Case Study - Amputation in Disasters and Conflicts

Original Editors - Naomi O Reilly

Top Contributors - Naomi O'Reilly, Kim Jackson and Olajumoke Ogunleye      

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Patient Characteristics

A six-year-old child presented to an EM T for closure of a below-knee guillotine amputation, wearing

a full leg cast on their other leg. On further investigation, it was revealed that this cast was hiding

an open tibial fracture, with an associated peroneal nerve injury. The management of injuries to the

non-amputated side was vital for the child to able to walk using a prosthetic. To complicate matters,

the child was distressed by their injury and terrified of health staff. They were accompanied by a

relative (not their parents). Managing their distress and educating them and their caregiver became

an essential part of early rehabilitation – building trust before any physical rehabilitation could begin.

Active exercise

Active exercise aims to improve muscle strength and mobility, reduce oedema, reduce muscle

atrophy, aid transfers and functional independence and aid psychological adjustment. Start active

exercises for residual limb and whole body as soon as possible, taking appropriate precautions

with any other injuries.

Core exercises

Core stability exercises are especially important with multiple limb injuries/patients with higher

level amputations

These exercises can start early, even on bed rest. Postural awareness is key, and continues

its importance through to prosthetic gait education. Kneeling is especially good for bilateral

transtibial amputations, including four-point kneeling in later stages. Hip extension and trunk

stability exercise can also be helpful in earlier stages.

Lower limb amputation exercises

It is important that the patient maintains their strength and range of movement, post-amputation.

The patient and their caregivers should be advised to keep all remaining joints moving throughout

their full available range, especially the joints above the amputated site (hip and knee) to prevent

contractures.

The following exercises are good basic strengthening and ROM.

Straight leg raise

Put your legs out in front of you

Tighten your thigh

Lift your leg off the bed

Hold for ten seconds

Slowly lower

Repeat ten times

Repeat the above with the other leg

Hip flexor stretch

Lie on your back, preferably without a

pillow

Bring your thigh towards your chest

and hold with your hands

Push your opposite leg down flat on to

the bed

Hold for 30 – 60 seconds, then relax

Repeat five times

Repeat the above with the other leg

Bridging

Lie on your back with your arms at the

side

Place a couple of firm pillows or rolled-

up blankets under your thighs

Pull in your stomach, tighten your buttocks

and lift your bottom up off the bed

Hold for five seconds

Repeat ten times

To make this exercise more difficult, ask your

patient to place their arms across their chest,

as shown in the picture

Hip abduction in side lying

Lie on your side

Bend the bottom leg

Keep hips and top leg in line with your

body

Slowly lift your top leg up, keeping your

knee straight

Slowly lower

Repeat ten times

NB Do not to let the patient’s hips roll for-

wards or backwards

Repeat the above with the other leg

Hip extension in prone

Lie flat on your stomach for ten minutes,

three time per day

Lie flat on your stomach, keeping your hips

flat on the bed left your leg off the bed

Hold for five seconds

Repeat ten times

Upper limb amputation pre-prosthetic exercises

Function, range and power of the upper limb are often neglected, but are key to good outcomes

and quality of life. Scapular range is very important if using upper limb for greater function, e.g.

following bilateral lower limb amputation, or a patient sustaining a triple amputation needing to

achieve getting on and off the floor independently. Also note that pectoral major/minor tightness

is very likely, due to greater sitting time, and needs to be counteracted.

All these exercises should be completed through your patient’s full available range, unless

indicated otherwise.