AMPUTATION & PROSTHESIS

Amputation
Is defined as removal of the limb through a part of the bone

Is the removal of the limb through the joint Stump The distal end of a limb left after amputation.

Disarticulation :

Note : injury is the most common cause for amputation

Amputation: the surgical removal of a part of the body, a limb or part of a limb

Cont
Incidence : Age : 50 75 years Sex : Male --75 % , Female : 25 % Limbs : Upper limb : 15 % Lower limb : 85 %

Age VS indication : Children ------- congenital anomalies Young adults ----- injuries Elderly -------- peripheral vascular disease

Indications to Amputations
1. Trauma and its complications (anaerobic infection, osteomyelitis)

2. Malignant tumors of skeleton and soft tissues of limbs

3. Vascular diseases (thrombosis, diabetic angiopathy, obliterating endarteritis)

Indications for amputation:

PVD Failed revascularisation Extensive tissue loss Unreconstructable Excess surgical risk

Indications for amputation:

Diabetes Overwhelming sepsis Extensive tissue loss Excess surgical risk

Indications for amputation:

Trauma - Crush - Nerve injuries

Others Spina bifida Contractures Neuropathy Bed bound

Indications to Amputations

1. 2. 3.

I. Absolute
Traumatic limb rupture Gangrene - injury of 2/3 of soft tissue - injury and crushing of major vasculo-nervous bundles -injury of bone

1. 2. 3. 4. 5.

II. Relative
Acute infectious process Chronic infection Massive trophic ulcer Irreparable deformation of limb - injury of 2/3 of soft tissue - injury of bone on considerable distance - without injury of vasculo-nervous bundle

Types
Closed amputation : elective procedure Skin is closed after amputation Open amputation : wound is left open over the amputation stump and is not closed Done as an emergency procedure in the case of life threatening infection ( severe infection , severe crush injury ) . Myodesis : muscle is sutured to the bone Myoplasty : muscle is sutured to the opposite muscle group under appropriate tension

Amputation levels

Amputation levels ( upper limbs )

Hand & Partial-Hand Amputations Finger, thumb or portion of the hand below the wrist Wrist Disarticulation Limb is amputated at the level of the wrist Transradial (below elbow amputations)Amputation occurring in the forearm, from the elbow to the wrist Transhumeral (above elbow amputations) Amputation occurring in the upper arm from the elbow to the shoulder Shoulder Disarticulation Ambutation at the level of the shoulder, with the shoulder blade remaining. Forequarter Amputation Amputation at the level of the shoulder in which both the shoulder blade and collar bone are removed

Amputation levels ( lower limbs )

Foot Amputations Amputation of greater toes and other toes Amputation through the metatarsal bones Lisfranc`s operation : at the level of the tarsometatarsal joints Chopart`s operation : through the midtarsal joints Transtibial Amputations (below the knee) Amputation occurs at any level from the knee to the ankle Knee Disarticulation Amputation occurs at the level of the knee joint Transfemoral Amputations (above knee ) Amputation occurs at any level from the hip to knee joint Hip Disarticulation Amputation is at the hip joint with the entire thigh and lower portion of the leg being removed.

Classification of Amputations
Primary amputation (within first 24 hours) Secondary amputation (7-8 days after injury) Re-amputation (repeated amputation)

Standard Above-knee Amputation (AKA)

Steps of Amputation
I. Cutting of soft tissue II. Treatment of periosteum and cutting of bone III. Stump treatment

Stages of Transfemoral Amputation

Types of Amputations
(according to soft tissues cutting)

1. Flap amputations: - single-flap amputation - double-flap amputation

2. Circular amputations: - one-step (guillotine) amputation - two-step amputation (variety cuff

method of forearm amputation)

- three-step (conical-circular) amputation

Transfemoral amputation Above-knee Amputation: marking-out of skin flaps

Creating of Flaps and Cutting of Soft Tissues

Callander Amputation
(this gives an excellent end-bearing stump)

Methods of Periosteum Treatment

1. Periosteal 2. Aperiosteal 3. Subperiosteal

Treatment of Periosteum and Cutting of Bone

Exposure and Ligation of Main Vessels

Arrest of Bleeding from Small Vessels by Electro coagulation after Removing of Tourniquet

Exposure and Cutting of Nervous Trunks

Stitching of Soft Tissues above Bone Stump and Draining of Wound

Aseptic Bandage and Immobilization of the Limb Stump

The most common complications of amputation are: massive haemorrhage infection skin breakdown caused by immobility, pressure, and other sources of irritation breathing problems associated with immobility neuromas joint contractures bone overgrowth (in children)

Complications of Amputation
Mistakes of I step of amputation:
1. conical stump 2. mace-shaped stump

Mistakes of II step of amputation:

3. terminal necrosis of bone 4. forming of large osteophytes

Mistakes of III step of amputation:

5. forming of trophic ulcers 6. phantom pain

7. Chronic osteomyelitis caused by secondary infection

inside a wound

Wound Infection
Multiplication of bacteria in the wound with host reaction

Erythema Pain/heat/swelling Increase in exudates Asc lymphangitis and Prox lymphadinopathy +/Systemic symptoms

Complications
Haematomas ( delays the wound healing and acts as a culture media for the growth of the organism ) Infections ( more common in peripheral vascular disease and DM ) Necrosis ( due to insufficient circulation ) Contractures ( preventable by positioning the stump properly ) Phantom sensation ( pseudo feeling of the presence of the amputated limb ) Causalgia ( Intense burning pain and sensitivity to the slightest vibration or touch ) : - due to division of the peripheral nerve

