Transcript of AMPUTATION. DEFINITION: Amputation is a procedure where a part of the limb is removed through one or...
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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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