Elderly Female with bilateral traumatic lower extremity amputations: Amputee Case Study

Title

Elderly Female with Bilateral Traumatic Lower Extremity Amputations

Abstract

The patient is an elderly woman who sustained bilateral LE injuries when she was hit by a car. Following failed attempts at limb salvage she eventually underwent a Left Trans-tibial amputation and a Right trans-femoral amputation. Following an extended hospital course she was transferred to a comprehensive rehabilitation unit and eventually home, with potential for prosthetic fitting in the future.

Key Words

Elderly, bilateral amputations, trans-tibial, trans-femoral

Client Characteristics

The patient is an 85 year old woman. Non-English speaker. Her general health is good, with only hypertension listed as a current medical condition. Her past medical history includes only her pregnancies and arthritis. She has a BMI within the healthy range and is small in stature. She lives with her daughter in a second story apartment. Prior to her accident she was active and independent. She did not use an assistive device for ambulation. She was able to complete all IADLs without difficulty and was still able to do her house work and cooking. She did not drive.

She was brought to the hospital after being backed over by a car. Her injuries were as follows: Right proximal comminuted displaced Tib/Fib fractures with degloving injury and bone loss. Left distal comminuted displaced Tib/Fib fractures with degloving injury and bone loss, as well as a left calcaneus fracture. Limb salvaging surgery was attempted initially with bilateral external fixation and four compartment fasciotomies. After multiple surgeries the patient opted for a left trans-tibial amputation and wound closure on the right with a full thickness skin graft. She underwent further surgeries on her right leg including debridement, muscle flaps and wound vacs however the leg could not be saved and she underwent a right trans-femoral amputation. Later during her hospital stay she underwent a revision of her L trans-tibial amputation due to a non-healing post-operative wound.

Examination Findings

Therapies were started while the she was in ICU. She had an extended hospital course with complications of anaemia, pneumonia and delirium. Her right residual limb was in a soft dressing. Her left limb was in a removable rigid dressing keeping her knee in extension.
The patient’s goal was to be as independent as possible and return home with her daughter.
Her care team included physicians, nursing, Physical Therapy, Occupational Therapy, Wound Care, Spiritual Care and Interpreter Services.
The Pain Analoge scale was used during immediate post-operative and pre prosthetic rehabilitation. FIM ratings (level of assist) were used to assess her mobility and progress toward mobility goals, but actual scores were not given. The BACPAR Outcome Measures project did not include any outcome measures in the Toolbox for these populations as there was not enough evidence to support their use.

ROM: UEs within functional limits. Hips bilaterally neutral to 90 degrees flexion. L knee -5 to 50 (limited by pain)
Strength: UEs 4/5, LEs: L hip- flexion 4/5, abduction 3+/5, adduction 4/5, IR/ER not tested. L knee- Flexion/extension ≥3/5 (unable to tolerate resistance due to pain)
Mobility: Bed Mobility – Max A; supine sit Max A, Transfers – Total Assist

ICF Findings: B LE Amputations (L Trans-tibial, R Trans-femoral)
Impairments- decreased muscle strength and endurance, decreased sitting balance, decreased mobility
Limitations- Transfers, locomotion, Self-cares, toileting, dressing

Clinical Hypothesis

The patient is an elderly woman with severely impaired mobility, decreased strength, endurance and balance, all due to bilateral LE amputations and the effects of prolonged hospitalization. Her impaired mobility is affecting most facets of her daily life including; transfers, locomotion, self-cares, dressing, toileting, domestic tasks and ability to interact in her community.

Intervention

Therapies were started while she was still in the ICU and continued through the rest of her hospital admission. She was then discharged to an inpatient rehabilitation unit.
Acute post-operative physical therapy included: ROM of both LEs, Strengthening of both residual limbs with in restrictions given by surgeon. UE strengthening. Positioning to prevent contracture. Oedema control. Balance exercises and trunk strengthening. Bed mobility and transfer training (bed wheel chair and bed drop arm commode) using a slide board. Wheelchair propulsion. Stump desensitization was not started to do complicated wound closure and delayed healing Occupational therapy focused on UE exercise, grooming, dressing, and toileting.
Therapies at the inpatient rehabilitation unit continued on with the previous interventions as well as adding family/ caregiver training. Due to the patients age (85 y/o) and the nature of her amputations (bilateral, trans-tibial and trans-femoral) her pre-prosthetic rehabilitation phase was limited. The patient stated she did want prostheses, however due to the increased energy expenditure it would require for her to ambulate and the increased risk of falls bilateral prostheses where deemed inappropriate for this patient.  However the use of a single trans-tibial prosthesis improve sitting balance and to assist with slide board transfers was considered and the pre-prosthetic therapy was altered to reflect this.

Outcome

At time of discharge from the inpatient rehabilitation unit the patient had reached the following functional outcomes:
Min Assist for slide board transfers to and from varied surfaces (bed wheelchair, Wheelchaircommode, Wheelchaircar). Independent wheelchair mobility. Independent feeding, grooming and upper body dressing. Modified independence with lower body dressing. Minimum assistance with bathing.
The patient discharged home with her daughter. During her rehabilitation the patient’s daughter was able to move into a first floor wheelchair accessible apartment. Her daughter had completed family training and was able to provide the assistance the patient needed for transfers and self-care.
The patient did not meet her functional goals of modified independence with transfers and bathing prior to discharge home. She is continuing with rehabilitation through home health physical and occupational therapy to continue to increase her independence. Home health nursing is following the patient for wound management. She does have a referral for follow up with a prosthetist when her wounds are healed.

Discussion

This case involved and elderly (85 y/o) female who suffered a trauma resulting in bilateral LE amputations (Left trans-tibial and right trans-femoral). The patient fortunately was in good health at the time of her accident, however her age was a consideration in goal setting and determining if she would be a prosthetic candidate. Based on research regarding energy expenditure with prosthetic use and the increase risk of falls related to prosthetic use, gait training with bilateral prostheses was deemed inappropriate. Following inpatient rehabilitation the patient has been referred to a prosthetist for follow up when her wounds heal to determine if she can be fitted with a left trans-tibial prosthesis to assist with transfers. This case was interesting because the patient did not fit many of the categories that we commonly see. She was not a young, active, traumatic amputee; and she was not an elderly, vascular amputee with multiple comorbidities. She fell somewhere in between, she was an elderly active woman with minimal health issues who sustained traumatic amputations. The fact that she had bilateral amputations at the trans-tibial and trans-femoral levels as well as her age were the factors ultimately guided her therapy and goal setting.