Assessment of Individuals

Following Lower Extremity

Amputation
 Incidence

• PVD (Peripheral Vascular Disease)

Dysvascular Ralated Amputations is the leading cause
(82% of limb loss)
Men more than women 2-3:1 and African American
Associated with smoking and diabetes
Infections can be a complication ie. Staph, Osteomyelitis
97% of PVD account for lower limb amputations
• Trauma is the second leading cause of amputation
68.6% are upper extremity amputations
MVA or gunshots
Leading cause in 20-30 age group
Men more than women 9-10:1
• Tumor is the third leading cause
Leading cause in 10-20 age group
http://www.amputee-coalition.org/fact_sheets/amp_st
 • Congenital limb deformities or absence of limb is a possible cause,
but more rare.
Studies show rates have stayed the same.
Transverse- Limb ends at location of deficit
Longitudinal- a total or partial absence of a structure along the long axis of
a segment, beyond which normal skeletal elements may exist. (ie- absence
of a tibia with a normal foot)
Amelia- absence of a whole limb
Apodia- absence of a hand or foot
Adactylia-absence of fingers or toes with MC or MT
Aphalangia- absence of finger or toes
Phocomelia- flipper limb due to absence of a limb segment
Levels of amputations
• Partial toe: any part of one
or more toes
• Toe disarticulation: at the
MP joint
• Partial foot/ray resection:
3, 4,5 metatarsal and digits
• Transmetatarsal:
midsection of all metatarsals
o Lisfranc-disarticulation
of all metatarsals and
digits
o Chopart-disarticulation
at the midtarsal joint
leaving calcaneus and
talus
Amputation Levels
Syme’s: (Named for James Symes,
1800)Ankle disarticulation with attachment
of heel pad
Long transtibial: >50% tibial length
Transtibial: between 20-50% tibial length
Short transtibial: <20% tibial length-
trauma usually
Levels of Amputations

• Knee disarticulation: Through knee joint, femur intact

• Long transfemoral: >60% femoral length
• Transfemoral: between 35-60% femoral length
• Short transfemoral: <35% femoral length
• Hip disarticulation: Through hip joint, pelvis intact
• Hemipelvectomy: resection of lower half of the pelvis
• Hemicorporectomy: Both LE and pelvis below L4-L5
Surgical Process
• Remove part of the limb to be amputated.
• Allow for proper wound healing.
• Usually equal length anterior and posterior flaps,
scar in the middle. With dysvascular patient,
sometimes a longer posterior flap because this is
better vascularized.
• Construct a stump for optimal prosthetic fit and
function
• Muscle stabilization achieved by: myofascial
closure, myoplasty(muscle to muscle),
myodesis(muscle to bone), tenodesis(tendon to
bone)
• Severed peripheral nerves form neuromas. Can be
painful.
• Hemostasis achieved by ligating major arteries and
veins.
Important Issues for the
Patient/Family to Understand
 Time Frame of Recovery
 Realistic time frame to help avoid unrealistic goals
 Usual expectation of 12-18 month
 Emotional Adaptation-
 Differs for everyone
 Prosthetic plan
 Role of P&O, PT, Funding,
 Expectations of the prosthesis
 Peer Support Groups:
 Golf, Cycling, Scuba
 National Groups (ACA)
 Marketing
 Educational Resources
Rehabilitation outcomes:
Post Surgical Phase-Concerns
 Minimize Systemic
Complications
 MI, DVT,
 Decubitus(Pressure
Ulcer)

 Contractures

 Phantom Pain

 Phantom Sensation
 Post-surgical Assessment

• Patient History

• Social History

•Prior level of
activity/employment

•Living environment/community
access
Assessment Continued
• General health

• Health behaviors

• Medical History

• Chief complaints

• Medications
• Communication, affect, cognition, language
and learning style
Impairments
Losses or abnormalities of anatomic,
physiologic, psychologic or mental structure
or function
Physical impairments
O Aerobic capacity and endurance
o Anthropometric measurements
 Circumference in cm -
 Document anatomical landmarks
o Skin assessment
 warm
 cool
 abnormally warm
Impairments
 O Stump length
 From tibial tubercle or ischial tuberosity to end of bone or
soft tissue
O Shape
 Bulbous
 Conical
 Cylindrical-best for total contact prosthesis
 Vascularity: both legs
 Capillary refill time <3 sec
 Pulses-Femoral, Popliteal, Posterior Tibial, Dorsal Pedal
 0=absent
 1+diminished
 2+normal
 3+increased
Impairments
o ROM-

o Strength

o Sensory integrity
 Skin sensitivity with Semmes-Weinstein Monoflimament-
 5.07 touch or higher = protective sensation
Impairments Continued
Cognitive impairment
(arousal, attention, cognition)
Psychological Impairments
(depression, anxiety)
Social Impairment
(social support, financial)
Activity Limitation

Restrictions of the ability to perform at the

level of a whole person
Assistive and adaptive devices
Self-care: BADL’s and IADL’s
Gait
Balance
Ergonomic and body mechanics
Disability
Inability to perform, or limitation in the
performance, of actions, tasks, and activities
expected in social roles
Accessibility/ Barriers

Ability to return to work

Safety
Amputation Specific Goals
Prevent Contractures
Reduce Post Surgical Edema
Improve Bed Mobility
Pain Management
Protect limb from trauma
Emotional care
Promote limb activity
Establish trunk stability
Prevention of Falls
Begin Ambulation
Prevent Contractures
Active Strategies
Positioning
Stretching
Passive Strategies
Immobilizers
Rigid dressings

Hip and knee

Reduce Post Surgical Edema
Compression
garments
Stump Wrapping
Liners
Positioning
Improve Mobility
Bed mobility
Transfer training
(bed, toilet)
ADL’s
Encourage
Independence
Pain Management
Must be controlled to facilitate mobility and
prosthetic use
Medicine
Manual desensitization
Protect limb from trauma
 Rigid dressings-
 Removeable (RRD)
 Non removable
 Plaster
 Custom molded – 1-2 weeks
 Soft dressings-
 elastic wraps
 Compression stockinet
 Shrinker socks
 Una paste-semi-rigid
 Gel liners

 Non-Removable rigid dressings with immediate

post-operative prosthesis (IPOP)
Prevention of Falls
Complications due to falls can increase
healing time, other injuries increased
hospitatilzation
Place chair next to bed
Promote limb Activity/Trunk
Stability
Exercise- begin day 1
Helps prevent muscle atrophy
Control pain
Improve Muscle mass
Edema control
Trunk stability-core strengthening
Ambulation
Non-pedal- w/c use
Uni-pedal- one remaining leg
Bi-pedal using a prosthetic pylon
With or w/out prosthetic device
Promote Social/Leisure
Activities
Access - ADA
Safety
Ability to return to work
References
O’Sullivan, SB, Schmitz TJ. (2007).
Physical Rehabilitation (5th ed).
Philadelphia: F.A. Davis Company.
Seymour, R. (2002). Prosthetics and
Orthotics, Lower Limb and Spinal.
Philadelphia: Lippincott Williams &
Wilkins.