Rehabilitation of Amputations in Disasters and Conflicts

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Original Editors - Ewa Jaraczewska

Top Contributors - Ewa Jaraczewska, Naomi O'Reilly, Kim Jackson, Arnold Fredrick D'Souza, Jess Bell, Tony Lowe and Tarina van der Stockt      

Introduction

Natural disasters and mass casualties that occur during military conflicts or industrial accidents can cause musculoskeletal trauma among military and civilian populations who are 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 disaster situations limb amputation as distally as possible is an acceptable approach to life-saving action.

Definitive Management

Medical and Surgical Intervention

General Considerations for Amputations

When amputations are performed in field hospitals or at the scenes of disaster, 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.

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

Medical Considerations for Amputations

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 is performed within 48-72 hours, primary closure is 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

Two main surgical procedures for limb amputation in regards to the muscles 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 that 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 the victims of disaster often need to rely on their own limited clinical experience, lack of or limited access to a multidisciplinary team, as well as lack of equipment and speciality services, including a prosthetist.

The entire 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

Objectives

The overall objectives for post-amputation and pre-prosthetic phases include recovery from surgery, tissue healing, treatment of concurrent injury if present, effective physiotherapy interventions based on thorough patient assessment, assessment of equipment needs and equipment delivery (wheelchair, ambulatory devices), assessment for prosthesis, and ongoing patient and caregiver education about, but not limited to phases of rehabilitation, further progress, mobility options, and services available post-discharged. In addition, ongoing pain management and psychological support are keys to achieving these objectives.

Recovery/Tissue Healing

The following complications may occur post-surgically and can delay the recovery, healing and rehabilitation:

• Wound infection
• Deep Vein Thrombosis (DVT)
• Delayed healing
• Pain
• Heterotrophic Ossification (HO)
• Bone spur
• Neuroma
• Pressure areas (pressure ulcers)
• Compartment syndrome
• Respiratory complications

Physiotherapy Interventions

Physiotherapy interventions in early rehabilitation include assessment, setting goals, establishing a treatment plan, choosing treatment modalities and outcome measures.

Assessment

A subjective and objective physiotherapy assessment is performed as early as possible.

During subjective assessment it is important to gain information on a patient's past and present medical history. The highlights include date and mechanism of injury, post-injury or post-surgical complications, surgical procedure(s) performed, precautions, restrictions related to advancing mobility and activity tolerance, chronic illnesses, pre-amputation level of function. Social history covers the patient's occupation and recreation, including work, leisure and family activities, living situation, social and family support. Determine discharge destination will help to gather information on disability services available in the area and access to specialised services. Knowledge about medication history can assist with pain management.

"Before rushing into assessment and treatment, check your patient’s psychological/emotional response to their current situation. Check the patient’s understanding of their amputation procedure and why it was carried out, as well as their cognitive status (ability to receive new information and act on it), motivations, depression, anxiety, etc."

Objective assessment consists of:

• Residual limb general assessment: length, healing stage, status of soft tissue and bone, shape, scar(s), color (vascular supply), pain, including phantom pain, tenderness, sensation.
• Bilateral upper and lower extremities passive and active range of motion and strength assessment with special consideration for flexion contracture risk in hip and knee in lower limb amputation.
• If the presence of oedema: circumferential measurements.
• Functional status: bed mobility, sitting balance, transfers on the level and uneven surfaces, wheelchair mobility, sit to stand transition, standing balance if applicable, ambulation.

Goals

The SMART system helps to set clear and well-defined goals. It stands for specific (S), measurable (M), achievable (A), realistic (R), and time-sensitive (T). The patient and the patient's caregiver with help from the rehabilitation team choose the goals that are related to what they want, what is important to them, and what is of benefit to them. The rehabilitation team will help to determine how much time is required to achieve these goals, and what resources are available to reach the target.