Osteo-plastic Amputations (Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Amputation in Middle Third of Leg

Syme Amputation(modified ankle disarticulation amputation) This amputation performed for extensive foot trauma and produces a painless, durable extremity end that can withstand full weight bearing

Schemes of Foot Amputations

After treatment
Rigid dressing concept : POP cast is applied to the stump over the dressing after surgery Advantage : Prevents oedema Enhance wound healing Decrease postoperative pain Reduce hospital stay Helps in early temporary prosthetic fiting Soft dressing concept : Stump is dressed with a sterile dressing and elastocrepe bandage are applied over it Bed is elevated to facilitate venous dranage and prevent stump oedema Suture are removed after 10 to 14 days and muscle exercise are commenced Prosthetic fitting is taken up as the last step

Removable rigid dressing plaster or fiberglass replace as residual limb shrinks

BKA (BELOW KNEE AMPUTATION) Immediate Postsurgical Period

Some "Don'ts" that will help prevent muscle tightening, or contractures

Prosthetics

Prosthetic
Prosthesis = in addition It is defined as a replacement or substitution of a missing or a diseased part

Classification Endoprostheses : implants used in orthopaedic surgery to replace joints Exoprostheses : replacement externally for a lost part of the limbs

Limb Prostheses
Definition A prosthesis is an artificial replacement for any or all parts of the lower or upper extremities, it is a device that is designed to replace, as much as possible, the function or appearance of a missing limb or body part.

Purpose
A prosthesis is used to provide an individual who has an amputated limb with the opportunity to perform functional tasks, particularly ambulation (walking), which may not be possible without the limb. The prosthesis may also be made for use during activities or sports, such as dancing, swimming, cycling, golfing, and climbing. The type of prosthesis (artificial limb) used is determined largely by the extent of an amputation or loss and location of the missing extremity.

Characteristics of a successful prosthesis:

Be comfortable to wear, Easy to put on and remove, Lightweight, Durable, and cosmetically pleasing. Function well mechanically and require only reasonable maintenance. Depends on the motivation of the individual, as none of the above characteristics matter if the patient will not wear the prosthesis

Considerations when choosing a prosthesis:

Amputation level. Contour of the residual limb. Expected function of the prosthesis. Cognitive function of the patient. Vocation of the patient (eg, desk job vs manual labor). A vocational interests of the patient (ie, hobbies). Cosmetic importance of the prosthesis . Financial resources of the patient.

Problems may occur when using prosthesis are:

The poor fitting of the prostheses, causes unequal weight load to lower limbs. This may cause extra stress or pressure on the other (unaffected) leg, or on the stump. The increased pressure may lead to pain and skin problems. Skin breaks that are not treated can become infected. Over time, this may also make another amputation necessary. Walking with prosthesis on takes extra energy. The stump should be checked every day for redness, blisters, soreness, or swelling. Prosthesis need to be adjusted several times before it fits well.

Prostheses (Artificial limbs) are typically manufactured using the following steps:
Measurement of the stump. Measurement of the body to determine the size required for the artificial limb. Creation of a model of the stump. Formation of thermo-plastic sheet around the model of the stump This is then used to test the fit of the prosthetic. Formation of permanent socket. Formation of plastic parts of the artificial limb Different methods are used, including vacuum forming and injection molding. Creation of metal parts of the artificial limb using die casting. Assembly of entire limb.

Prostheses are either preparatory (temporary) or definitive (permanent).

temporary prosthesis is fitted while the residual limb is still maturing. A preparatory prosthesis allows the patient to train with the prosthesis several months earlier in the process. Use of a preparatory prosthesis often results in a better fit for the final prosthesis, since the preparatory socket can be used to mold the residual limb into the desired shape. During this period, the patient test drives the prosthesis and learns what it can and cannot do.

The advantage to using a temporary prosthesis:

It shrinks the residual limb more effectively than the elastic wrap. It allows early bipedal ambulation. Certain individuals can return to work. It is a positively motivating. It reduces the need for complex exercise program. It can be used by individuals who may have difficulty obtaining payment for permanent prostheses.

Lower Limb Prostheses

There are several levels of lower limb amputation, including: 1) Partial foot, 2) Ankle disarticulation, 3) Transtibial (below the knee), 4) Knee disarticulation, 5) Transfemoral (above the knee), 6) Hip disarticulation. The most common are transtibial (mid-calf) and transfemoral (mid-thigh).

Components of the Prosthesis

Socket- Forms the connection between the residual limb and the prosthesis. Sleeve- Provides suction suspension for prosthesis. Shank (pylon)- Transfers weight from socket to the foot-ankle. Foot-ankle- Absorbs shock and impact and provides stability.

http://materials.anu.edu.au/student_essays/c ampbell_prosthetic_leg.pdf

Types
Temporary prosthesis :
Used following an amputation till the patient is fitted with permanent prosthesis

Permanent prosthesis

Does every amputee need a Prosthesis ?

A prosthesis is just a tool and choosing to use one or not or merely to use one part time, depends on the amputees personal needs, desire and ability.

