Amputations

Causes of amputations

• Diabetes mellitus
• Chronic leg ulcer leading to Septicaemia
• Phocomelia (congenital absence of the upper arm or leg)
• Malignant tumours e.g. sarcoma (cancer of the connective tissue)
• Arterial insufficiency leading to death or decay of body tissue (gangrene)

Levels of amputations

• Through or just above the ankle
• Below the knee
• Above the knee
• Through the foot
• Through the knee
• The whole leg or disarticulate leg
• Removal of the buttock

Signs and symptoms of gangrene

• The tissue is cold and blue (Cyanosis)
• Pain
• Intermittent claudication (a cramping pain, induced by exercise and relieved by rest, caused by an inadequate supply of blood to the affected muscles)
• Clamp-like pain because of a spasm in the arteries of the leg
• Intense ischaemic pain
• Increased prevalence in smokers because nicotine causes spasms of blood vessels
• Most often found in muscles of the leg and calf as a result of atheroma of the arteries
• Leg pulses are often absent

Location of pulses

• Foot pulse (Medial malleolus or dorsum of the foot)
• Popliteal (behind the knee)
• Femoral (within the femoral triangle)
• If a leg has been amputated because of gangrene, the remaining leg is examined for a pulse

Special investigations

• X-rays
• CT scan
• Angiogram (outlines blood vessels)
• Doppler ultrasound (occlusion of vessels)
• Venogram and arteriogram
• Radioactive dye injected into the blood

Arterial insufficiency

• Surgery to improve circulation
• Bypass grafts (autogenous graft uses a vein to bypass the obstructed area)
• Synthetic grafts

Management

Buerger’s exercises

• Stimulates collateral blood flow in the patient’s leg
• It is performed for 20 min.
• The leg is elevated until the toes go white, then lowered, then level
• Repeat 2-3 times to improve collateral circulation

Balance and gait retraining

• Improve static and dynamic balance
• Use Parallel bars, walking frame then Crutches (in that order)
• Therapist stands on the amp side, using a belt around the patient’s waist to support
• Rest if the patient feels tired

Short wave diathermy (SWD)

Through the pelvis to warm the arteries (contraindicated in patients with arterial insufficiency because the warmth leads to increased metabolism, causing a greater demand for nutrients, which are not available)

Post-operative care

• Maintain function in the remaining leg and stump to maintain peripheral circulation
• Maintain respiratory function (important with smokers and those patients under general anaesthesia)

Stump care

• For hygiene and skin care see handout on amputations
• A hip flexion Contracture may develop because of elevation to reduce swelling
• Stump bandaging is done to ‘cone’ the stump, thereby preventing oedema, which occurs because there is no muscle pump and the stump hangs
• Swelling must be prevented to allow proper attachment of the Prosthesis, and the prevention of Pressure sores
• The stump sock is put on first, then the prosthesis
• The prosthesis must be cleaned and maintained (Children who are still growing, grow out of their prostheses)

Types of wheelchairs

• For double lower limb amputations, the wheels are set further back