AMPUTATION

I.

DEFINITION
It is the surgical cutting of a limb or a projecting part of the body.
Resorted to only if to leave the part would be dangerous to life or affect
the health of the patient.

II.

CLASSIFICATION
1. Acquired Amputation
- Loss of 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.
2. Congenital Amputation
- Loss of a limb in uterus 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.
* A transverse deficiency has no distal skeletal elements: all others are
longitudinal deficiencies. The transverse level is named after the segment
beyond which no bony elements exist. Digital buds do not count.
* Longitudinal level names the bones affected, and indicates whether the
bones are partly or totally affected.

III.

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

IV.

ETIOLOGY
1. Trauma
- Amputation is done where blood supply or tissues are so destroyed,
gangrene is inventible or reconstruction is impossible i.e. blast injuries
2. Cancer
- result from disruption in the control mechanism normally exerted over
all reproduction and differentiation
- for primary malignant tumors not possible to resects 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 and
pathological fracture
3. Peripheral Vascular Disease (PVD)
- Bergers 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
4. Congenital Anomaly
- refers to the absence or abnormality of a limb evident at birth or no
etiology
- i.e. polydactyl, congenital absence of a distal part
General Indication for Amputation
1. Irreparable loss of blood supply in a diseases or injured limb
2. Injury that is so severe that function would be better after
amputation
3. To save life when infection is uncontrollable
4. To remove part or all of a congenital abnormal limb for cosmoses or
improving functions

V.

PATHOPHYSIOLOGY
The selection of the surgical level probably one of the most important
decisions that must be made for the amputee. The viability of soft tissue
and the amount of skin coverage with adequate sensation usually
determine the most distal possible functions level for amputation. After
surgery, the patient with an UL amputation should ideally be able to use a
prosthesis during most of the day. Bony prominences, skin scars, soft
tissue traction, shear and perspiration can complicate prosthesis use. For
these reasons the residual limb must be surgically constructed with care to
optimize the intimacy of fit, maintain muscle balance, and allow
assumption of stresses necessary to meet the limbs new function.

VI.

CLINICAL MANIFESTATIONS
- 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

suffar motor, sensory, 2 automatic neuropathy, all of which lead to
ulceration
VII.

COMPLICATIONS
1. Phantom Pain
Phantom sensation: not necessarily painful and a feeling that all
or a part of the amputated limb still resent
Three Categories of Phantom sensation
1. Kinesthetic sensation posture length, volume
2. Kinetic sensation willed movement, spontaneous
movement, associate movement
3. Extroceptive sensation touch, temperature, pressure
Phantom Pain: if the sensation of the absent limb is painful and
disagreeable with strong paresthesias. It is usually experience
in the first few months after amputation
Residual Limb Pain: pain arising in the residual limb from a
specific anatomical structure that can be identified
2. Delayed Healing Stump
Delayed healing is broad term used to describe a range of
superficial to deep skin and tissue lesion that can be either clean or
infected, underlying causes of delayed on non-healing of the stump is:
Vascular insufficiency
External forces external on the stump
Loss of reduced skin sensation
Simple open stitches
Complex open suture line (superficial deep, infected), sinus
damage, ulceration, necrosis.
3. Contractures

Level of Amputation
Above knee

Typical Contracture
Extend

Abduction

Flexion
Below Knee

Hip Flexion

Method of Prevention
When supine in bed,
the patient should be
positioned with sand
bags to prevent
external rotation
exercise are also
indicated.
Range of motion
exercises and resistive
exercises exercise to
the hip abductors are
useful
The patient spent large
portions of each day in
the position
Methods of prevention
are identical to those
listed under above
knee amputation when
sitting, the leg should