SMART goal example: patient will be able to propel a wheelchair (realistic and achievable) independently (specific) 500 meters on an uneven path (measurable) to get to his mailbox (specific) by March 2022 (time-sensitive).

Treatment Plan/Interventions

Oedema management

Management tools for residual limb oedema reduction include active exercise, residual limb elevation and compression. Guidelines for management of postoperative oedema in lower limb amputation can be found here.

Pain Management

Effective pain management requires proper assessment and collaboration of the entire rehabilitation team. Pain assessment will help to determine the pain type and to choose the most appropriate intervention:

• post amputation pain: nociceptive pain. If persistent and prolonged may indicate infection and requires medical attention
• residual limb pain: nociceptive pain. Usually occurs near the area of amputation
• phantom limb sensation: typically not a noxious stimulus, patient education is a key
• phantom limb pain: neuropathic pain. Treatment may include adaptations, peripheral sensitisation, relaxation, acupuncture, massage, TENS, biofeedback.

Residual Limb Care

Compression: rigid dressing, shrinker, or bandaging. There are pros and cons for each of these modalities. All of them assist with oedema reduction and reduce healing time. Soft types of compressions (shrinker or bandaging) assist with phantom pain reduction but can be expensive and not always available. The rigid dressing reduces the risk for the development of contracture and protects the limb from injury, but must be applied by trained personnel. Bandaging as residual limb compression is most commonly used in conflicts and disasters.

Positioning: for prevention of contracture, pressure ulcers, and respiratory complications, oedema reduction. In bed: lower extremities extended, NO pillow under the knee for below-knee amputations. The prone position is ideal to achieve full knee extension and neutral position of the hip.

Sitting in the wheelchair: residual limb extended (wooden board, sliding board, etc), NO sitting with residual limb down

Exercises

The purpose of teaching the patient to perform exercises routinely is to improve overall muscle strength and mobility, reduce oedema, reduce muscle atrophy, helps to achieve independent transfers and functional independence and assist with psychological adjustment.

Lower limb amputation exercises:

1. Active exercises: general strengthening exercises, endurance exercises, breathing exercises
2. Core exercises: postural awareness and core stabilisation exercises in supine, sitting, kneeling, standing

Watch the following video presenting the examples of exercises for lower limb amputation:

Upper limb amputation exercises:

• Active exercises: general strengthening exercises, endurance exercises, breathing exercises
• Core exercises: postural awareness and core stabilisation exercises in supine, sitting, kneeling, standing
• Upper body exercises: neck, trunk rotation, shoulder girdle, elbow, wrist

Functional mobility

Achieving independent mobility requires independent ability to roll in bed, transition from supine or side lying to sitting at the edge of bed, scooting up and down in bed, maintaining unsupported sitting balance and transferring between two surfaces either via sit to stand transition or lateral transition. Standing and/or walking increases the risk for falls due to phantom pain sensation, changes in the centre of mass due to loss of body part, and pain that occurs with the lower residual limb hanging down. Fall prevention strategies must be incorporated early in rehabilitation and continue through all phases.

If a patient is sleeping at home on the floor, transfer to/from the floor must be taught prior to discharging from the hospital. If using toilet at home requires squatting, this skill must be included in the training protocol.

Patient and Caregiver Education

Patient and caregiver education should be provided in all phases of rehabilitation, however, it is important to gauge the amount of information that the patient and family are able and willing to accept and absorb.

• Possibility of complications,
• phases of rehabilitation,
• further progress,
• mobility option,
• different prosthetics option,
• dietary/nutrition consultation
• fall prevention
• positioning

Outcome Measures

Resources

1. International Search And Rescue Advisory Group (INSARAG):https://www.insarag.org
2. Limbs4life: https://www.limbs4life.org.au
3. Guidance for the multidisciplinary team on the management of post-operative residuum oedema in lower limb amputees: https://bacpar.csp.org.uk/system/files/guidance_v.8_0.pdf

References