Objectives

Given a hypothetical case of a patient

who has undergone an amputation, the
student will be able to:
Define briefly what an amputation is,

including:
Naming the systems affected,
Describing their commonalities, and
Enumerating their common clinical

manifestations
Describe briefly the classification systems

used in describing amputations

Objectives

Given a hypothetical case of a patient

who has undergone an amputation, the
student will be able to:
Discuss significant epidemiologic indicators
Enumerate known causative factors or

agents that result in amputations

Outline the series of events that occur with
each causative factor or agent
Enumerate and discuss each of the primary
signs and symptoms observed in an
amputation

Objectives

Given a hypothetical case of a patient

who has undergone an amputation, the
student will be able to:
Enumerate and discuss the possible

secondary signs and symptoms in

amputations
Enumerate and discuss the techniques by
which the health professions, overall, use to
diagnose an amputation
Differentiate an amputation from other
similar orthopedic surgical conditions

Objectives

Given a hypothetical case of a patient

who has undergone an amputation, the
student will be able to:
Describe positive and negative prognostic

factors which affect the expected outcomes

for a patient with an amputation
Describe the principles and interventions
performed or applied on patients with
amputations by physicians

Objectives

Given a hypothetical case of a patient

who has undergone an amputation, the
student will be able to:
Describe the responsibilities and

interventions performed or applied on

patients with amputations by other health
professionals

Objectives

Given a hypothetical case of a patient

who has undergone an amputation, the
student will be able to:
Enumerate and discuss the essential

components of the physical therapy

examination that results in a comprehensive
evaluation for a patient with an amputation

Objectives

Given a hypothetical case of a patient

who has undergone an amputation, the
student will be able to:
Evaluate the probable problems seen in a

patient with an amputation

Decide on an appropriate physical therapy
diagnosis or diagnostic classification
Formulate appropriate expected outcomes
and anticipated goals based on the list of
problems seen in a patient with amputation

Objectives

Given a hypothetical case of a patient

who has undergone an amputation, the
student will be able to:
Identify appropriate specific interventions to

achieve the expected outcomes and

anticipated goals in a patient with an
amputation

Definition

Amputation
From Wikipedia.org:
The removal of a body extremity by trauma,
prolonged constriction, or surgery.
As a surgical measure, it is used to control
pain or a disease process in the affected limb,
such as malignancy or gangrene.
In some cases, it is carried out on individuals
as a preventative surgery for such problems.
A special case is that of congenital
amputation, a congenital disorder, where fetal
limbs have been cut off by constrictive bands.

Classification

As to Cause
Acquired amputations
Loss of part or all of an extremity as the direct
result of trauma or by surgery.
It is also done to revise a congenital limb amputation

or alter a deformity secondary to burns or trauma.

Congenital amputations
Loss of a limb in utero and are believed to
result from such stimuli as drug toxicity.
There is failure of formation or strangulation of limb

buds by the umbilical cord.

Classification

As to Deficiency (Parts Missing)

Transverse deficiency
Has no distal skeletal elements
The transverse level is named after the segment

beyond which no bony elements exist.

Digital buds do not count.

Longitudinal deficiency
Names the bones affected, and indicates
whether the bones are partly or totally
affected.

Classification

As to Type of Surgery Performed

Open Amputation (Guillotine Amputation)
Stump is not closed over with a skin flap allows
the free drainage of purulent or infections material
Often indicated for infection
Closed Amputation (Flap Amputation)
Stump is closed or covered by a flap of skin
sutured over the bone end of the stump
There is no evidence of infection and
consequently no need for extensive open drainage

Classification

As to Type of Surgery Performed

Minor Amputation
Amputation done through or distal to the
metacarpus or metatarsus
Major Amputation
Done proximal to the metatarsal or metacarpal
bones
Designed to produce a stump suitable for an
artificial limb
Joint Amputation/Disarticulation
Amputation done at the joint

Classification

As to Level
See Appendix A (Levels of Amputations)

Epidemiology

Generally:
5:1 Ratio of lower limb to upper limb

amputees, majority are men than women

90% lower extremity

5% partial foot and ankle

50% below knee
35% above the knee
7 10% at the hip

Epidemiology

As to cause:
Peripheral Vascular Disease (PVD)
PVD without diabetes ranges 2-5% among
individuals
PVD with diabetes ranges 6-25%
7-13% usually is associated with other
medical problems such as cardiac dose and
stroke
caused by a number of underlying pathologies
of the arterial, venous or lymphatic systems,
including occlusion, inflammation, vasomotor
dysfunction or neoplasms

Epidemiology

As to cause:
Trauma
75% of acquired amputation in UE
primarily men aged 15-45 yrs. Old
next most common cause for LE amputation
about 20%

Epidemiology

As to cause:
Disease and Tumors
responsible for about equal number of the
remaining acquired UE amputations
in LE, it accounts approximately 75% of all
acquired amputations among 60 years and
above
it is the most frequent cause of all amputation
in both the UE and LE among children aging
10-20 yrs. old

Epidemiology

By Age Range:
1st year of life

Congenital deficiencies
1 to 10 years of age.
Motor vehicular accidents, tumor and
trauma.
10 to 20 years of age
Malignancy is the most common cause.
55 years of age
Peripheral vascular disease

Etiology
Trauma
Neoplastic Tumors
Peripheral Vascular Disease
Congenital Anomaly
Thermal, Chemical, or Electrical Injury
Infection
Other

Pathophysiology

Trauma
Amputation is done where blood supply or

tissues are so destroyed, gangrene is

inventible or reconstruction is impossible i.e.
blast injuries

Pathophysiology

Neoplastic Tumors
result from disruption in the control mechanism

normally exerted over all reproduction and

differentiation
for primary malignant tumors not possible to resect
or irradiate without heavy risks or recurrence
without metastasis amputation is curative
with metastasis it is palliative (reliever pain; in acute

or chronic infections that cant be controlled by medical

or ordinary surgical treatment and has local or
systematic sequelae or prevents a pathological
fracture

