Rehabilitation of Amputations in Disasters and Conflicts

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

Amputation remains a common orthopaedic consequence seen in disasters and conflicts and can occur either traumatically during the event itself as a direct limb transection or as a result of limb amputation following complex fractures or severe neurovascular injury from conflict-related trauma (weapon-related injuries) or disaster-related trauma (crush injuries, crush syndrome and compartment syndrome). Battlefield limb wounds are typically characterised by high-energy injury, with extensive soft-tissue damage and prolonged injury-to-surgery time, and are typically accompanied by a host of other complex injuries including additional fractures, soft tissue damage, peripheral nerve injury, traumatic brain injury, and post-traumatic stress disorder. In the aftermath of conflict, landmines are also a major cause of lower-limb amputations. Disasters on the other hand, like earthquakes and other mass-casualty disasters, tend to be more low-energy, resulting in prolonged, crushing trauma, with extensive soft tissue damage and late presentation secondary to increased time required to extricate patients and transfer them to medical facilities and unsalvageable limbs. Amputation in a setting of crush injury should be considered in all cases of severe soft-tissue damage, with or without fractures, with deteriorating renal and cardio-respiratory function, and sepsis. In both cases, whether conflict or disaster, the risk of infection following these types of injuries is significant, which results in high levels of amputations.

Amputation in disaster and conflict settings is generally performed in field hospitals or at the scenes primarily for the purpose of saving patients’ lives when no delay or transfer is possible. Irreparable vascular injury, completion of a partial amputation, and overwhelming sepsis are the main indications for such amputations. Guillotine amputations, which is an amputation performed without closure of the skin, are sometimes seen in these situations and in rare cases are used to enable extraction. These types of amputation typically require further definitive amputation, and can often delay initial access to rehabilitation as stump closure and soft tissue coverage are compromised where the dead muscle is missed resulting in uneven distribution of tissue necrosis.

The loss of a limb has severe implications for a person’s mobility, and ability to perform activities of daily living, which can negatively impact their participation and integration into society . Early rehabilitation within disaster and conflict settings is important in the prevention of severe mobility and self-care limitations, postural disorders, reduction in body's endurance, and inability to tolerate physical activities.

Immediate Emergency Care

Amputations are one of the most common serious injuries seen in disaster and conflict settings and as such proper care and knowledge regarding amputee management are critical in any emergency response. Where possible, rehabilitation input should commence from the pre-operative stage of care to advise on the implications of the level of amputation for fitting and use of a prosthetic where possible with links to local prosthetic providers and prescription of appropriate assistive devices established as early as possible. Given the challenges in disaster and conflicts as a result of the surge in numbers of patients requiring amputations, early deployment of specialised emergency medical teams, both national and international, to meet the immediate needs is often a key element of the initial emergency response, and is guided by a range of World Health Organization initiatives, including the Emergency Response Frameworks (Standards and Guidelines), Coordination Mechanisms, and the Emergency Medical Team Accreditation Process ensuring that only rehabilitation professionals, with appropriate experience and skills, form part of the Emergency Medical Teams.

Emergency Medical Teams

Emergency Medical Teams. with specialist capacity for the rehabilitation of amputees can play a vital role in supporting the care of individuals who have amputations following disasters and conflicts. Generally, teams will be required in the first week of a disaster and stay for an extended period of time, but timeframes for the arrival of these specialised teams may vary significantly within disaster and conflict settings depending on the safety of the environment. Rehabilitation professionals cover a range of professions, including physical therapy, physiotherapy, occupational therapy, orthotics and prosthetics, rehabilitation nursing, physical rehabilitation medicine, psychology, speech and language therapy, nutrition, and social work. These professionals ideally work collaboratively in a multidisciplinary team, each contributing their specialty to achieve comprehensive care and management following amputations. Table 1 provides an overview of the rehabilitation input by Emergency Medical Team type, and specific discharge considerations:

Table 1: Minimum Technical Standards for Amputee Specialist Team in Emergency Medical Teams

Type 1			Type 2	Type 3	Referral and Discharge Considerations
Basic Wound Management Refer to Type 2 or 3 EMT or National Facility			Preoperative advice according to prosthetic availability and functional outcomes Stump Management Provide Temporary Assistive Devices Pain Management Range of Movement and Strength Functional Retraining Patient and Caregiver Education		Referral to a local provider for long-term assistive devices, such as prosthetic and/ or wheelchair if indicated Rehabilitation Follow-Up

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 clavicle (Forequarter)

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.

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:

• Irreparable Vascular Injury
• Completion of a Partial Amputation
• Overwhelming Sepsis
• Each Country Cultural Imperatives
• 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: 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 skin pallor, 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.

