed in another bone is a

surgial proedure often used in orthopaedi pratie" The tehni(ue onsists ofplaing li!e bone piees in lose ontat $ith a health# ra$ bone surfae to stimulate

gro$th of bone tissue in the ne$ area"

The grafted bone ats as a soffold around $hih ne$ bone tissue is laid b#

creeping substitution b# !asular in!asion from the surrounding tissues" It also

stimulates ne$ bone formation b# the priniple ofinduction.


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Indiations

The indiations for bone grafting are as follo$s"

2" In the treatment of nonunion of fratures"

3" )or filling a!ities in bone"7" )or bridging gaps in the shafts of bones aused b# trauma' infetion or

e*ision of tumour"

8" In the surgial fusion /arthrodesis0 of %oints"

T#pes of 5one grafts

The bone used for grafting ma# be obtained from a donor site from

a0 the same person /autogenous graft0

b0 a different person /homogenous graft or allograft0

0 a different speies /heterogenous *enograft0 li+e alf or pig"

The best is the autogenous graft but it is diffiult to get enough bone for use in

hildren" In suh ases' the maternal homogenous graft is the best alternati!e

soure"

Cadaver bone' stored in Tissue 5an+s is e*tensi!el# used not onl# to fill gaps but

also to replae diseased ends of long bone or e!en total %oints"

In terms of anatomial t#pes' the graft ma# be either Corticalbone graft in

!arious shapes or Cancellous bone piees in the form of sli!ers of hips" The

anellous bone is more osteogeni as its !asularisation is (ui+er and boneindution better" The ortial bone funtions as a fi*ation de!ie and anellous

bone promotes osteogenesis"

5one 5an+

&ith inreasing use of bone grafting proedures for !arious onditions' the

need for large (uantities of bone is great" This is met b# storing bone in bone ban+s

$ith speial tehni(ues of storage in sterile and !iable ondition"

5one grafting operations

The t#pe of bone grafting proedure depends on the biologial and mehanial

situation in a partiular ase"

On laybone graft is the most ommon t#pe $herein a ortial graft from tibia

in the retangular shape of a plate is fi*ed aross the prepared reipient site $ith

metalli sre$s" This method is often used in the treatment of nonunion of


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fratures" It ats mehaniall# to immobiliBe the fragments and also promotes

osteogenesis"

.anellous bone hips ta+en from the ilia rest are ommonl# used as

supplement to a ortial graft or a metalli plate in the treatment of nonunion of

fratures of tibia' humerus or the forearm bones" It is also used as autogenous graftfrom the ilia rest or homogenous ban+ bone in filling up bone a!ities after

uretting or e*ision of #sti lesions in bone" Its funtion is mainl# osteogeni"

Spinal fusion is the proedure $hih needs the largest (uantit# of anellous

bone graft in the operation for soliosis" .anellous bone hips are used to

supplement ,arrington or other metalli rods" A ortio anellous plate of bone

ta+en from the ilia bone is used as a , shaped graft to stabilise lumbosaral

%untion' supplemented b# anellous hips"Pieces of ribs are used in anterior and

anterolateral spinal fusion after uretting or tuberulous lesion in the !ertebra in

the ,ong+ong operation" The upper end of fibula is !er# useful as a bone graft for

replaing the lo$er end of radius affeted b# giant ell tumour"

4asularised bone graft

The suess and the rate of integration of the bone graft $ith the reipient site

is !astl# impro!ed $hen the blood suppl# is retained" This has been ahie!ed b#

remo!ing the graft $ith a !asular pedile" This proedure re(uires the anastamosis

of the !essels b# microsurgicalmethods in addition to the fi*ation of the bone" This

is used mostl# $hile using fibula or rib as a graft"

PLASTER O) PARIS TE.,NI>UES

GENERAL

The use of loth bandages stiffened b# egg albumin and starh paste for

immobilising fratured limbs has been pratied e!en in anient Indian and

Eg#ptian medial pratie" E!en no$ it is used b# traditional bone setters in rural

areas" The use of anh#drous g#psom as a material for splinting fratures $as

introdued b# a militar# surgeon in Paris' Antonius Mathesen' 2CC #ears ago and

hene the name Plaster of Paris" This is a landmar+ in the histor# of frature

treatment"

