Rehabilitation of Amputations in Disasters and Conflicts

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Original Editors - Add your name/s here if you are the original editor/s of this page.  Ewa Jaraczewska

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Introduction

Natural disasters and mass casualties that occur during military conflicts or industrial accidents can cause musculoskeletal trauma among military and civilian populations involved in these disasters.As a result of crush injury, crush syndrome or compartment syndrome a different than the non-disaster approach to amputations may be warranted. Early rehabilitation is important in the prevention of severe mobility limitations, self-care limitations, postural disorders, reduction in body's endurance, and inability to tolerate physical activities.

Types of Amputations

The level of amputation defines different types of lower and upper limbs amputations.

Upper Limb Amputations

Shoulder level:

• Shoulder disarticulation
• Amputation of the arm, scapula and clavical (Forequater)

Elbow level:

• Above elbow (Transhumeral)
• Elbow disarticulation
• Below elbow (Transradial)

Wrist and Hand level:

• Partial hand (Transcarpal)
• Hand and Wrist disarticulation

Lower Limb Amputations

Hip level:

• Hip disarticulation
• Amputation of the leg and pelvis (Hemipelvectomy)

Knee level:

• Above-knee amputation (Transfemoral)
• Knee disarticulation
• Below-knee amputation (Transtibial)

Foot and Ankle:

• Ankle disarticulation
• Partial foot (Chopart)
• Syme's

Initial Trauma Care

In disaster situations the following principles of trauma care are often critical: rapid triage, transport, early stabilisation, and definitive management.

Rapid Triage

Life-saving is a primary purpose of limb amputation during the disaster as the wounds sustained at the battlefield usually present with extensive soft tissue damage, and delayed injury- to-operation time. These are high-energy wounds as compared to wounds sustained during other mass-casualty events (eg. earthquake) which are characterised by low-energy injury, extensive soft tissue damage and late presentation.

Transport and Early Stabilisation

Prehospital field amputations may improve patient outcome. Research shows that in a disaster situation limb amputation as distally as possible is an acceptable approach to life-saving action.

Definitive Management

Medical and Surgical Intervention

Considerations for Amputations

When amputations are performed in field hospitals or at the scenes of disaster, the selection of the level of amputation need to include the following factors:

• The potential for healing of the stump
• Patient’s general condition
• The risk of additional surgeries
• The fitting of the prosthesis (if the patient is likely to be a candidate for prosthetic rehabilitation)
• The probable functional outcome
• Length of viable tissue and bone
• The age of the patient

Factors to be considered when deciding about the need for limb amputation are related to:

• Trauma complications
  • crush injury: direct pressure that damages the extremities' soft tissues—skin, muscles, nerves, and blood vessels, often as a result of an earthquake. This may lead to the development of compartment syndrome.
  • crush syndrome: is characterised by high morbidity and mortality. This is due to electrolyte imbalance, impairment in circulation, and multiple organ failures as a result of severe rhabdomyolysis and reperfusion injuries. It requires four to six hours to fully develop. Initial symptoms may include tissue swelling, pain, redness or pallor of the skin, paresthesia and motor impairment. Benefits from an early amputation vs fasciotomy are still under investigation.However preservation of a patient’s cardiac, renal, metabolic and circulatory fluid volumes is a priority for saving lives over saving the limb.
  • compartment syndrome: compression of the tissues within a compartment with progressive impairment in circulation and tissue function resulting in tissue necrosis.

• Irreparable vascular injury
• Completion of a partial amputation
• Overwhelming sepsis
• Each country cultural imperatives.

Medical Considerations

There are two factors contributing to the level of amputation: clinical factors and the mechanism of injury.

Clinical Factors:

• Blood loss: haemorrhage control via direct pressure followed by a tourniquet placement
• A type of crush injury: assessment of neuromuscular, bone and soft tissue functions and conditions, foreign bodies' presence
• Wound contamination: early and aggressive debridement will minimise wound infection and sepsis. Bone fragments, foreign bodies should be removed. The second debridement was performed within 48-72 hours, primary closure was delayed for 5- 6 days.

Mechanism of injury:

• preservation of viable tissue: amputation at the lowest possible level of viable tissue
• vacuum- assisted wound closure

Surgical Intervention

There are two main surgical procedures for limb amputation in regards to the muscles. The type of procedure may have a direct impact on the rehabilitation processes:

1. Myoplasty: the goal is to provide distal muscle stabilisation. This technique is based on suturing the muscle to the muscle (agonist to antagonist) and placing it over the bone before the wound is closed.
2. Myodesis (myopexy): muscles are attached to the bone through the holes drilled in the bone. This technique is preferable from the rehab perspective as it provides more stability to the residual limb.

Rehabilitation Considerations

Early rehabilitation for people who had a limb amputated as a result of the injury related to conflicts or disasters can be very challenging. The physiotherapists who work with them often need to rely on their own limited clinical experience, lack of or limited access to a multidisciplinary team, lack of equipment and speciality services, including a prosthetist.

The rehabilitation process can be divided into four stages:pre-amputation , early rehabilitation (post-amputation and pre-prosthetic phases), prosthetic rehabilitation , and post-rehabilitation.

Early Rehabilitation

Assessment Considerations

Treatment Considerations

Prosthesis consideration

Sturdy and well-padded with ample muscular soft tissue to distribute the shearing stresses of weight-bearing evenly

Muscularly balanced, so that agonist and antagonist muscle groups counteract each other to prevent joint deformity or contracture

Not affected by any deformity or contracture

Free of pain

Resources

International Search And Rescue Advisory Group (INSARAG):https://www.insarag.org

References