What is amputation

• intentional surgical removal of a limb or body

part. It is performed to remove diseased
tissue or relieve pain.
• Most amputations involve small body parts
such as a finger, rather than an entire limb
• About 65,000 amputations are performed in
the United States each year.
 Why perform
amputation?

• Amputation is performed for the

following reasons:
• to remove tissue that no longer has an
adequate blood supply
• to remove malignant tumors
• because of severe trauma to the body part
• The blood supply to an extremity can be
cut off because of injury to the blood
vessel, hardening of the arteries,
arterial embolism, impaired circulation
as a complication of diabetes mellitus,
repeated severe infection that leads to
gangrene, severe frostbite, Raynaud's
disease, or Buerger's disease.
 What is acquired
amputation?

• The loss of part or

all of extremity as a
direct result of
trauma or by
surgery.
 What is congenital
amputation?

• The absence of part or all of an

extremity at birth.
 What is elective
amputation?

• This is performed when the hand or

entire limb has no sensation and
function as a result of brachial plexus
injury.
 What is an open
amputation?

• Amputation in which the surface of the

wound is not covered with skin but left
unclosed. This is done to control
infection.
 What is closed
amputation?

• Usually a final or definitive amputation

performed to create a stump that can
be used effectively with a prosthesis.
 What is minor
amputation?

• Amputation through
of distal to the
metacarpus or to the
metatarsus.
 What is major
amputation?

• Amputation proximal to the metacarpal

or metatarsal bones.
 What is a
disarticulation?

• Amputation performed through a joint

 What are the causes of
amputation?
• 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
• The right arm is more frequently
involved in work related injuries.
 Lower Extremity
Amputation

• The major cause of LE amputation id

peripheral vascular accident
• The most common cause of PVD is
atherosclerosis
• After PVD the second leading cause is
trauma
• This is followed by tumors (Osteogenic
sarcoma) and last by congenital cases.
 Congenital Amputations

Causes:
• Intrauterine development
• Hereditary
• Teratogenic agents
• Maternal diabetes
 What are the classification
of congenital amputation?

• Amelia
Complete absence of the entire upper
extremity or lower extremity.
• Hemimelia or Meromelia
Partial limb absence
• Acheiria
Terminal transverse hemimelia, wrist level
Amelia Hemimelia
• Adactylia
Absent digit
• Apodia
Absent foot
• Phocomelia
Transverse total humeral radial , ulnar
deficiency
 Franz and O’Rahilly
Classification

• Terminal
Complete loss of the distal end of an extremity
• Intercalary
Absence of intermediate parts with preserved
proximal and distal component of the limb.
• Transverse/Horizontal
Absence of all skeletal elements distal to the
deficiency along a designed transverse axis.
 Percentages

Above Elbow
0% - Shoulder Disarticulation
0-30% - Humeral Neck
30-50% - Short Above Elbow
50-90% - Long Above Elbow
Below Elbow
0-35% very short below elbow
35-55% short below elbow
55-90% long below elbow
90-100% wrist disarticulation
 Percentages for Above and
Below Knee Levels

• Delisa
• <33% short above knee or below knee
stump.
• 33-36% medium length below knee or
above knee stump.
• >66% long above knee or below knee
stump.
• Sullivan
• Transtibial
>50% of tibial length – long below knee
20-50% - below
<20% of tibial length – short below
knee
 What contractures are common
for lower extremity amputations?

• For below knee amputees

Knee flexion contractures
• For above knee amputees
Hip abduction and flexion
 Symes Amputation

• An amputation at the ankle with removal of

the malleoli and formation of a heel flap.
• The Symes amputation can be one of the best
amputation of the lower extremity. 
• When it is done right, it creates an excellent end-
bearing stump and  allows for a functionally most
satisfactory prosthesis. 
• The talus and calcaneus were removed.
• The level of the amputation in generally
at the distal tibia and fibula 0.6cm
proximal to the periphery of the ankle
joint and passing through the dome of
the ankle centrally. 
 Chopart

• This is an amputation where the talus

and calcaneus are preserved.
• forefoot/midfoot level procedure and
suffers from gait disturbances during
walking. 
• prone to form an equinus deformity
 Lisfranc Amputation

• Amputations proximal to the

transmetatarsal level often result in
considerable gait problems during
walking.  This is secondary to the loss of
support and push-off.  
 Transmetatarsal
Amputation

• The transmetatarsal amputation is more

disabling than simple toe amputations, but as
in the toe amputations there is no need for a
prosthesis other than a shoe filler.   The loss
of push-off in the absence of a positive
fulcrum in the ball of the foot is chiefly
responsible for impairment of gait.  The more
proximal the amputation, the more disability
is present. 
 What is Phantom Pain?