Plaster of Paris is hemih#drated alium sulphate" On adding $ater it solidifies

b# an e*othermi reation into h#drated alium sulphate" GauBe bandages an be

manuall# impregnated $ith plaster po$der to get plaster bandages" Read#made

plaster of paris bandage rolls and slabs in !arious $idths are no$ a!ailable in the

mar+et' pa+ed in air tight plasti bags and tins" The moistened plaster sets anmd

hardens normall# in 7 to 9 minutes"


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APPLI.ATION O) .OMMON PLASTER O) PARIS SLA5S

Plaster of paris slabs are !er# useful as first Aid splints for fratures of the

limbs' as the# an be moulded to the in%ured part" The tehni(ue of their appliation

in a manner omfortable and safe to the patient should be +no$n to e!er# medial

pratitioner" Read# made plaster of paris rolls' in $idths of 29 ms' 2C ms and =ms are a!ailable in sealed $ater proof plasti pa+ages" A fe$ of eah siBe should

be a!ailable in e!er# Primar# ,ealth .entre and also $ith e!er# general

pratitioner as part of the )irst Aid Dit"

The ommon t#pes of plaster of paris slabs used in the limbs are the follo$ing"

Upper limb

2" 5elo$ Elbo$ Plaster slab

3" Abo!e Elbo$ plaster slab

7" U Slab

Lo$er limb

2" 5elo$ Dnee Plaster slab

3" Abo!e Dnee Plaster slab

7" Tube Plaster slab

These plaster slabs are also used in theprimary treatment of frtures' to

immobilise the fratures after manipulati!e redution" The patient should beasked

to report the next day.The irulatuion in the fingers should be he+ed and the

presene of an# edema loo+ed for" If there is an# e!idene of the bandage being tootight' the bandage must beslit from end to endand a fresh dr# gauBe bandage

applied o!er it" The slabs are later on!erted into plaster asts 7 to 9 da#s after the

manipulati!e redution" The dela# gi!es time for the loal edema in the limb to

appear and then subside"

Appliation of complete plaster castsimmediatel# after the redution of

fratures e!en $ith padding' is dangerous' as the fratured limb al$a#s s$ells up

after manipulation and a ast ould beome dangerousl# tight and endanger the

irulation to the limb"

5ELO& EL5O& PLASTER SLA5

This is used in all ases of in%uries to the $rist and the metaarpal bones' either

as a first aid splint or for primar# immobilisation after the redution of the

fratures"

Tehni(ue of Appliation


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The plaster slab e*tends from a point about 9 m belo$ the top of the oleranon

to the le!el %ust pro*imal to the +nu+les in the dorsum of the hand and the distal

rease in the palmar aspet"

2" Measure the abo!e distane $ith a guaBe bandage strip and plae it on the

smooth tabletop"

3" A role of 29 ms plaster of paris bandage is unrolled on the table to a length

e(ual to the

measured bit of bandage and ta+en to and fro o!er it' forming < la#ers of

slab in a dr#

form" Its ends are folded in an onertina fashion and +ept read#"

7" Appl# a la#er of dr# guaBe bandage around the forearm to %ust belo$ the

elbo$"

8" ,old th#e folded plaster slab in the folded position and immerse it in $ater

for about ;

seonds b# $hih time theair bubbles stop comingup"

9" Ta+e it out of the $ater and gentl# s(ueeBe out the e*ess $ater"

;" Spread the slab on the table top and smoothen the surfae b# stro+ing $ith

the palm till the

slab is smooth and free from air bubbles"


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the metaarpo phalangeal %oints" The splinted forearm is suspended from the

ne+ using a

uff and ollar"

A5O4E EL5O& PLASTER SLA5

This is used in the first aid splinting as $ell as in the primar# treatment of

fratures of the forearm bones" This e*tends from the middle of the upper arm to

the point %ust pro*imal to the +nu+les in the dorsum of the hand"

2" A slab e(ual to the abo!e length is prepared dr# as desribed abo!e' in

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Amputation.doc