Amputation

What is acquired amputation?

The loss of part or all
of extremity as a
direct result of trauma
or by surgery.

What is congenital amputation?

The absence of part or all of an extremity
at birth.

What is elective amputation?

This is performed when the hand or entire
limb has no sensation and function as a
result of brachial plexus injury.

What is an open amputation?

Amputation in which the surface of the
wound is not covered with skin but left
unclosed. This is done to control infection.

What is closed amputation?

Usually a final or definitive amputation
performed to create a stump that can be
used effectively with a prosthesis.

What is minor amputation?

Amputation through of
distal to the
metacarpus or to the
metatarsus.

What is major amputation?

Amputation proximal to the metacarpal or
metatarsal bones.

What is a disarticulation?
Amputation performed through a joint

What are the causes of amputation?

1st year of life
Congenital deficiencies
1 to 10 years of age.
Motor vehicular accidents, tumor and trauma.
10 to 20 years of age
Malignancy is the most common cause.
55 years of age
Peripheral vascular disease

The right arm is more frequently involved

in work related injuries.

Lower Extremity Amputation

The major cause of LE amputation id
peripheral vascular accident
The most common cause of PVD is
atherosclerosis
After PVD the second leading cause is
trauma
This is followed by tumors (Osteogenic
sarcoma) and last by congenital cases.

Congenital Amputations
Causes:
Intrauterine development
Hereditary
Teratogenic agents
Maternal diabetes

What are the classification of

congenital amputation?
Amelia
Complete absence of the entire upper
extremity or lower extremity.
Hemimelia or Meromelia
Partial limb absence
Acheiria
Terminal transverse hemimelia, wrist level

Adactylia
Absent digit
Apodia
Absent foot
Phocomelia
Transverse total humeral radial , ulnar
deficiency

Franz and ORahilly Classification

Terminal
Complete loss of the distal end of an
extremity
Intercalary
Absence of intermediate parts with preserved
proximal and distal component of the limb.
Transverse/Horizontal
Absence of all skeletal elements distal to the
deficiency along a designed transverse axis.

How is acquired amputation

classified?
UE Measurement of Amputation
Above Elbow Stumps
Normal Length
Tip of acromion process to lateral
epicondyle
Stump Length
Tip of acromion process to end of stump

Bilateral Upper Extremity Amputations

Normal Upper Arm Length
Patients height x 0.19
Normal Forearm Length
Patients height x 0.21

Percentages
Above Elbow
0% - Shoulder Disarticulation
0-30% - Humeral Neck
30-50% - Short Above Elbow
50-90% - Long Above Elbow

Below Elbow
0-35% very short below elbow
35-55% short below elbow
55-90% long below elbow
90-100% wrist disarticulation

What is forequarter amputation?

shoulder disarticulation amputation in
which the shoulder blade and collar bone
are removed

Lower extremity Amputation

Above knee
Normal Length
Ischial tuberosity or the greater
trochanter to lateral tibial plateau.
Stump Length
Ischial tuberosity or the greater
trochanter to end of stump.

`
Below knee
Stump Length
From medial tibial plateau to end of
bone
Normal Length
From medial tibial plateau to medial
malleolus

What is a hip disarticulation?

Hip disarticulation is the surgical removal
of the entire lower limb at the hip level. A
traditional hip disarticulation is done by
separating the ball from the socket of the
hip joint, while a modified version retains a
small portion of the proximal (upper) femur
to improve the contours of the hip
disarticulation for sitting.

What is a transpelvic amputation?

Transpelvic amputation is the removal of
the entire lower limb, plus a portion of the
pelvic bones. It occurs in a skeletal zone
that can include, from the socket on the
outside to the spinal column in the middle,
the acetabulum, ischium, rami, ilium and
sacrum.

What is a Lisfranc amputation?

Partial amputation of the foot at the
tarsometatarsal joint, with the sole being
preserved to make the flap. The technique
was used to treat forefoot gangrene from
frostbite. Lisfranc was widely known for his
ability to amputate a foot in less than a
minute.

What is a Syme Amputation?

An amputation at the ankle with removal of
the malleoli and formation of a heel flap.

What is the ideal stump size?