Reasons to wear a Prosthesis

Its ability to help them adjust emotionally Its ability to help them avoid drawing attention to themselves if it looks like a real limb Its ability to achieve advanced levels of function (work, sports and hobbies)

Reasons not to wear a Prosthesis

Lack of mental ability Increased energy expenditure Pain Loss of sensation because the prosthesis is a barrier between skin and environment Expense

Process of getting a Prosthesis

Choose a prosthetist ( www.abcop.org) Getting a prescription from the primary care doctor or a physician in an amputee clinic Being sized and measured for the prosthesis. Delivery of your prosthesis Progressing a wear schedule for the prosthesis Receiving training ( usually with a physical therapist) to learn how to use the prosthesis

Time line for getting a Prosthesis

Day 1-15: Stitches and staples are intact Day 15-Week 4: Sutures and staples are out and patient progresses to wearing a shrinker. First appt with the Prosthetic team Week 4-6:Visit prosthetist for fitting of the trainer limb Week 8-10: After approval from the insurance company the trainer limb is built and fitting and training starts Months 3 -6: Wearing schedule is progressed with the temporary prosthesis

Time line for getting a Prosthesis

(cont..)

Months 7-9: Gait training with the physical therapist is completed. Residual limb is now fully shaped. Prescription is given for a permanent prosthesis. Every 6-9 months: Return to the amputee Clinic or the prosthetist for basic check-ups of the skin and prosthesis.

Remember to inspect the skin daily before and after wearing the prosthesis. If there are any areas that remain red for greater than 10 minutes the prosthesis should not be worn for the rest of the day. If the redness persists or worsens then see the prosthetist and do not wear the prosthesis.

Types of Prosthesis

PROSTHETICS LOWER EXTREMITY

BELOW KNEE

KNEE DISARTICULATION

ABOVE KNEE

HIP DISARTICULATION

WHAT IS THE FUNCTIONS OF THE UPPER LIMBS?

The whole upper limbs function to place hand in adequate position to fulfill a particular task. Hand tasks: 1- Manipulative tasks. 2- express feeling. 3- Explore environment. No prosthesis can replace all function satisfactory. Selection is based in specific requirement of the amputee.

Cosmetic Upper Limb Prosthesis

This is the simplest and lightest type available. For transradial (forearm = below elbow) it consists of: 1- Foam filled glove with 2- Wired fingers 3- Fitted to a self suspending socket.

Advantage of this prosthesis

It provides best cosmetic replacement but with minimal functional benefit e.g.: Holding objects steady or carrying things over forearm. N.B: Individually sculpted silicon hands are available which are excellent cosmetically but expensive and not strong enough for any practical daily tasks.

Functional U.L. Prostheses

These are upper limb prostheses that includes a control mechanism of the hand component (terminal device), and different joint replacement units (either for wrist or elbow joints). There are two types of control systems namely: Body- powered control system Electric control system

A) Body powered: This prosthesis is the simplest functional prostheses. Body movement is harnessed to control the terminal device (and elbow). A set of appendages harness the body movement.

Examples
(1) biscapular protraction, (2) shoulder flexion (and elbow extension = in cases of transradial amputation) are used to control terminal device. Shoulder depression, extension, internal rotation, & abduction operate the elbow lock in trans humeral amputation. This type of prosthesis is a working tool & it is functional rather than attempting to be cosmetic

Body Powered functional U.L. Prosthesis: Terminal device, Wrist unit, operating cord, suspension loop

Electric control systems: A battery operated motor moves the hand and/or gripper, wrist or elbow by either: Myo-electric control. Servo control. Switch control. Rechargeable.

1- Myo-electric control
Electrodes pick up microvolts of electricity produced by contractions in the muscles of the residual limb. Signals are amplified and thereafter they activate the motor. In operating hand there may be 2 electrodes; one on extensor muscles and one of flexor muscles groups for opening & closing the hand respectively.

 Alternatively a single site placement for voluntary opening & automatic closing can be used. Wrist movement can be controlled myo-electrically using 2 site system. An electric elbow lock can be activated be a single site placement

2) Servo Mechanisms
The same movements used to control body powered prosthesis, can operate an electric hand but with less shoulder girdle movement. Where mechanical energy is transmitted into electric energy to operate the device motor
(s).

3) Switch control

Using harness or touch pads to control electric devices in different ways.

Terminal devices
Used to replace the task of the hand, It may be cosmetic or functional / passive or active.

*** The most commonly used active functional device is the split hook. It consists of once static one movable new. Grip is achieved by elasticated bands holding the two jaws together, and can be increased by increasing number of bands. The device is activated by harness attached to the lever of the moving jaw as residual limb moves, harness pulls the jaw open, providing good proprioceptive feed back.

 If cosmoses are important, a cosmetic hand can be provided. If patient seeks combination between cosmoses and function, same device as above is used but with mechanical hand same shape as the human hand and body power pulling the thumb and fingers apart.

Mechanical hands have some disadvantages that include:

1- It is harder to operate than the split hook. 2- It has a poorer grip. 3- Bulky & making precision difficult. Despite this it is helpful if an amputee not demands high level of manipulative skill from the prosthesis.

 Terminal devices with special tasks: Active: pliers tweezers- Pen holders (using operating cord). Passive: hammer, fishing red holder tool holder.

Prosthetic Joints
Wrist unit: A cylindrical wrist unit either hand or electrically operated to provide 360 rotation, allow positioning of the terminal device in adequate supination/ pronation range for the required task. Usually wrist units have a disconnect facility allow change of terminal device.

