limb amputation

2. 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.

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

5. 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, Berger’s disease, atherosclerosis,
embolism, arterial thrombosis, arteriovenous aneurysms
or trauma etc. are indications for amputation.

6. 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. It may lead to auto amputation in neglected
patients e.g. Hansen's disease. 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.

7. 3) Congenital anomalies : Rudimentary limbs,
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.

8. Closed Amputation Open Amputation
TYPES OF AMPUTATION

9. CLOSED AMPUTATION

10. 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.
Some basic principles to be followed are as follows
:
1) Tourniquet: Use of a tourniquet is highly
desirable except in case of an ischaemic limb.
2) Level of amputation : With modern techniques
of fitting artificial limbs, strict levels adhered to in the
past are no longer tenable.
3) Skin flaps : The skin over the stump should be
mobile and normally sensitive.

11. 4) Muscles : They should be cut distal to the level of
bone. Following method of muscle suture have
been found advantageous :
i) Myoplasty : The opposite group of muscles are
sutured to each other.
ii) Myodesis : The muscles are sutured to the end of
the stump.
5) Nerves : They are gently pulled distally into the
wound. Large nerves such as sciatic nerve contain
relatively large vessels and should be ligated before
they are divided. Nerves cut sharply

12. 6) Blood Vessels : They are double ligated and cut.
7) Bone : The bone is sectioned above the level of
muscle section. Excessive periosteal stripping
proximally may lead to formation of ring
‘sequestrum’ from the end of the bone. Sharp edges
of the cut bone should be made smooth.
8) Drain : A corrugated rubber drain should be used
for 48-72 hours post operatively.

13. GUILLOTINE OR OPEN AMPUTATION
In this type of amputation the skin is not closed primarily
and later it is followed by any one of the closure methods
like secondary closure or re-amputation.
Indications are severe infections, severe crush injuries.
Types :
i) Open amputations with inverted skin flaps is the
method of choice.
ii) Circular open amputation : Here the wound is kept
open and closed secondarily either by secondary
suture after a few days, split thickness skin graft, or by
reamputation.

14. 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.

15. LOWER LIMB AMPUTATIONS

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

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

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

19. 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.

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

21. SYME’S AMPUTATION
Amputation just
above the ankle
joint.

23. ANKLE DISARTICULATION
Complete tarsal
amputation

24. CHOPART DISARTICULATION
Partial Tarsal Amputation

25. LISFRANC’S AMPUTATION
Complete Metatarsal
Amputation through
tarsometatarsal joint

26. TRANSMETATARSAL AMPUTATION
Partial Metatarsal Amputation
through the metatarsal bones

27. TOE AMPUTATION
Complete phalangeal
amputation

28. 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.

29. 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

30. 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.

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

32. 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

33. (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.

34. 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.

35. (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.

36. 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.

37. (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.

38. 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.

39. 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.

40. 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.

43. 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

44. 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.

45. 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.

46. 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.

47. (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.

48. Elderly patients may need initial ambulation practice in
parallel bars.

49. 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.

50. 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.

51. 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.

52. 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) Syme’s amputation : Same as in below-knee
amputation

53. 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.

54. THANK YOU