Rehabilitation of Amputations in Disasters and Conflicts
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Introduction[edit | edit source]
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.[1]As a result of crush injury, crush syndrome or compartment syndrome a different than non-disaster approach to amputations may be warrant. [1]Early rehabilitation is important in prevention of severe mobility limitations, self-care limitations, postural disorders, reduction in body's endurance, and inability to tolerate physical activities. [2]
Types of Amputations[edit | edit source]
The level of amputation defines different types of lower and upper limbs amputations.
Upper Limb Amputations[edit | edit source]
Shoulder level:
- Shoulder disarticualtion
- 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[edit | edit source]
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 dysarticulation
- Partial foot (Chopart)
- Syme's
Initial Trauma Care[edit | edit source]
In disaster situations the following principles of trauma care are often critical: rapid triage, transport, early stabilisation, and definitive management.
Rapid Triage[edit | edit source]
Life saving is a primary purpose of limb amputation during the disaster as the wounds sustained at the battlefield usually presents 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[edit | edit source]
Prehospital field amputations may improve patient outcome. [3]Research shows that in the disaster situation limb amputation as distally as possible is an acceptable approach to life saving action.[4]
Definitive Management[edit | edit source]
increased risk of infection and higher levels of amputation[1]
Medical and Surgical Intervention[edit | edit source]
Considerations for Amputations[edit | edit source]
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 [5]
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[1]. May lead to development of compartment syndrome.
- crush syndrome: is characterised with a high morbidity and mortality. This is due to electrolyte imbalance, impairment in circulation, and multiple organ failure 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.[1] Benefits from an early amputation vs fasciotomy are still under investigation.[6]However preservation of a patient’s cardiac, renal, metabolic and circulatory fluid volumes is a priority for saving life 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.[1]
- Irreparable vascular injury
- Completion of a partial amputation
- Overwhelming sepsis
- Each country cultural imperatives.[1]
Medical Considerations[edit | edit source]
Healing Considerations[edit | edit source]
Assessment Considerations[edit | edit source]
Treatment Considerations[edit | edit source]
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[5]
Resources[edit | edit source]
International Search And Rescue Advisory Group (INSARAG):https://www.insarag.org
References [edit | edit source]
see adding references tutorial.
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Wolfson N. Amputations in natural disasters and mass casualties: staged approach. Int Orthop. 2012 Oct;36(10):1983-8.
- ↑ Herasymenko O, Pityn M, Kozibroda L, Mukhin V, Dotsyuk L, Galan Y. Effectiveness of physical therapy interventions for young adults after lower limb transtibial amputation. Journal of Physical Education and Sport. 2018 Jul 1;18:1084-91.
- ↑ Yang C, Ross W, Peterson M. Prehospital field amputation leads to improved patient outcome. J Emerg Med Serv. 2018;43.
- ↑ International Search And Rescue Advisory Group (INSARAG). Available at:https://www.insarag.org. Last access 01.03.2022.
- ↑ 5.0 5.1 Lathia C, Skelton P, Clift Z. Early rehabilitation in conflicts and disasters. Handicap International: London, UK. 2020.pp:115-148.
- ↑ Arango-Granados MC, Mendoza DF, Cadavid AE, Marín AF. Amputation in crush syndrome: A case report. International Journal of Surgery Case Reports. 2020 Jan 1;72:346-50.