 Elbow joint: Several forms of prosthetic elbow joints are in use. Hand operated joints are commonly used with cosmetic prosthesis. In addition, body powered elbow joints, used with body powered prostheses, are utilized. They are operated using operating and elbow lock cords. Operating cord operates the terminal device when the elbow is locked, while with elbow unlocked it operates the elbow joint.

Suspension
For hand amputation and wrist disarticulation self suspension is used that depends on hanging the socket to bony prominences, namely radial and ulnar styloid processes. For transradial amputation when using a supra condylar socket, self suspension is applied using medial and lateral humeral epicondyles for hanging the prosthesis.

N.B.: In case of transradial amputation cup socket is used when amputee need carry heavy objects, with very short residual limb, or bilateral amputation. Supracondylar socket is used with cosmetic and passive terminal devices.
In wrist disarticulation supination /pronation is controlled by wrist unit or by split socket with one section at the wrist and the other at the distal part of the arm, sparing the forearm to perform movement.

Lower Limb Prosthesis

Types of lower limbs prostheses : Types of L.L. prostheses depend on different stages after amputation. There are three types: - Immediate postoperative prosthesis. - Temporary prosthesis - Definitive prosthesis.

Types of Prosthesis
PROSTHETICS LOWER EXTREMITY

BELOW KNEE

KNEE DISARTICULATION

ABOVE KNEE

HIP DISARTICULATION

The basic components of a lower extremity prosthesis include: the socket, a sock or gel liner, a suspension system, a knee joint (articulating joint), the shank (a pylon), and a foot (terminal device) .

I- Immediate post- operative prosthesis

Used for young patients, usually after a traumatic injury. - Consists of rigid dressing pylon, and foot. - Pylon is usually made of aluminum, steel or plastic. - It helps patient to gain psychological support, early walking (with assistive device 5-12 days post operative) leads to less hospital stay, and reduce phantom pain.

 Disadvantages are the possibility of impaired healing & falls due to early ambulation. Contraindication: History of slow wounds healing. Extreme obesity. Excessive preoperative edema. Lack of 45 days preoperative ambulation.

II Temporary prostheses
It is usually used for 3 to 6 month after amputation. It helps early weight bearing, and reduces edema in the residual limb stamp. The most common type of temporary prosthesis is adjustable prosthesis. It consists of a socket, pylon, foot. It can be modified so that the foot in moved in medial, lateral, anterior, posterior inversion, eversion direction. These adjustments help to correct gait deviations, increase energy efficiency, and make walking more efficient and cosmetic. Therefore it is used in early stages of gait training. Temporary prosthesis can be converted to definitive or final prosthesis with cosmetic modifications.

III- Definitive prosthesis

It is used when limb volume becomes stable. It can be applied 3-9 months postoperative. Life span 3-5 years. Changes are needed when there is residual limb atrophy, weight gain or loss., and excessive wear after prosthesis.

Prosthetic foot
It should be: 1- Providing stable base of support. 2- Shock absorption. 3- Joint & muscles stimulation. 4- Cosmetic appearance.
Types

Conventional

Dynamic response

I) Conventional
a) Articulated Single axis: Have a single Metal axis that allows plantar (15 degree) and dorsiflexion ( 5-7 degree). Internal keel surrounded by foam-rubber outer lining. Loaded with dorsiflexion bumper that replaces eccentric contraction of plantar flexors, and plantarflexion bumper that replaces eccentric contraction of dorsiflexion. It allows level- floor ambulation but does not allow for walking on a steep incline.

Multiple- axis foot

The multiple axis foot has two joints, a rubber rocker block that allows dorsiflexion and plantarflexion and a transverse ankle joint that allows rotation, eversion and inversion. It contains a wood keel and outer cover of foam rubber. It allows walking on level ground and inclines

b) Non articulated 1- Solid Ankle Cashion Heel (SACH) Consists of wood keel that extends forwards to the toe break and is surrounded by molded foam. The SACH Compressible rubber heel simulates plantar flexion. At loading response the heel wedge comprises to simulate plantar flexion.

2- Stationary Attachment Flexible Endoskeletal foot (SAFE)

The SAFE foot keel, is composed of rigid polyurethane plate at an angle 45 in the sagittal plane to provide eversion and inversion. To elastic bands extend on the plantar surface that courses the keel to dorsiflex from mid- to terminal stance. At pre swing the keel releases.

II) Dynamic Response

1- Articulated College Park True Step It has three axes one vertical and two transverse axes. These axes allow mobility in the three planes of motion. Two bumpers, dorsi- and plantar flexion bumpers are included. In front there are two split toes of carbon fibers. College Park designs, manufactures high quality prosthetic feet and components.

2- Non- Articulated A) SHORT KEEL 1- Stored Energy foot

(STEN)
The keel is subdivided into compressible and non compressible segments, a structure that allows energy storage from loading response to mid swing and release it at push off.

2- Carbon Copy II Consists of two carbon fiber deflection plates that return energy during walking and running. It has a strong keel covered by polyurethanefoam.

B- LONG KEEL 1- Flex foot: Two elastic carbon fibers attached to a horizontal carbon foot plate. Carbon fibers extend to include the pylon. 2- Springlite foot: Similar to flex foot, but consists of one elastic carbon fibers and one fiber glass filaments surrounded by a soft cover. It is 30% less expensive than flex foot.

1- Flex foot:

2- Springlite foot:

Sockets
Sockets for below knee amputation is either Patellar tendon bearing or total surface Bearing sockets. Total surface bearing Complete weight bearing evenly distributing pressure on the contact surface

Suspension
Types

1- Supra condylar (medial wedge). 2- Supra condylarsupra patellar system. 3- Supra condylar cuff. 4- Thigh corset. 5- Waist belt.

