Case study lower limb amputation: Amputee Case Study
Case Study Lower Limb Amputation: Amputee Case Study
A case study about a 10-year-old Nepali boy, receiving amputation surgery following his congenital club foot to improve his gait pattern. Surgery has been successful and he now has a better gait pattern and no problems in other joints.
paediatric limb deficiency, transtibial amputation, developing country, club foot
Nishan S. is a 10-year-old boy from Nepal. He lives in a children's home designed for disabled children, but goes to a normal public school. Nishan was born with Spina Bifida, most likely in the form of Aperta Meningocele according to his conditions: a paralyzed left lower leg, left club foot and incontinence. His detailed medical file from birth is unknown at the children's home. It is known that he was operated after birth to remove the sensitive fluid bulge on his back. This area is still sensitive to this day for Nishan. There is little communication with Nishan's parents and the children's home, as the parents do not want to keep in contact. He was abandoned after his disability became clear. Nishan is very happy in the children's home and does not want to leave. He says this is his new family. He is a very chatty boy and even though he has trouble keeping up with his friends in running, he still tries and wants to participate.
Nishan's left foot was amputated, as his gait was disturbed and other problems, such as his left knee and hip, started to diminish as well. The operation was postponed for a long time, as the parents needed to give their permission. After months to years of trying, the parents did give their consent to amputate his left foot.
The main aim of amputation for the children's home was to increase his independence level. Nishan had trouble walking and running with the club foot and had a lot of pressure sores on this foot. He had trouble putting on shoes and walking on the stairs. He falls often because of his imbalance, but can stand up by himself individually.
Furthermore he has trouble with his incontinence and has to wear a diaper throughout the day. It is impairing him in his daily life, but he is accustomed to it and knows how to change diapers and keep himself hygienic.
Because of his altered gait pattern, he began having trouble in his knee, hip and back as well. A trans-tibial amputation would be a solution to these problems, as well as his original altered gait pattern coming from his club foot. With a prosthesis he would be able to walk with a regular gait pattern.
Before the parents gave permission for the operation and it was still unknown what the future would bring, we mostly trained Nishan's balance on his other leg. The right leg was trained for strength, balance and endurance, as well as the knee and hip of the left leg. Also we trained his core stability for more overall stability.
After he had the amputation surgery, he had to wait a short while before his prosthesis was ready. In that time we trained balance and strength on the right leg, and knee and hip strength of the left leg. When he got the prosthesis, he already knew how to put it on, because he's living with other children who also have prosthesis. One of his best friends in the house also has a trans-tibial amputation prosthesis and Nishan already helped him with putting on prosthesis sometimes.We had to show him a couple times to do it by himself, but he learned very quickly.
Because of pressure spots, he had to wear the prosthesis one hour on, one hour off, and so on. Now he is used to wearing his prosthesis all the time. In the beginning he walked with a walker, indoors and outdoors. When indoor walking was good, he still used a walker to walk to school, as it is a long walk and very unstable surface. Now, he walks without walker.
Nishan now has a good functioning prosthesis and no longer has problems with other joints such as knees and hips. His gait is still altered but improved in comparison to before. The use of the walker was nice because the surface was difficult for him to walk on, so he could still go to school, even without wearing his prosthesis.
The training on his other leg was very useful, especially with the walker so he could start standing and walking on his other leg. Because we also trained the other knee and hip, he was already a little bit stronger to start wearing the prosthesis.
His wounds on his stump have healed slowly, but are now fully healed. He is accustomed to using his prosthesis and knows how to put it on and use it correctly. He can clean his own prosthesis and can do exercises by himself. Sometimes he still trains in the physio room to check if everything is still going fine.
The living circumstances are already difficult, even if you do not have a disability. Nepal has a lot of hills and the street stones are not evenly placed, so it is very difficult to walk on with a prosthesis. Living in an environment with other disabled children, it was to his advantage that he already knew how to put on a prosthesis. Because of this, he was not scared for the operation and result of it.
Because we trained the healthy side as well, Nishan realised it was a problem that could be partially fixed. He was always thinking about his foot that was not working, but by training the one that worked well, he became a happier boy. He was more positive and looked forward to being able to walk properly with his prosthesis. This was also part of patient education, to help him understand this was not a restriction.
Research also shows that in developing countries children make up a big percentage of the patients and they should be dealt with accordingly. Healthcare is usually geared towards adults, but children should be regarded as paediatric patients, not small adults.
- Thorax, pelvis and hip pattern in the frontal plane during walking in unilateral transtibial amputees: biomechanical analysis. Molina-Rueda F, Alguacil-Diego IM, Cuesta-Gómez A, Iglesias-Giménez J, Martín-Vivaldi A, Miangolarra-Page JC, Braz J Phys Ther. 2014 May-Jun;18(3):252-8.
- Pediatric Orthopedic Injuries Following an Earthquake: Experience in an Acute-Phase Field Hospital. Bar-On E, Lebel E, Blumberg N, Sagi R, Kreiss Y; Israel Defense Forces Medical Corps, Petah Tikva, Israel. J Trauma Nurs. 2015 Jul-Aug;22(4):223-8. doi: 10.1097/JTN.0000000000000143.
- Evaluation and comparison of á priori alignment techniques for transtibial prostheses in the developing world - field trial in Nicaragua. Reisinger KD, Casanova H, Wu Y, Moorer C. Disabil Rehabil Assist Technol. 2009 Nov;4(6):393-405. doi: 10.3109/17483100903125860.