be positioned on board
so that knee is full
extension

4. Skin Problems
Skin lesions of the residual limb can expand rapidly, so early
intervention is required, particularly for diabetic patients
5. Choke Syndrome
Lack of total contact with proximal restriction results in distal edema
called choke syndrome. The distal, strangulated residual limb becomes
darkened with hemosiderin deposition
6. Verrucous Hyperplasia
A wart-like skin overgrowth, usually of the distal residual limb,
resulting from inadequate external compression and edema
7. Skin Infection
Folliculitis is a hair-root infection resulting from poor hygiene,
sweating, poor pocket fit or positioning.
Epidernoid cysts occur when sebaceous glands are plugged by
keratin, and usually do not appear until months or years after a
prosthesis is worn. They grow up to 5 cm in diameter and can break
to discharge purulent fluid.
Tinea corposis and Tenia crusis mainly result from sweating
8. Contact Dermatitis
Allergic contact dermatitis can arise from tropical medications or
from agents used in prosthetic manufacture. Eczema can appear
acutely, with small blisters and, later with scaling and erythema
9. Bone Problems
Symptomatic bone spurs can arise from bone from which the
periosteum was incorrectly stripped during surgery or trauma. Bone
pain can also result from a hypermobile fibula that is left longer than
the tibia.
If a balanced myodesis was not performed in the
transfemoral amputation, the femur can extrude through the muscle
and present subcutaneously.
10. Pain
Incisional pain should subside with healing although shear forces or
an adherent scar can be painful. Deep massage helps prevent scar
adhesions.
11. Neuromas
Every severed nerve develops a pressure sensitive neuroma. The
surgeon should sever nerves proximally to avoid socket pressure.
Palpating directly over the neuroma typically elicits lancinating pain.
VIII.

PROGNOSIS
Massively crushed or burned muscle and ischemic tissue release
myoglobin and cell toxins, which can lead to renal failure, adult respiratory
distress syndrome, and death.
In addition, the risk of infection

contractures, and nerve injuries that interfere with function needs to be

considered. Recent studies show the value of early amputation not only in
saving lives but also in preventing the emotional, marital and financial
disaster narcotic analgesic addiction.
IX.

MEDICAL/SURGICAL MANAGEMENT
General Procedure:
1. Surgeon removed part or all of the limb
- type of amputation is at the dissection of the surgeon and the
extent of the extremity at the time of the amputation.
2. Allow for 1 or 2 wound healing
3. Construct a resident limb for optimum prosthetic fitting and function.
A. Types of Surgical Amputation
1. Open Amputation (Guillotine Amputation)
- often indicated for infection
- stump is not closed over with a skin flap allows the free drainage
of purulent or infections material
2. 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
3. Minor Amputation
- Amputation done through or distal to the metacarpus or
metatarsus
4. Major Amputation
- done proximal to the metatarsal or metacarpal bones
- design to produce a stump suitable for an artificial limb
5. Joint Amputation
- amputation done at the joint
B. Levels of Amputation
Amputation is performed at the most distal point that will heal
successfully. The site of amputation is determined by two factors:
circulation in the part-and the requirements of the prosthesis.
1. Amputation of the Lower Extremity
- the surgical level may be classified on an anatomical or functional
basis.
- objective: create a stump optimum for weight bearing
a. Foot and Ankle
a.1 Lisfrancs Amputation/Distraction
- a transometatarsal disarticulation
a.2 Chopart Amputation
- disarticulation at the midtarsal joint through the
talonavicular and calcaneocuboid joints
- the remaining foot often develops a significant equinovarus
deformity
- adequate extensor lengthening has been advocated to
prevent this deformity
a.3 Symes Amputation
- an ankle disarticulation for destructive and infective lesions
of the foot that cannot be treated with a transmetatarsal
amputation