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

Below knee
8 to 18 cm or 5 to 7 inches below medial
tibial plateau.

Percentages for Above and Below

Knee Levels
Delisa
<33% short above knee or below knee
stump.
33-66% medium length below knee or
above knee stump.
>66% long above knee or below knee
stump.

Sullivan
Transtibial
>50% of tibial length long below knee
20-50% - below
<20% of tibial length short below knee

What contractures are common for

lower extremity amputations?
For below knee amputees
Knee flexion contractures
For above knee amputees
Hip abduction and flexion

What is Phantom Pain?

This is a normal sensation occurrence
after amputation of a limb. The part
amputated is still present.

What are the Types of Phantom

Pain?
Cramping (most common)
Electric shock
Burning
Squeezing and wrenching

What are the Steps for Prosthetic

Management?
Preprosthetic
Pre-Operative
Operative
Post-Operative
Prosthetic Fitting and Training
Prosthetic Follow-Up Care

Preoperative
Evaluation and Assessment
Emotional Counseling
Therapy Counseling

Operative Management
The cardinal rule is to preserve as much as
length as possible.
Avoid the following level:
Hindfoot
Distal 1/3 of the leg
Supracondylar of femur

Muscles are just distal to the level of

intended bone section.
Bone must be bevelled and should be
covered with a good padding of the tissue.
Nerves should be pulled before cutting to
retract.
Blood vessels (major blood vessels are
ligated the smaller ones are cauterized).

Skin closure
Above knee amputee-fish mouth or middle
flap.
Below knee amputee-posterior flap/anterior
suture.

Post-Operative Management
Healing of wounds
Pain control
Preparation for prosthetic fitting
Maintenance of range of motion
Independent mobility
Independent self-care

What muscles need to be

strengthened for crutch walking?
Shoulder depressors
Shoulder adductors
Flexor, extensor and abductor of the arm
Extensor of the forearm at the elbow.
Wrist extensor
Finger and thumb flexors.

Post-Operative Dressing
Rigid
Made of Plaster of Paris
Change every 5-10 days.

Advantages
Limits post-operative edema
Allows for early ambulation
Reduces length of time for shrinking

Disadvantages
Requires careful application
Requires close supervision
Does not allow early wound inspection

Semi-Rigid
The Unna Paste Dressing
A compound of zinc oxide, gelatin, glycerin and
calamine maybe applied in the operating room.

Advantage
Better control of edema

Disadvantage
May loosen easily

Soft Dressing
Oldest method of post-surgical management
of residual limb.

Advantage
Inexpensive
Lightweight and readily available
Easily laundered

Disadvantage
Poor control of edema
Requires skill of application
Need frequent reapplication
Can slip and form a torniquet

What are the appropriate sizes of

bandages for amputees?
For above knee amputees two 6 inches
bandages sewn together and one 4 inch
bandage.
For below knee amputee two 4 inch elastic
bandage can be used.

What is the golden age of

prosthetic fitting?
It is the first 30 days following the
amputation.
Activities
Learn to put prosthesis
Weightshifting
Progressive ambulation between parallel bars
Walker-crutches-cane-unassisted on flat
surfaces.

Uneven terrain-stairs-ramps-curbs
Falling and getting-up
Transfer activities.

What are the different energy

expenditures for amputees?
Single BKA
9-28%
Double BKA
41-100%
Single AKA
40-65%
Double AKA
150%
Single AKA and BKA
75%
Unilateral hemipelvectomy
with prosthesis
125%

Crutch ambulation without

prosthesis
Wheelchair

50%
9%

What are the functional

classifications of amputees?
Class 1 Full Restoration
The individuals is functionally equivalent to
normal

Class 2 Partial Restoration

The artificial limb is completely functional. The
person is able to work and engage in sports
but on a selective basis.

Class III
Self-Care Plus
The individual is disabled and has physical
limitation, requires frequent adjustment of
prosthesis.

Class IV
Self-Care Minus
Needs help from others because he is
severely disabled. Cannot go up and down
the stairs without assistance.

Class V
Cosmetic Plus
The amputee is better off without a prosthesis

Class VI
Not feasible. Only a wheelchair is prescribed.

End of Lecture