Different Types of Prosthesis

Types of Prosthesis

Lower Limb Prosthesis

Lower Limb Prosthetic Aids are manufactured in fibreglass. These are fitted to following levels of amputations or loss: *Through Hip *Above Knee *Through Knee *Below Knee *Through Ankle (Symes) *Partial Foot (Chopart)

5 basic functions of the prosthetic foot

Prosthetic feet are as follows: Provide a stable, weightbearing surface Absorb shock Replace lost muscle function Replicate the anatomic joint Restore cosmetic appearanc

Jaipur foot and below knee prosthesis.

ABOVE THE KNEE PROSTHETIC SOCKETS

Upper limb prosthesis

Cont

Orthotics
Is an appliance which is added to the patient to enable better use of that part of the body to which it is fitted

Action of orthosis : (FARSHVL )

F --- free A --- assist R --- resist S --- stop H --- hold V --- variable L --- lock

Varieties of orthoses
Spinal orthosis Cervical orthosis Lower limb orthosis Upper limb orthosis

Spinal orthosis
Functions :
To relieve pain To support weakened paralysed muscles To support unstable joints To immobilise joints in functional position To prevent deformity To correct deformity

Cont

Cont

Thoracic-Lumbar-Sacral Orthosis (TLSO)

Indications: post-operative stabilization of the spine anterior compression fractures slippage of one vertebrae over another stable lumbar/thoracic fractures and musculoskeletal injuries

Lumbar-Sacral Orthosis (LSO)

Indications: post-operative stabilization of the spine lumbar vertebrae fractures

chronic back pain

slippage of one vertebrae over another stable lumbar fracture

C.R.O.W. (Charcot Restraint Orthotic Walker)

Indications: patients with foot ulcers patients with insensate feet charcot joint (progressive degeneration of a weight bearing joint )

Custom Foot Orthotics (FO)

Indications: foot deformity arthritis joint chronic painful skin lesion peripheral vascular disease neuropathy plantar fascitis

Knee Orthosis (K.O.)

Indications: knee instability ruptured ACL other knee ligament injury or rupture osteoarthritis (degenerative joint disease)

Knee Ankle Foot Orthosis (KAFO)

Indications: spina bifida cerebral palsy paraplegia polio trauma muscular dystrophy

Ankle Foot Orthosis (AFO)

Indications: fractures, sprains, arthritis and trauma stroke cerebral palsy spina bifida drop foot

Hip Abduction Orthosis

Indications: hip dislocation post total hip replacement surgery

Cervical-Thoracic Orthosis (CTO)

Indications: C-1 to T-1 spinal immobilization cervical management

Hyper-Extension Spinal Orthosis

Indications: stable compression fractures of T-7 to L-2 needed thoracic extension to correct kyphotic posture thoracic instability needed extension or hyperextension for spinal alignment and reduce pain

Lumbar-Sacral Orthosis (LSO)

Indications: post-operative support acute and chronic low back pain compression fracture spinal stenosis spondylolysis spondylolisthesis

Post-op Knee Ranger

Indications: locked or limited motion control of knee during rehabilitation after operative procedures injury to knee ligaments or cartilage stable or internally fixed fractures of tibial plateau, condyles, or proximal tibia and distal femur

Walking Boot
Indications: stable fracture of foot and/or ankle severe ankle sprain post-operative use

Elbow Brace
Indications: soft tissue repairs stable elbow fractures post dislocation post subluxation

Elbow Orthosis
Indications: severe or chronic elbow instability trauma post-operatively immobilization arthritis muscle strength imbalance

general principles of good prosthetic hygiene

Anne Alexander in a
1975 booklet entitled Amputees Guide: Below the Knee (12), as follows: Bathe your leg daily with warm water and soap. Ideally, you should bathe at night. Bathing in the morning may cause the
limb to swell from the warm water, making it more difficult to put on your prosthesis. Do not shave the residual limb because this might cause injury to sensitive skin. Wash your socks every day with warm water and non-detergent soap. Follow the guidelines of the sock manufacturer. Clean the prosthesis socket every day using a damp cloth and mild soap or alcohol. Wipe out the insert with a dry cloth every day.

Amputee Rehabilitation program

Covers a wide spectrum of care from pre-amputation to reintegration into the community Includes: Pre-amputation counseling Amputation surgery Acute post- amputation period Preprosthesis training Preparatory prosthesis fitting Prosthesis fitting and training Reintegration to the community Long Term Follow up
Physical Medicine and Rehabilitation, Randall L. Braddom

Rehabilitation of lower limb amputee

Pre-operative Assessment
Neurovascular and functional status of extremity Function and Condition of residual limb (in case of traumatic amputation) Circulatory status and function of unaffected limb Signs & Symptoms of infection (culture required)

Nutritional Status
Concurrent medical problems Current medications

 Emotional reaction to amputation Circumstances surrounding amputation (ie. Traumatic versus surgical) Occupational and social Rehabilitation

Pre-amputation Counseling
Direct communication with patient, family and surgeon to discuss need for amputation and surgical outcome Meet with physiatrist, therapist and other members of the

treatment team
Talk about pain management, phantom pain, realistic expected functional outcomes

