AMPUTATIONS

& PROSTHETICS
Amputation is defined as the surgical removal of a
part or whole of a limb.

Contents

►Indications
►Types
►Levels of amputation
►Stump and its management
►Complications
►Amputation in Children
►Prosthetic fitting and Rehabilitation.
 Types of Amputation
►primary,
►secondary,
►late
►repeated (reamputations).

Primary amputation is carried out in the order of

primary surgical d-bridement for the elimination of the
nonviable part of extremity.

Secondary amputation is carried out when the

conservative measures and surgical treatment are
ineffective.
 Types of Amputation

Late amputations are those in connection

with the nonhealing wounds, fistulas, at the
long course of osteomyelitis, threatening
the amyloid degeneration of parenchymal
organs or functionally useless extremity.
 Types of Amputation

Repeated amputations or reamputations

are applied after the unsatisfactory results of
previous truncations of extremities or at the
defect stumps preventing prosthetics, at the
extension of the tissues necrosis after
amputation by the reason of gangrene as a
result of obliteration of the vessels or
anaerobic infection progress.
 Indications for Amputation

The indications for amputation are most

easily remembered as the three Ds:
dead, dangerous and damned nuisance.
 Indications for Amputation

Dead (or dying)

Peripheral vascular disease
accounts for almost 90 per cent of
all amputations. Other causes of
tissue death are severe trauma,
burns and frostbite.
 Indications for Amputation

Dangerous
'Dangerous' disorders are malignant tumours, potentially
lethal sepsis and crush injury. In crush injury, releasing the
compression may result in renal failure (the crush syndrome).
 Indications for Amputation
There had been
severe neglected
club foot during
the whole life in
this elderly
woman.

Amputation of an unstable lower limb

segment may allow more efficient load
transfer and more stable walking.

Damned nuisance
Retaining the limb may be worse than having no limb at all -
because of pain, gross malformation, recurrent sepsis or
severe loss of function.
 Selection of Levels
of Amputation

The classical sites of amputation of limbs were determined

on the basis of the following considerations:

1. The disease process for which the amputation was done

to eradicate the pathology.
2. The vascular supply to the skin flaps.
3. The requirements of limb fitting procedures and
techniques available at that time.
 Levels of Amputation

The levels of amputation in the

upper limbs are as follows:

1. Forequarter amputation.
2. Shoulder disarticulation.
3. Above elbow amputation.
4. Elbow disarticulation.
5. Below elbow amputation.
6. Wrist disarticulation.
7. Finger amputation.
 Levels of Amputation

The levels of amputation in the

lower limbs are as given below:

1. Hind quarter amputation.

2. Hip disarticulation.
3. Above knee amputation.
4. Through knee disarticulation.
5. Below knee amputation.
6. Syme's amputation.
7. Forefoot amputation.
8. Toe amputation.
 Guillotine Amputation
Guillotine amputation is used in emergency situations for
contaminated wounds or infection.

1. Divide the skin, muscle and bone at or near

the same level.
2. Tie all bleeding vessels and cut the nerves
sharply while under gentle tension, allowing
them to retract into the wound.
3. Debride and lavage the wound every 2–5
days until it is free of dead tissue and
infection. At that point, perform a definitive
amputation and closure.
Forearm Amputation
Line of incision

Below-elbow amputation
Periosteum removed 1/2–3/8
in above level of resection.
Bone ends beveled.
Musculotendinous tissues
tapered. Skin and fascial flaps
formed.
 Disarticulation of Wrist

Line of incision

Styloid processes removed

(broken lines) to facilitate
fitting of prosthesis
 Transtibial Amputation

Myofascial
closure

Tapered posterior
muscle flap

Short anterior and long posterior Posterior muscle flap sutured to

skin flaps created. Tibia and fibula anterior fascia and periosteum
resected.
 Transtibial Amputation

Myofascial
closure
Drain
Skin closure

Completed closure
 Knee Disarticulation Amputation
Line of incision

Patellar ligament being

sutured to the cruciate
ligaments

Cruciate
ligaments

Medial condyle
of femur

Myocutaneous flap Completed closure

Gastrocnemius

bellies
 Transfemoral Amputation

Myofascial and skin

Skin and myofascial flaps tailored
flaps closed
for closure
 Amputations of the Foot
Line of incision Transmetatarsal
amputation

Plantar
flap Completed closure
Fascial and skin flaps formed. (blue line indicates
Bones transected and beveled fascial closure)
 Amputations of the Foot

Plantar flap

Amputation of toe
Line of incision. Entire
nail and part of distal
phalanx excised
Amputation of 5th ray
5th ray removed. Wound closed with
plantar flap
Stamp and its Management

The Stump is the residual

part of the limb left after
the amputation.
The care of the stump is
very important to provide
good function in the limb.
Stamp and its Management

A good stump should neither be too long nor too

short. It should have good muscle power with full
movement in the proximal joint and a healthy non
adherent scar. It should have a fleshy end with no
bony spurs.