- advantage: if successful, the patient can walk on the symes

residual limb without a prosthesis, at least for short
distances
- disadvantage: * the heel pad can migrate posteriorly on
mediolaterally if it is not adequately anchored to the cut
end of the tibia
* uncosmetic because of the inability to match the shape of
the contralateral leg.
b. Transtibial/Below knee Amputation (BKA)
- transtibial amputation
- performed at the function of the middle and upper thirds of
the tibia, between 8 and 10 cm below the tibial plateau
b.1 Short Below Knee
- less than 20% of tibial length
b.2 Long Below Knee
- more than 50% of tibial length
b.3 Non-ischemic Limb
- ideal level for amputation below the knee is at the musculotendinous junction of the gastrocnemius muscle
- distal third of the leg is not satisfactory because the tissue
are relatively vascular & soft padding is scanty
- In adults, the ideal bone length for a BKA stump is 12.5 to
17.5 cm depending on a body weight
b.4 Ischemic Limb
- performed customarily at a higher level, for example 1012.5 cm. distal to the joint line, than are amputations in nonischemic limbs.
C. Amputation through or just above the knee joint
c.1 Gritti-strokes
- amputation done though the femoral condyles and the
patella is attached directly over the wet end of the femur
- a supracondylar amputation
- gives a very durable stump with full end bearing
- the best kind of amputation
c.2 Kirks Amputation
- a supracondylar tensoplastic amputation
- done through the calcaneus bone of supra condylar region
of the femur below the shaft
- symmetrical in contours from spurs and of maximum
functional length
of the stump is 2 inches higher
c.3 Knee Disarticulation
- through the knee joint
c.4 Long above knee
- amputation of more than 60% femoral length
d. Above knee Amputation/Transfemoral
- usually performed with equal anterior and posterior length
flaps
- does not tolerate total end weight bearing
- the surgeon typically transects the quadriceps just proximal
to the patella, transects the adductor magnus from the
adductor tubercle, and transects the smaller muscles 1 to 3
inches longer than the bone cut
- ideal length is 10_12 inches below the greater trochanter

e. Hip Disarticulation
- involves removal of the entire femur; in practice however,
the proximal femur is usually left to provide prosthetic
stabilization and to avoid an uncosmetic cavity
f. Hemipelvectomy (Hind Quarter Ablation)
- resection of lower left of the pelvis and bears weight on soft
tissues and chest cage
g. Hemicorporectomy (Humpty-Dumpty)
- translumbar amputation
- performed for pelvic malignancy, intractable decubitus
ulcer, infection, or trauma
2. Amputation of upper Extremity
Objective: preserve maximum length and function since prosthesis offer a
substitute and cosmesis is equally important
a. Finger Amputation
- occur at the distal interphalangeal, proximal
interphalangeal and metacarpophalangeal levels
b. Transradial Amputation
- preferred in most cases
- performed at three levels
Long forearm residual - preferred when optimal bodypowered prosthetic restoration is the goal
Medium forearm residual limb optimal externally
powered prosthetic restoration is the goal
Short transradial amputation
complicates
suspension and limit elbow flexion strength and
elbow range of motion
c. Elbow disarticulation
- advantages surgical techniques permits reduction in
surgery time and blood loss, provides improves prosthetic
self-suspension while permitting the use of the a less
encumbering rocket
- reduces the rotation of the socket on the residual limb, as
compared with the transhumeral level of amputation
Disadvantages:
- marginal cosmetic appearance caused by the necessary
external elbow mechanism
- current limitations in technology, which impede the use of
externally powered elbow mechanisms at the level of
amputation.
d. Transhumeral Amputation
- performed at three levels (long, medium and short residual
links)
- long arm residual limb ( 7 to 10 cm from the distal humeral
condyle) is preferred for optimal prosthetic restoration.
g. Shoulder disarticulation and forequarter amputations
- fortunately are seen less frequently than amputation at
other levels
C. Approaches
- healing is enhanced by gently handling of the residual limb,
controlling residual limb edema through rigid or soft compression
dressings, and using aseptic techniques in wound care to avoid
infection
Rigid Cast dressings


X.

a closed rigid cast dressing is frequently used to provide

uniform compression, to support soft tissues and thereby
control pain and to prevent contractures
the original cast may be left on for 10 to 14 days unless
contraindicated by factors such as elevated body
temperature, secure pain, or loose fitting Cast
a second cast is then applied and changed usually 10-14
days after the initial cast is changed
Soft Dressings
when frequent infections of the residual limb (stump) is
desired, a soft dressing, with or without compression, may
be used
an immobilizing splint may be incorporated in the dressing

