AMPUTATIONS

Question 1

types

Answer 1

 Ablation (removal) of the whole or part of thelimb
 Amputation = through the bone
 Disarticulation = through the joint

Question 2

incidence

Answer 2

 Lower limb = 85% of amps
 Upper limb = 15% of amps
 R vs L = equal distribution
 PVD & diabetes mellitus (50 – 75 yr)

Question 3

indications

Answer 3

 Dead / dying tissue
 Dangerous conditions (injury or disease)
 Limb is a nuisance (useless)

Question 4

Peripheral Vascular Disease

Answer 4

 Definition:
 Atheromatous lesions lead to stenosis or occlusions in arteries –insufficient blood flow todistal limbs.
 Muscle ischaemia arises during exercise = pain.
 Pain at rest = tissue loss/gangrene

 Pathophysiology:
◦ Anaerobic metabolism in distal skeletalmuscles = extreme vasodilation & pain
◦ Relieved by rest = intermittent claudication →no permanent skeletal muscle damage
◦ Claudication is pain caused by too little blood flow, usually during exercise.
◦ Persistent pain at rest = critical ischaemia
 Ankle Brachial Pressure Index = level of critical ischaemia
 Ankle-brachial pressure index (ABPI) or ankle-brachial index (ABI) is the ratio of the blood pressure at the ankle to theblood pressure in the upper arm (brachium).
 Normal ABPI = 1.1
 Moderate PVD = 0.5 ABPI
 Severe occlusion = 0.25 ABPI

Question 5

Peripheral Vascular Disease

risk factors and medical assessment

Answer 5

 Risk factors:
◦ Smoking
◦ High serum cholesterol/ lipid concentrations (serum is an amber-coloured, protein-rich liquid which separates out when blood coagulates)
◦ Hypertension
◦ ↑ fibrinogen levels (fibrinogen is a protein produced by the liver)
◦ < 55 yr age = poor prognosis

Medical assessment:
◦ Doppler ultrasonography: (Doppler ultrasound is a noninvasive test that can be used to estimate your blood flow through blood vessels by bouncing high-frequency sound waves (ultrasound) off circulating red blood cells)
◦ Treadmill testing (The cardiac stress test is done with heart stimulation, either by exercise on a treadmill, pedalling a stationary exercise bicycle ergometer, or with intravenous pharmacological stimulation, with the patient connected to an electrocardiogram )
◦ MRI
◦ Angiography (an X-ray photograph of blood or lymph vessels, made by angiography)

Question 6

PVD Management

Answer 6

Surgical
◦ Vascular reconstructive surgery
◦ Amputation
Medical
◦ Antiplatelet drugs
◦ Antilipid therapy
◦ Prostacycline (inhibits platelet activation and is also an effective 
vasodilator)

Question 7

Indications for Amputations, dangerous conditions, Damn Nuisance

Answer 7

Dead/dying tissue
◦ PVD
◦ Severe trauma
◦ Burns/frostbite
◦ ↓blood supply → necrosis → toxin spread → death PVD = 90% amps

Dangerous conditions
◦ Malignant tumour
◦ Potentially lethal sepsis (gas gangrene)
◦ Crush syndrome (controversial)

Damn Nuisance (useless)
◦ Having the limb is worse than no limb at all
◦ Pain
◦ Gross malformation
◦ Recurrent sepsis
◦ Severe loss of function (Usually requested by patient)

Question 8

Levels of amputations

Answer 8

 Aim to preserve length of a limb
 Level of most distal palpable pulse
 End-bearing vs non end-bearing

Lower limb
 Symes
 Midtarsal
 Tarsometatarsal
 Metatarsal
 Toe
 Hip disarticulation
 Above-knee
 Knee disarticulation
 Below-knee

Upper Limb
 Wrist
 Below-elbow
 Above-elbow

Question 9

Lower limb levels of amputations

Answer 9

Toe amputation
 1st toe – Decreased push-off
 2nd toe – hallux valgus
 All toes – limp with rapid gait – running
 Prosthesis = shoe filler

metatarsal amputation
 More proximal  more loss of push-off
 Limp with normal gait
 Prosthesis = shoe filler

Tarsometatarsal
 Lisfranc’s amputation
 No push-off and no spring
 Equinus deformity (is a condition in which the upward bending motion of the ankle joint is limited)

Midtarsal amputation
 Chopart’s amputation
 Develop severe equinovalgus deformity (Equino- means plantarflexed and valgus means that the base of the heel is rotated away from the midline of the foot (eversion) and abduction of foot)
 Must arthrodese (immobilize) hind foot for functional walking

Symes amputation
 End-bearing stump
 Bones cut 0,6 cm proximal to ankle joint and ankle is disarticulated
 Heel flap pads distal end of stump
 Bottom of stump is flared  large bulky prosthesis
 Poor cosmetic result, but functional

Below the knee amputation
 Most common amputation
 Preservation of knee joint facilitates rehabilitation
 Ideal level = musculotendinous junction of gastrocnemius
 Tendency to develop knee and hip flexion contractures

Question 10

disarticulation

Answer 10

 End-bearing stump
 Good prostheses available
 Long lever arm controlled by strong muscles
 Knee joint of prosthetic leg is distal to normal leg

Above-knee disartuclation
 Second most common
 Aim for the longest stump possible
 Knee joint takes 9 – 10 cm of length
 Develop hip flexion / abduction deformities
 Weight bear through ischial tuberosity and bulk of thigh

Hip disarticulation
 Prostheses are cumbersome
 No lever to activate prosthesis
 Use pelvic tilting to move
 Very tiring

Question 11

Upper limb levels or disarticulation

Answer 11

 If distal radio-carpal joint preserved, still have pronation and supination
 Long lever arm
 Prostheses = hook and cosmetic hand

Question 12

Below the elbow amputation

Answer 12

 Preserve length and elbow joint

 Develop elbow supination and flexion deformity