Pathophysiology

Peripheral Vascular Disease (PVD)

Buergers Disease or Arteriosclerosis
Emboli or thrombus may cause a loss of blood
supply to extremity resulting to ischemia,
ulceration, or gangrene requiring amputation
Mostly involve lower limbs

Pathophysiology

Congenital Anomaly
refers to the absence or abnormality of a

limb evident at birth or no etiology

i.e. polydactyly, congenital absence of a distal

part

Thermal, Chemical, Electrical Injuries

excess of these creates severe tissue

damage resorting to amputation

Infection
i.e. chronic osteomyelitis, gas gangrene of

high virulence

Pathophysiology

Other
Punitive
Self-inflicted
Cultural

Pathophysiology

General Indications for Amputation

Irreparable loss of blood supply in a

diseased or injured limb

Injury that is so severe that function would
be better after amputation
To save life when infection is uncontrollable
To remove part or all of a congenital
abnormal limb for cosmesis or improving
functions

Clinical Manifestations

Immediate Concerns Post-amputation:

edema is common following amputation
phantom limb, phantom pain and painful

residual limb
joint contractures occur between the time of
amputation and prosthesis fitting
amputees on chemotherapy have residual
limb volume fluctuation
diabetic patients not only experience
vascular compromise, but also suffer motor,
sensory, 2 neuropathy, all of which lead to
ulceration

Complications

Abnormal Sensations
Phantom Pain
Phantom Limb
Residual Limb Pain

Delayed Healing Stump

Contractures

Complications

Skin Problems
Choke Syndrome
Verrucous Hyperplasia
Skin Infection

Contact Dermatitis

Bone Problems
Bone Spurs

Bone Hypermobility

Neuromas

Diagnosis
History
Physical examination

Stump
Skin
Muscles
Bones
Nerves and vascular structures

Nearby areas
Cardiovascular/Pulmonary Status

Differential Diagnosis

Differentiate as to:
Cause
Level
Type of surgery performed

Etc.

Prognosis
Poor

Ideal

Age

Older

Younger

Smoking

Smoker

Non-smoker

Co-morbid Conditions

Present

Absent

Infections

Present

Absent

Severity of pre-operative
condition

Severe and complicated

Uncomplicated

General Medical / Surgical /

Pharmacologic Management

General Principles:
Surgeon removes part or all of the limb
type of amputation is at the discretion of the
surgeon and the extent of the extremity at the
time of the amputation.
Allow for 1 or 2 wound healing
Construct a residual limb for optimum

prosthetic fitting and function.

General Medical / Surgical /

Pharmacologic Management

Other Basic Considerations:

TOURNIQUET
LEVEL OF AMPUTATION
MUSCLES

SKIN FLAPS
BLOOD VESSELS
BONE ENDS

DRAINS

General Medical / Surgical /

Pharmacologic Management

Other Basic Considerations:

TOURNIQUET
except in ischaemic limb, the use of tourniquet
is highly desirable
LEVEL OF AMPUTATION
it should be through tissues that will heal
satisfactory and at a level that will remove the
abnormal or diseased part.
The cardinal rule is to preserve all possible
length consistent with good surgical judgment.

General Medical / Surgical /

Pharmacologic Management

Other Basic Considerations:

MUSCLES
they are just distal to the level of the intended
home section so that their ends will retract to
that level.
Bone beveling is done to obtain a stump
shape properly.
Major muscles are stabilized by myofascial
closure, myoplasty, myodesis, or tendesis,
which allows maximum retention of function.

General Medical / Surgical /

Pharmacologic Management

Other Basic Considerations:

SKIN FLAPS
the skin at the end of the stump should be
mobile and is normally sensitive.
The scar should be well healed, pliable,
painless, and non adherent.

General Medical / Surgical /

Pharmacologic Management

Other Basic Considerations:

BLOOD VESSELS
to achieve homeostasis, major blood vessels
should be isolated, individually ligated.
Larger ones should be doubly ligated and a single

ligatable or smaller vessels

Before the amputation stump is closed, the

tourniquet should be released and all bleeding

points should be clamped and ligated.

General Medical / Surgical /

Pharmacologic Management

Other Basic Considerations:

BONE ENDS
it should be covered good padding of soft
tissue and physiologically prepared for
prosthetic wear.
Bone beveling is the process of smoothing the
cut ends of bone to prevent rough edges and
spurring that interferes ambulation.
Bones such as the fibula are often cut slightly shorter

for the same reason.

General Medical / Surgical /

Pharmacologic Management

Other Basic Considerations:

DRAINS
meticulous hemostasis should obtain before
the amputation stump is closed
The drain or tubes are removed 43-72 hours
after surgery.

General Medical / Surgical /

Pharmacologic Management

Approaches
healing is enhanced by
gentle handling of the residual limb,
controlling residual limb edema through rigid,
semi-rigid, or soft compression dressings, and
using aseptic techniques in wound care to
avoid infection

General Healthcare
Management

Physical Therapy
Examination

Physical Therapy Evaluation

Determination of Amputation Level

Minimize systemic complications
Prevent contractures
Bed mobility and transfers
Pain management
Protect amputated limb from trauma
Fall prevention
Emotional care/education
Manage and teach about wound healing
Promote residual limb muscle activity
Early ambulation
Advanced ambulation
Control limb volume changes
Trunk and body motor control and stability

Physical Therapy Evaluation

Physical Therapy Diagnosis

Impaired motor function, muscle

performance, range of motion, gait,
locomotion, and balance associated with
amputation