• This is a normal sensation occurrence

after amputation of a limb. The part
amputated is still present.
 What are the Types of
Phantom Pain?

• Cramping (most common)

• Electric shock
• Burning
• Squeezing and wrenching
 What are the Steps for
Prosthetic Management?

• Preprosthetic
• Pre-Operative
• Operative
• Post-Operative
• Prosthetic Fitting and Training
• Prosthetic Follow-Up Care
• Preoperative
• Evaluation and Assessment
• Emotional Counseling
• Therapy Counseling
• Operative Management
• The cardinal rule is to preserve as much as
length as possible.
• Avoid the following level:
• Hindfoot
• Distal 1/3 of the leg
• Supracondylar of femur
• Muscles are just distal to the level of intended
bone section.
• Bone must be bevelled and should be
covered with a good padding of the tissue.
• Nerves should be pulled before cutting to
retract.
• Blood vessels (major blood vessels are ligated
the smaller ones are cauterized).
• Skin closure
• Above knee amputee-fish mouth or middle
flap.
• Below knee amputee-posterior
flap/anterior suture.
• Post-Operative Management
• Healing of wounds
• Pain control
• Preparation for prosthetic fitting
• Maintenance of range of motion
• Independent mobility
• Independent self-care
 What muscles need to be
strengthened for crutch walking?

• Shoulder depressors
• Shoulder adductors
• Flexor, extensor and abductor of the
arm
• Extensor of the forearm at the elbow.
• Wrist extensor
• Finger and thumb flexors.
• Post-Operative Dressing
• Rigid
• Made of Plaster of Paris
• Change every 5-10 days.
• Advantages
• Limits post-operative edema
• Allows for early ambulation
• Reduces length of time for shrinking
• Disadvantages
• Requires careful application
• Requires close supervision
• Does not allow early wound inspection
• Semi-Rigid
• The Unna Paste Dressing
• A compound of zinc oxide, gelatin, glycerin and
calamine maybe applied in the operating room.
• Advantage
• Better control of edema
• Disadvantage
• May loosen easily
• Soft Dressing
• Oldest method of post-surgical
management
of residual limb.
• Advantage
• Inexpensive
• Lightweight and readily available
• Easily laundered
• Disadvantage
• Poor control of edema
• Requires skill of application
• Need frequent reapplication
• Can slip and form a torniquet
 What are the appropriate sizes of
bandages for amputees?

• For above knee amputees two 6 inches

bandages sewn together and one 4 inch
bandage.
• For below knee amputee two 4 inch
elastic bandage can be used.
 What is the golden age of
prosthetic fitting?

• It is the first 30 days following the

amputation.
• Activities
• Learn to put prosthesis
• Weightshifting
• Progressive ambulation between parallel bars
• Walker-crutches-cane-unassisted on flat
surfaces.
• Uneven terrain-stairs-ramps-curbs
• Falling and getting-up
• Transfer activities.
 What are the different energy
expenditures for amputees?

• Single BKA 9-28%

• Double BKA 41-100%
• Single AKA 40-65%
• Double AKA 150%
• Single AKA and BKA 75%
• Unilateral hemipelvectomy
with prosthesis 125%
 What are the different energy
expenditures for amputees?
• Single BKA
• Double BKA
• Single AKA
• Double AKA
• Single AKA and BKA
• Unilateral hemipelvectomy
with prosthesis
• Crutch ambulation without prosthesis
• Wheelchair
 What are the functional
classifications of amputees?

• Class 1 Full Restoration

• The individuals is functionally equivalent to
normal
• Class 2 Partial Restoration
• The artificial limb is completely functional.
The person is able to work and engage in
sports but on a selective basis.
• Class III
• Self-Care Plus
The individual is disabled and has physical
limitation, requires frequent adjustment of
prosthesis.
• Class IV
• Self-Care Minus
Needs help from others because he is severely
disabled. Cannot go up and down the stairs
without assistance.
• Class V
• Cosmetic Plus
The amputee is better off without a
prosthesis
• Class VI
• Not feasible. Only a wheelchair is
prescribed.