PT ASSESSMENT
Before surgery, the neurovascular and functional status of the
extremity must be evaluated through history and physical assessment.
A. Pre-prosthetic Assessment Guide
1. General Medical Information
a. cause of amputation
b. associated disease and symptoms
c. current physiological state (port-surgical cardiopulmonary status,
vital signs, duration of time out of bed, pain)
d. medications
2. Vascularity (both limbs if amputation cause is vascular)
a. pulses (e.g. femoral, popliteal, dorsalis, pedis, posterior tibial
b. color (e.g. red, cyanotic
c. temperature
d. edema (circumferences, measurement water displacement
measurement, caliper, measures)
e. pain (type, location, duration)
f. trophic changes
3. Neurologic
a. pain (phantom)
b. neuropathy
c. cognitive status (abort, oriented, confused
d. emotional status (acceptance, body image)
4. Range of Motion
a. residual limb (specific goniometric measurements are necessary
b. other extremities (gross for major joints)
5. Muscle strength (MMI)
a. residual limb (MMI for the involved LE will write until most healing
occurred.
b. other extremities (gross MMI of UE and uninvolved LE is done
early post-op)
6. Skin
a. scar (healed, invaginated, flat)
b. other lesions ( size, shape, open scar tissue)
c. moisture (moist, dry, scaly)
d. sensation (absent, diminished, hyperesthesia)
e. grafts (location, type, healing)
f. dermatologic (psoriases eczema, cysts)
7. Residual Limb Shape
a. bone length (below knee limbs measurement from medial tibial
plateau, above knee limbs measured from ischial tuberosity or

greater trochanter)
b. soft tissue length (note redundant tissue)
c. circumferential measurements (taken as soon as dressing and
then taken regularly through-out the pre-prosthetic period).
8. Functional Status
a. transfers (e.g. bed to chair)
b. mobility (ancillary support supervision)
c. ADLs
d. Instrumental ADL (e.g. cooking, cleaning)
STUMP EVALUATION
does not experience excessive bleeding
free of local and systematic sign of infection
free of pressure related problems
absence of pain
B. Formulae for the levels of Amputation:
A. Upper extremity
If unilateral:
Percentage from normal
a)
Transhumeral
0
0-3
30-50
50-90

Classification
Shoulder disarticulation
Humeral neck
Short transhumeral stump
Long transhumeral stump
Elbow disarticulation

b)
Transradio-ulnar
0-35
35-55
55-90
90-100
100

Classification
Very short transradio-ulnar
stump
Short transradio-ulnar stump
Transradio-ulnar stump
Wrist disarticulation
Transcarpal

* measurement
Transhumeral stump normal measurement from tip of the
acromion process to the lateral epicondyle
Transradio-ulnar stump normal measurement: from the
medial epicondyle to ulnar styloid
%age = length of the residual limb x 100
length of the sound limb
if bilateral then:
Upper arm = patients height in cm. x 0.19
Forearm = patients height in cm. x 0.21
B. Lower Extremity

Percentage from normal

a)
Transfemoral
0-35
35-60
60-100

Classification
Short transfemoral stump
Medium transfemoral stump
long transfemoral stump

Transtibio-fibular
0-20

Classification
Very short transtibio-fibular
stump
Short transtibio-fibular stump
Long transtibio-fibular stump

b)

20-50
50-100

* measurement :
Transfemoral stump = normal measurement: perineum to
medial femoral condyle
Transtibio-fibular stump = normal measurement: medial tibial
plateau to medial malleolus
% age = length of residual limb x 100
length of sound limb
Levels of Impairment

XI.

Upper Extremity
Thumb
Index finger
Middle finger
Ring/little finger
Wrist
Elbow
Shoulder
Forequarter
All fingers except thumb

%age of impairment
22%
14%
11%
5%
54%
57%
60%
70%
32%

Lower Extremity
Big Toe
Other toes
Choparts Amputation
Symes Amputation
Energy Requirements:
Type of Amputation
Unilateral transtibio-fibular
Bilateral transtibio-fibular
Unilateral transfemoral
Bilateral transfemoral
Unilateral transfemoral/unilateral
transtibio-fibular

%age of impairment
5%
2% (each)
21%
28%

PHYSICAL THERAPY MANAGEMENT

I. Pre-Operative Management

METS (% greater from normal)