In lower limb amputations, the functions to be

restored are weight bearing and locomotion and
sensory feedback.
 Stamp and its Management

The care of the stump consists of:

a) Stump bandaging with crepe bandage to

improve its shape for limb fitting.
b) Stump exercises to improve its motor
power and movements in the proximal joint.
c) Stump hygiene to maintain the skin and scar
in good condition.
Complications of Amputation

Hematomas
Infections
Necrosis
Neuromas
Phantom sensations
Deep venous thrombosis
Terminal overgrowth
Bony spurs
Contractures
Complications of Amputation

Flexion contracture of Necrosis of wound edges

knee in below-knee caused by patient's poor
amputation prevents full circulation or excessively
extension of limb tight sutures
 Complications of Amputation

Phantom pain describes a

painful sensation that can
occur in a limb that is no
longer present due to trauma
or surgical amputation. It is
often described as a Phantom limb
shooting or burning type pain
pain.
 Phantom pain
The exact cause of phantom pain is unknown, but it's
associated with the following:
- Pain experienced prior to amputation
- Nerve damage
- Prior arterial blood clot
- Neuroma (nerve tumor)

Treating Phantom Pain:

Treatment of phantom pain includes medications and other
options. Medications used include opioids, anticonvulsants,
antidepressants, and anesthetics, to name a few. Non-
pharmacological management measures include TENS-
devices, acupuncture, and electroconvulsive therapy.
 Amputation in Children
The special feature of
amputations in children is the
growth potential of the bone in
the stump.

The quickly growing bone

may stretch the skin and even
protrude. This will need a
revision amputation
to excise the excess bone.

Terminal over growth

Amputation in Children

Radiograph of transtibial
amputation of a child shows
typical “pencil point”
overgrowth of tibia and
fibula that leads to tenting
of the skin and inability to
use the prosthesis.
Amputation in Children
Types of the prostheses

► Cosmetic prostheses

► Functional

Body-powered prostheses

Myoelectric protheses
Body-powered prosthesis
Unilateral above-elbow
deficit. Standard above-
elbow prosthesis operated
with shoulder movements

Cable to
elbow lock

Cable to
terminal
device
 Myoelectric Prosthesis,
Transhumeral Amputee
Below-elbow
myogelectric
prosthesis

Battery pack

Motor

Cosmetic
glove

Below-elbow prosthesis with grasping

hook, which is interchangeable with other
terminal devices (hammer, saw, pliers)
 Characteristics
of a Successful Prosthesis
 comfortable to wear,
 easy to use,
 light weight and durable, and cosmetically
pleasing
 good mechanical function,
 reasonable maintenance,
 compliance with the motivation of the individual.
 What should be considered when
choosing a prosthesis?

 amputation level
 expected function of the prosthesis
 cognitive function of the patient
 patient's vocation
 patient's hobbies
 cosmetic importance of the prosthesis
 patient's financial resources
REQUIREMENTS TO FIT A PATIENT WITH
A LOWER EXTREMITY PROSTHESIS

 sufficient trunk control,

 good upper body strength,
 static and dynamic balance,
 adequate posture.
 Components of prosthesis
The major components of a lower extremity prosthesis are:

► the socket, a sock or gel liner,

► a suspension system,
► an articulating joint (if needed),
► a pylon,
► a terminal device.

The terminal device is typically a foot but may take other

forms for water or sports activities.
Lower limb prosthetics

The prosthesis
used after below
knee amputation
Lower limb prosthetics

The prosthesis
used after above
knee amputation
 Lower limb prosthetics

The prosthesis The prosthesis

after the hip after the hip
amputation exarticulation
Foot prosthetics
 Prosthesis Fitting and Testing
A temporary prosthesis can be fit in surgery, so when the
patient awakes he or she can visualize a limb in place.

Prostheses are either preparatory or definitive.

Sometimes a preparatory prosthesis is not feasible because

of financial considerations. In this case, a patient can only be
fitted for the definitive (final) prosthesis. If a patient is being
fitted for a final prosthesis without ever having a preparatory
prosthesis, delay fitting for the socket until the residual limb
is fully mature (usually 3-4 mo).
 What is the difference between
a prosthesis and an orthosis?

A prosthesis is a device or an artificial substitute

designed to replace, as much as possible, the
function or appearance of a missing limb or body
part.
An orthosis is a device designed to supplement or
augment the function of an existing limb or body part.
 Orthosis

Orthosis are intended for children and adults with congenital

and acquired pathology of the extremities. Orthosis make it
possible to restore lost functions without a prolonged
immobilization