Pre-rehabilitation program when possible to strengthen

the trunk and other muscle groups

After the amputation patients experience: -PAIN

-GRIEF
-FEAR -Sometimes a sense of relief

Primary Amputation

Above the Knee Primary Amputation

Site of Amputation

 Monitor for complications Pain management Education & support Promote mobility/ independent self-care Enhancing Body Image Promote wound healing

 Wash at night Mild, fragrance free soap or antiseptic cleaner

Rinse well
Dry thoroughly General wound care

Rehabilitation for Amputation and Prosthetic Fitting after Burn Phase I

Characteristics of amputated limb which can functional well in prosthesis

Pain free Well padded by soft tissue Non adherent scar Cylindrical shape Greatest bone length Normal sensation

Prosthetic Rehabilitation Following Burn Amputation

Phases of Rehabilitation
Acute Post Surgical Phase Pre- Prosthetic Phase
Prosthetic Prescription and Fabrication Phase

Prosthetic Training Phase

Functional & follow up Phase

Time: Amputation Surgery to Suture Removal

Goals
Promote wound healing
Control incisional and phantom pain Maintain joint(s) ROM

Promote positive nitrogen balance

Mobilize entire body

Promote Wound Healing

1-A superficial skin defect can usually be closed adequately with a Split thickness skin graft (STSG). 2-Full thickness defect over bony prominence is better handled with full thickness coverage (either with local flap, pedicle flap, or free island flap). Physical therapy can enhance wound healing and reduce associated complication (such as development of hypertrophic scar) through using low level laser therapy (LLLT) (Helium neon laser therapy and or Gl-Al-Ars), with following treatment protocol;

Control Incisional and Phantom Pain

Incisional Pain: 1-It is a natural part of any surgical procedure where skin subcutaneous tissue, nerve and muscles have been cut .It usually goes away when swelling reduced and healing occurs. 2-Incisional pain should be controlled with adequate amounts of narcotic preferably given intravenously on regularly prescribed dose basis. This is usually helpful for the first three postoperative days. Subsequently oral analgesic should be adequate if there are no other sources of significant pain

Control Incisional and Phantom Pain

Phantom Pain: 1-This is a pain in the missing or amputated part of the limb. It varies tremendously from person to person .It can include burning, tingling, squeezing and cramping, shocking, and shooting description. 2-Phantom pain should be explained to the patients since they occur in the early postoperative period. 3-The patient should expect that phantom pain sensation and phantom limb changes and usually diminished, and may be become long term problem. 4- Use of oral pain medication for significant phantom pain has not usually produced adequate pain reduction over period of time exceeding one week.

Control Incisional and Phantom Pain

Phantom Sensation: This is sensation or feeling in the part of the limb that has been removed. it include itching , tingling , warmth, cold, cramping , constriction , movement, and any other imaginable sensation , and all persons with limb loss experience some phantom sensation. Rresidual limb pain: This kind of pain occurs in what is left of your natural limb after the amputation, as the residual limb always is more sensitive than other parts of body.

Maintain Joint ROM &Strength

1-Positioning is an important part of a patient's exercise program. It is done to prevent shortening of soft tissue and joint(s) contractures, that can result from ; (i) Soft tissue shortening . (Ii) Muscle imbalance. (iii) Protective withdrawal reflex. (iv) Faulty position. 3-If possible patients with an amputation should lie prone intermittently to enhance hip and knee extension, however care should be taken to avoid over stress on cardiovascular system during assuming this position. 4-The positioning program should emphasize active or active assistive ROM of the joint (s) proximal to the amputation. 5-Elevation of residual limb on a pillow can lead to the development of hip flexion contracture and so should be avoided.

Description
Lying supine: make sure that hips and knees are straight, the patients should lie on a firm surface and avoid pillows under the residual limb. The legs should be held close together.

Lying prone; pillow should be avoided under the hip and the hip should be kept straight, and the leg close together. The patients should lie prone or on wither side for up to 15 minutes, four times a day. This position will extended the hip and knee

Side lying; the hip should be kept in a neutral position. The patient should not sleep with large pillow between the legs or under the back .Pillow in these positions enhance hip flexion and abduction.

Sitting: when sitting patients should use a sliding board or other firm surface under the residual limb to promote knee extension.

 Exercises
1-The exercises program is designed individually and includes ROM, exercises, isometric, isotonic, and endurance activities, and these dependent largely on (i)-Postoperative healing. (ii)-Postoperative pain (iii)-Post-surgical dressing. 2-This exercise should not produce more than mild discomfort and put less stress on suture line, otherwise stop exercises. 3-The hip extensor, abductors and knee extensor and flexors are particularly important for prosthetic ambulation.

 4-Strengthening exercise for upper extremity muscles of shoulder depressor, elbow extensor, wrist extensor, and hand flexor should encouraged, with general strengthening program for trunk and abdominal muscles. 5-The program should emphasize active or active assistive ROM of the joint (s) proximal to the amputation, at 1st to 2nd day postoperative. 6- Active motion of all proximal joints through the full ROM should be obtained by 10 -14 days following amputation unless grafting procedure precludes exercising.

 7-Gentle isometric exercises can be started at the 5th postoperative day. * A brief repetitive isometric exercises (BRIME), regimen is an extension of the original isometric .A patient with an imputation may use this regiment which consists of up to 20 maximum contractions. Each held for 6 second (Why?). A 20 seconds rest after each contraction is recommended (Why?). Rhythmic breathing during the contraction is recommended (Why?). * Multiple angle isometric exercises should be performed. 8- Isotonic exercises can be encouraged at 7 -10 days postoperative. 9-Program of muscle contraction and joint motion (8-10 repetition for 3sets) should be repeated several time daily (4-6 times), and once when adequately performed no need for supervision.