10-40%
41%
65%
110%
75%

Primary goal: education and prevention of further adversity

a. Psychological Aspects
- preoperative counseling by the rehabilitation team and peer
counseling by other amputees facilitates recovery
- therapy includes range of motion exercise, strengthening, and
ambulation with an assistive device
- Keep in mind that a new amputee typically experiences
depression, especially options for future function and ambulation
b. Surgical Decision and Level of Amputation
- it is often better to choose early amputation and prosthetic, fitting
over limb salvage of questionable functional benefit
- it is difficult to select the optimum level of amputation based on
clinical assessment of tissue viability. Many noninvasive vascular
studies are available to determine level of amputation. The pre
operative noninvasive vascular studies are crucial in preserving
limb, length so that the level selected is at the edge of tissue
viability. If the limb infection is present, then the limb blood flow
should be evaluated to asses whether healing will occur
c. Physical Assessment
- sensation, ROM, strength, mobility, ambulation, cardiopulmonary
function, coordination, positioning of the residual functional
assessment ADLs and self-care skills Teach Therapy Programs
- the therapist should teach the patient on relaxation techniques
transfer skills and proper bed limb and conditioning exercise
The patient is often more able to absorb and comply with a therapy
program during the pre-operative period when incisional pain
medication or apprehension are not yet present.
II.
Post-operative Management
a) Preventive measure for cardiovascular complication
- identification and modification of risk factors
- dietary counseling
- stress management training
- instructions in an sustainable exercise regimen

b) Management to increase or maintain ROM on all joints

- post operative, range of motion exercise are started early
because contracture deformities develop rapidly. Range of
motion exercise are carried out or the hip and knee for
below the knee amputations and to the hip for above the
knee amputations.
- postoperative positioning to prevent development of hip or
knee contracture is important. According to the surgeons
preference, the residual limb position or elevated for a brief
period after surgery. If the residual limb is to be elevated,
the front of the bed should be raised. The residual limb
should not be placed on a pillow because of a flexion
contraction of the hip may result
- In a lower extremity amputation, the patient should be
encouraged to turn from side to side after the first 24 to 48
hours and to assume a prone position to stretch the flexor
muscles and to prevent flexion contracture of the hip.
- ROM Exercises
PROM-AAROM-AROM& Self Assist ROM

* functional exercise, diagonal patterns

c. Strengthening exercise for future use of assistive device
- an overhead trapeze can be used by the patient to change
position and strengthen the biceps. The triceps, necessary
in crutch walking can be strengthened by pressing the
palms against the bed while pushing the body upward
(push-up exercise)
- a patient with an above-the-elbow amputation or shoulder
disarticulation is likely to develop a pothead abnormality
caused by loss of weight of the amputated extremity. Thus,
pothead exercises are helpful.
- As skill and strength improve, these parameters are altered
making exercise more difficult
- Stools and sandbags in graduated sizes are employ to
increase difficulty and for strengthening the muscles
d. Bandaging techniques for LE Amputation
- Elastic bandages will not only help control edema but also
shrink the bandage, a figure-eight wrap usually incorporate
the proximal joint closest to the stump. Wrapping from the
distal to proximal site should provide distal compression.
The stump should be wrapped every 4 hours or whenever
the bandages losen skips or bunches. An elastic stump
shrinker may used if elastic wrapping is impractical
- double-length 4 inch bandages should be used for
transtibial limb, and double-length 6-inch bandages for the
transfemoral limb
e. Choosing of ideal prosthesis
1. Must fit comfortably and be cosmetically appealing
2. Should be functional throughout all phases of gait
3. Allow joint movement whenever possible and appropriate
4. Weightless
5. Without cost
6. Maintenance free
f. Fitting OF Prosthetics
- sterile stocking held under firm tension us the rigid dressing
is applied. Pressure relief pads and distal polyurethane and
in place prior to application of the plaster of paris, rigid
dressing. Complete assembly of components for the
immediate post-surgical prosthetic fitting
g. Prosthetics training prior to discharge
- Preprosthetic training includes active range-of-motion
exercise, positioning, muscles strengthening, skin care,
wheelchair mobility, transfers, ambulation with patient and
family education
- goals should be realistic and individualized to challenge
each amputee to his or her maximum potential based on
functional considerations of age and health.
- after completing the final prosthetic evaluation, a period of
gait training using the prosthesis is required. Gait training of
course on an outpatient bases from 1 week to 1 month or
more with 5-5 visits per week. The more proximal levels of
amputations require lengthy training then distal levels,

longer training for upper limb than lower limb amputees, for
bilateral than unilateral amputees, for adults the for children
Probable Prosthetic Candidates:
1. Readable cardiovascular
2. Adequate healing and skin coverage
3. Good range of motion and muscle strength
4. Adequate motor control and learning ability