The selection of the level of amputation need to include the following factors:

• Potential for healing of the residual limb
• Patient’s general condition
• Risk of additional surgeries
• Fitting of the prosthesis (if the patient is likely to be a candidate for prosthetic rehabilitation)
• Probable functional outcome
• Length of bone and viable tissue (definition below)
• Age of patient

"Viable tissue is red (granulating) or pink (epithelialising) and represents an environment conducive to normal wound healing. Non-viable tissue may be black ( necrotic) or yellow ( sloughy) and if left in the wound, creates the ideal conditions for bacterial growth and infection."

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 day

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 rehabilitation 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 specialty 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.

Pre-Amputation Phase

It is now well recognised that the decision to amputate following severe limb injury, where there is no immediate threat to life, can be delayed, in conflict and disaster settings, which means that vital theatre time is saved in the immediate surge of patients during an emergency, but more importantly, it allows time to ensure the right decision in relation to amputation and amputation level is taken. Rehabilitation professionals have a role to play during this pre-amputation phase, and should be actively involved wherever possible with the following objectives;

1. To contribute to the multidisciplinary team surgical planning process
2. To complete a holistic baseline assessment of the patient to support goal setting, aid early identification of potential barriers to use of a prosthesis, and provide an insight into the patient’s acute stress response and coping style.
3. To prepare the patient and the caregivers for what they can expect and help to alleviate anxieties about post-operative treatment and long-term rehabilitation
4. Observe the patient’s psychological/emotional status and refer for support if required
5. Ensure familiarity with locally available services which the patient (or family and caregivers) will require (prosthetic, wheelchair, psychological, psychosocial, etc.)

Early Rehabilitation/Post-Amputation Phase

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.

Complications

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

Assessment

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

During the 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).

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:

A 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

Exercise Prescription

The purpose of teaching the patient to perform exercises routinely is to improve overall muscle strength and mobility, reduce oedema, reduce muscle atrophy, help 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, the transition from supine or side-lying to sitting at the edge of the bed, scooting up and down in bed, maintaining unsupported sitting balance, and transferring between two surfaces either via sitting to stand transition or lateral transition. Standing and/or walking increases the risk for falls due to phantom pain sensation, changes in the center 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 continued through all its phases.

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

Assistive Technology

• Wheelchairs: they are safe, can reduce the risk for falls, and the risk of residual and sound limb injury. In conflict and disaster setting wheelchairs availability may be low, maintenance can be expensive, and require trained personnel. When a patient is being discharged home, stair negotiation may be problematic or impossible.
• Crutches: can be used on stairs, can increase the risk for falls.
• Other mobility devices: pneumatic post-amputation mobility aids (PPAM aids): expensive and not available in conflict and disaster settings.

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. The following are the topics that should be included in the patient/caregiver education.

• possibility of complications
• future phases of rehabilitation
• further progress
• mobility options
• different prosthetics option
• dietary/nutrition information
• fall prevention
• positioning.

Outcome Measures

Outcome measures for patients with lower limb amputations are presented here.

Early Rehabilitation Pre-Prosthetic Phase

Objectives

The objectives for this stage of rehabilitation include:

• Assessment for prosthetic needs and wants
• Pre-prosthetic training

Assessment for Prosthetic Needs and Wants

When the most appropriate prostheses are selected, it improves the user's mobility, function, aesthetics and comfort. Factors affecting the decision regarding fitting for prosthesis are as follows:

• Living environment
• Level of amputation or presence of a double amputation
• Cognitive issues: difficulties learning, retaining, and using new information
• Patient’s own goals and motivation
• Physical condition and ability
• Concurrent injuries/co-morbidities
• Availability of prosthetic services
• The presence of significant hip or knee contractures
• The presence of open wounds or other stump complications

In conflict and disaster setting the option for upper-limb prosthesis can be very limited. Cosmetic prostheses or static terminal devices may be the only option available to the patients.

Pre-prosthetic Training

Exercise Prescription

• Active exercises: general strengthening exercises, endurance exercises, breathing exercises
• Core exercises: postural awareness and core stabilisation exercises in supine, sitting, kneeling, standing
• Specific exercises for residual limb
• Sitting and standing balance exercises
• Functional activities exercises.

Exercises examples for patients with transtibial amputation you can find here.

Exercises examples for patients with transfemoral amputation you can find here.

Resources

Early Rehabilitation in Conflict and Disasters, Humanity and Inclusion

Rehabilitation in Sudden Onset Disasters, Humanity and Inclusion

International Search And Rescue Advisory Group (INSARAG)

Limbs4Life

Guidance for Multidisciplinary Team on the Management of Post-operative Residuum Oedema in Lower Limb Amputees