10-These exercises help to (i)-Reduce edema, and promote healing. (ii)-Maintain joint ROM, (iii)-Prevent contracture and correct existing contracture (iv)-Allow early mobility self care and (v)-Maintain muscle strength, and kinesthetic sense of residual and phantom limb, which can later be used in prosthetic training

Exercises for post-burn amputation

Exercises Suggestion
Hip Extension

*Lie supine on firm matters,

with towel placed under the residual limb; the residual limb is pressed firmly into the towel, raising the buttocks off the resting surface. *Bridging: lie supine with sound knee 90degrees of flexion, with foot is pushed down into the resting surface. The residual limb should be raised until both hips are of equal height. * Lie prone; lift the leg off the mat, at time with knee extended.

Hip abduction *Lie side on amputated side, with towel under the residual limb. The sound limb rested in pillow, stool in front of residual limb. The residual limb is depressed down on the towel. *Lie side on sound side, raising the residual limb, with weight around the distal tibia. *lie supine with rubber banding around the distal end of both limb, the patients pulls the residual limb away from sound limb.

Knee Extension

leg rising *Short arc quad sets *Lie Prone; the patient is prone with towel under the residual limb. the distal residual limb is pushed into the towel , and extended the knee

*Straight

Knee Flexion

*Lie supine, with a towel under the residual limb, the patient pulls back into the towel, slightly bending the knee. *Lie prone and flex the knee against gravity.

Pre-Ambulation Exercises Program

Concurrent Activities

Strengthening

Coordination

Transfer Training

Wheelchair Walking aid

Parallel Bar and Ambulation Activities

Turning & Returning

Stepping Forward Backward

Standing Balance

Parallel Bar Activitie s

Anterior Posterior Weight Shift Lateral Weight Shift Hip Hiking

Standing Push up

Walking with crutches

(For persons with single leg amputations only):
First move the crutches forward about (30 cm). Step forward with your residual limb/prosthesis. Land it between your crutches. Lift your natural limb and step to, or past the crutches.

Going up stairs:
Step up with your natural limb first. Then bring your crutches and residual limb/prosthesis up.

Going down stairs: Dont hop. Move your crutches down first, then step down with your residual limb/ prosthesis. Lastly, step down with your natural limb.

What is PLP? The somatosensory homonculus

Acupuncture Exercise Anaesthetics Heat Biofeedback Magnetic Therapy Chiropractic Massage Cold Medications Cranial Sacral Therapy Psychotherapy Desensitization Shrinker Socks Dietary and Herbal Wearing Your Supplements Artificial Limb Electrical Stimulation

There are 5 Stages of Rehabilitation: 1. Healing and Starting Physiotherapy 2. Visiting the Prosthetist

3. Choosing an Artificial Limb 4. Learning to Use your Artificial Limb

5. Life as a New Amputee

Rehabilitation of lower limb amputee :

Therapy plays an integral role in preparing a patient for a lower-extremity orthotic or prosthetic device and training them with that device once it has been fabricated. Once a patient receives a prosthetic or orthotic device, the therapist is then responsible for evaluating that patient with their device

Exercise After Amputation

ROM to prevent flexion contractures, particularly of the hip and knee Trapeze and overhead frame Firm mattress Prone position every 3 to 4 hours Elevation of lower-leg residual limb controversial

Stretching

Stretching

Milestones after limb loss

Getting out of bed Walking with an assistive device Meeting family and friends for the first time Joining a peer group Restoring physical conditioning Reducing residual limb swelling Meeting the prosthetist Receiving the first prosthesis Learning to use the prosthesis Getting back to work/ leisure activities ACCEPTING THE NEW BODY IMAGE

Common Amputee Problems

Dermatological Bone Problems Pain Depression

Dermatological Problems
Folliculitis Boils or abscesses Epidermoid cysts Tinea Corporis or Tinea Cruris Hyperhidrosis Allergic Dermatitis Choked Stump Verrucous Hyperplasia

Problems relating to the Bone

Bone Spurs Hypermobile fibula Bony overgrowth (in children) Heterotopic Ossification

Bone Spurs
If the periosteum is not stripped properly during surgery or trauma, bone spurs can arise Cause pressure on the skin and pain Socket modifications help May require surgery

Hypermobile fibula
Occurs when a balanced myodesis was not performed in a transfemoral amputation causing the femur to extrude through the muscle Causes pain May need prosthetic adjustments or surgery

Bony overgrowth
Occurs mainly in children after amputation of a long bone before it reaches maturity Continued bone growth that pushes through the skin Skin Traction is preferred but surgery may be required

Heterotopic ossification
Bone formation in the soft tissue Risk factors include immobility, fracture of long bones, pressure ulcers and edema Causes pain and decreased ROM Medications and surgery

Heterotopic Bone

Heterotopic Bone

Heterotopic Bone

PAIN
Residual limb pain
Post operative incision pain Edema of the limb Presence of a neuroma (nerve ending exposed after surgery) Pain referred from the back After tumor amputation, there could be local recurrence of the tumor Infection Problems with the prosthesis Bone spurs

Phantom Pain or Sensation

It is an awareness of pain in the portion of the extremity that has been amputated.

Phantom Sensation or Phantom Pain

Common Examples of Phantom Sensation

Gnawing/eating Stabbing Burning Squeezed Painfully twisted Terrible cramps Shocking/shooting

Sherman, Richard A. Phantom Pain. New York: Plenum Press, 1997

Treating the Pain

Physical Intervention
Decrease swelling of the residual limb-shrinker/ace wrap Acupuncture Transcutaneous Electrical Stimulation (TENS) Vibration or Ultrasound Desensitization by tapping ,rubbing or massage of the residual limb

Medical Intervention
Narcotic pain medication- mainly in the acute post operative period Tricyclic antidepressants, Gabapentin Anticonvulsants Capsacin Lidoderm patches

Treating the Pain (contd.)

Psychological Intervention
Hypnosis Biofeedback Cognitive therapy Support Groups Relaxation therapy Voluntary control of the phantom limb

Procedures and Surgical Intervention

Less favorable Nerve blocks with Phenol Steroid injections

Depression
Reaching out is the first step in emotional recovery from limb loss Peer support in the form of Peer visitation, online support group and local support groups Contacting the National limb loss Information Center at 888-AMP-KNOW

Phases of Recovery
Amputee Coalition of America uses these six phases to describe the recovery process : Enduring Suffering Reckoning Reconciling Normalizing Thriving

Wound and Skin Care

Phase 1: Pre-closure of the Residual limb Goal: Promote healing of the underlying soft tissue and to treat or reduce the risk of infection
Keep the wound dry Wash the hands and wear gloves when cleaning or dressing the wound Exercise caution when moving in bed or getting out of bed Eat a good diet helps with wound and tissue healing Talk to the rehab team if they experience pain or any discharge or discoloration of the wound

Wound and Skin Care

Phase 2: Definitive Closure of the residual limb Goal: to prepare the residual limb for prosthetic fitting
Sutures removed in 14-21 days Wear a shrinker or a rigid dressing or ace wrap to help shape the limb Desensitization techniques like massage and tapping scar mobilization Inspection of the residual limb using a mirror

Reintegration into the Community

Disability Rights Laws These laws serve to prevent discrimination,set up systems to provide services for the disabled, and/or allow people with disabilities to participate in all aspects of their lives without barriers.

Disability Rights Laws

Architectural barriers Act of 1968 Urban Mass Transit Act of 1970 Rehabilitation Act of 1973 Civil Rights Restoration Act 1988 Air Carrier Access Act of 1988 Fair Housing Act of 1988

American With Disability Act 1990

Four Major Areas
Title I: Employment Title II: Public Services Title III: Public Accomodation and Commercial Facilities Title IV: Telecommunications

Disability Rights Laws

Social Security Act New Freedom Initiative Resources for Disability rights:
http://www.ada.gov www.mdod-maryland.gov htttp://www.dors.state.md.us/dors Maryland Statewide Independent Living Council 410-544-5412

Driver Education and Training

Obtain a physician referral for driver education or training Pre-driving screening assesses
Vision , perception, cognition, functional ability, motor /sensory function and reaction time

Once completed a prescription for vehicle modification will be given Vendor performs modifications and the modified vehicle is taken back to the program for inspection

Driver Education and Training

Driver training programs
Workforce and Technology Center 410-554-9205 www.dors.state.md.us Sinai Hospital 410-601-8823 www.lifebridgehealth.org

Home Accessibility Resource Guide

Home Modification Equipment Supplies Funding sources and Loan Programs Home Assessment and Equipment Evaluation Information and Referrals Licensed Home Improvement Contractors Volunteer Organizations

Vocational Rehabilitation (VR)

Vocational rehabilitation is a national program for assisting eligible people with disabilities to define a meaningful career goal and become employed VR accomplishes its mission through Vocational Counseling and Guidance, VR services, Training and Education and Job Placement

Therapeutic Recreational Rehabilitation

BARS Relaxation Training Sports Education Series Leisure Skill Development

Preventing Secondary Conditions

Weight Management Strength Training Exercise self-discipline Assess the risks of choosing not to wear the prosthesis Work with your physical therapist and physician to treat physical problems and impairments ( eg. joint pains, back pain)

Preventing Secondary Conditions

Beware of interactions between prescription medicines and foods, herbal supplements and other drugs Review the insurance policy regularly to make sure that no changes have been made to reduce or eliminate reimbursement for the prosthesis

References
Day, R.A., Paul, I., Williams, B., Smeltzer, S., Bare, B.G. (2009) Brunner and Suddarth's Textbook of

Canadian Medical-Surgical Nursing, 2nd ed. Lippincott Williams & Wilkins

Canadian Association of Wound Care. (2011). Statistics on Diabetic Foot Ulcers. Retrieved from http://

cawc.net/index.php/public/facts-stats-and-tools/statistics/

Mosby. (2008). Mosby's Dictionary of Medicine, Nursing & Health Professions. 8th ed. A Mosby

Title

National Limb Loss Information Center. (2008). Amputation Statistics by Cause Limb Loss in the United States. Retrieved from <http://www.amputeecoalition.org/fact_sheets/amp_stats_cause.html>
National Limb Loss Information Center. Statistics on Hand and Arm Loss. Retrieved from <http:// www.aboutonehandtyping.com/statistics.html> Net Wellness. (2011). Amputation Overview. Retrieved from <http://www.netwellness.org/ healthtopics/amputation/overview.cfm> War Amps (2009) Retrieved from <http://www.waramps.ca/CMSMasterHome.aspx?&LangType =1033>