The Amputation

Amputations are caused by:
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Accidents Disease Congenital Disorders

The accidents most likely to result in amputation are traffic accidents, followed by farm and industrial accidents. Amputations in the case of disease are performed as a lifesaving measure. The diseases that cause the most amputations are peripheral vascular disease (poor circulation of the blood) and cancer. Congenital disorders or defective limbs present at birth are not amputations, but rather are a lack of part or all of a limb. A person with a limb deficiency can usually be helped by use of an artificial limb. Sometimes amputation of part of a deformed limb or some other type of surgery may be desirable before the application of an artificial limb. The distribution of amputations by cause is shown below: There are slightly more than 1.5 amputees per 1000 persons in the United States and Canada. Therefore, the present total in the United States is approximately 380,000. There are more "below-knee" (trans-tibial) amputees than any other type as can be seen from the chart below. Surgeons preserve the knee joint whenever it is practical to do so and will fashion the stump at the lowest practical level. Very short stumps make fitting extremely difficult and very long below-knee stumps are prone to circulation problems.

The bandages are removed and reapplied throughout the day. or gait. This depression is usually replaced early by a will to resume an active life. training can begin even before the healing period is complete. The dressing applied by the surgeon is either "rigid.The Syme's amputation. (Instructions for application of elastic bandages are given in the next section. or "pylon"." usually made of plasterof-Paris. when present. prevent efficient use of a prosthesis. or "soft. and an artificial foot are attached to the rigid dressing so that walking. except possibly those who have suffered intense pain for a period just prior to the amputation. When the rigid dressing is used it is left in place for 10 to 14 days during which time most of the healing takes place.) Regardless of the type of dressing used. Sometimes a simple aluminum tube. . The Immediate Postsurgical Period Nearly every amputee feels quite depressed immediately after the surgery. usually results in a stump that will bear a substantial part of the body weight over the end. exercises are extremely important to prevent contractures (tightening of the muscles) which. which is essentially removal of the foot at the ankle. elastic bandages are used soon after surgery to aid circulation." using ordinary cotton bandaging techniques. When the soft dressing is used.

and while not considered by some to be as effective as a properly applied bandage. Whether an elastic bandage or a shrinker sock is used. It is most important that the prescribed exercises be carried out regularly. tension is used to maintain about two-thirds of the maximum stretch. are shown above. the bandage must be removed and rewrapped. Edema will be present to some extent in all cases. During the course of the wrapping. a "shrinker sock" is better than a poorly applied elastic bandage. If throbbing should occur. elastic bandages are used to keep edema from developing. Preparation for Fitting the Prosthesis In general the earlier a prosthesis is fitted the better it is for the amputee. one or two elastic bandages four inches wide are used.Some "Don'ts" that will help prevent muscle tightening. or swelling of the stump. The patient is taught the proper technique for bandaging and is generally expected to do this for himself as shown on the next page. After the rigid dressing has been removed and when a prosthesis is not being worn. For the average adult. . and it makes fitting of the prosthesis difficult. It must never be kept in place for more than 12 hours without rebandaging. but certain measures can be taken to reduce the amount of edema. and the positions shown above be avoided if the greatest benefit is to be obtained from the prosthesis. The bandage or sock must be reapplied immediately after the massage. or contractures. One of the most difficult problems facing the amputee and the treatment team is edema. The use of a rigid dressing seems to control edema. it should be removed at least three times daily and the stump should be massaged vigorously for 10-15 minutes. owing to the accumulation of fluids. Special elastic "shrinker socks" are available for use instead of elastic bandages. but the bandage should be changed every four to six hours. The stump should be bandaged constantly.

the most important factors in the usefulness of an artificial leg are fitting of the socket and alignment of the various parts with respect to the body and with respect to each other. . Bandaging Technique 1. Fitting affects alignment. Fitting and alignment are difficult procedures that require a great deal of skill on the part of the prosthetist and a great deal of cooperation on the part of the patient. continue over the upper part of the kneecap and down under the back of the knee. extensive training is carried out later by the physical therapist. Bring the bandage under the back of the knee. Bring the bandage diagonally down the back of the stump and around over the end of the stump.Special Note: Regardless of the functions provided by the most sophisticated mechanical devices. it is necessary for the prosthetist to train the amputee in the basic principles of walking in order for the prosthetist to arrive at the best set of conditions for the amputee. and both affect comfort and function. 2. 4. 3. In addition. Start with the bandage held in place on the inside of the thigh just above the knee and unroll the bandage so that it is laid diagonally down the outer side of the stump while maintaining about two-thirds of the maximum stretch in the bandage. During fitting and alignment of the first prothesis. Bring the bandage over the inner end of the stump and diagonally up the outer side of the stump. alignment affects fitting. The end of the bandage is held in place with the special clips that are provided. It is important that the tightest part of the bandage be at the end of the stump. Continue up the back of the stump to the starting point on the inside of the thigh and repeat the sequence in a manner so that the entire stump is covered by the time the roll is used up.

The prosthetist and therapist can suggest the sock or socks to be used. Although a variety of shoes may be worn with artificial limbs. Most prosthetic socks are woven of virgin wool. A specially woven nylon sock known as a prosthetic sheath is used by many amputees between the skin and the regular prosthetic sock to provide additional protection from abrasion. The socket of the preparatory prosthesis may be made of either plaster-of-Paris or a plastic material. The sheath also allows perspiration to escape to the prosthetic sock and thus to the atmosphere. (A chart to guide in selection of sock thickness is shown in Care of the Stump. Fitting as soon after surgery as possible also helps to combat edema. but only the patient can determine the proper selection. The aluminum pylons are usually designed so that the position. A preparatory prosthesis is frequently used for several weeks or months until the stump has stabilized before the "permanent". A belt about the waist is usually used to help keep the prosthesis in its proper place on the stump.) Prosthetic socks must be changed daily to reduce the chance of irritation of the skin and dermatitis. or definitive. prosthesis is provided. the patient should consult with the prosthetist before selecting the shoes to be used because heel height is a major factor in alignment of the artificial leg. and 6 ply. Prosthetic socks require special care in laundering. At least one prosthetic sock is worn between the socket and the body to provide for ventilation and to protect the skin from rubbing. or alignment. . Additional socks can be used to compensate for stump shrinkage if the amount of shrinkage is not too great. of the foot with respect to the socket can be changed when necessary. Three thicknesses are available: 3 ply. but socks of synthetic yarns are also used. and is usually attached to an artificial foot by an aluminum tube often called a "pylon".The Preparatory Prosthesis 5. Instructions are provided by the manufacturers. 5 ply.

The shank may be either a hollow shell (crustacean) or a tube (pylon) covered by foam and a flexible outer layer (endoskeletal). depending upon the user¶s preference. a shank. and a foot. by the shape of the brim of the socket. Any of several types of artificial feet may be used. The prosthesis may be held in place by any of a number of ways: by a cuff above the knee cap. although many amputees prefer a "hard" socket because it is considered to be cooler. or by suction between the socket and amputee produced by an elastic sleeve or flexible inner liner of silicone and attached mechanically to the prosthesis. Sockets are made of plastic. The pylon may contain provisions so that alignment may be adjusted at any time during the life of the prosthesis. . or shin.The Definitive Prosthesis Most prostheses for amputations between knee and ankle consist of three major parts: a socket. The most common socket used is some form of the PatellarTendon-Bearing (PTB) design where all of the weight of the amputee is carried through the stump. The PTB socket totally encloses the stump and usually contains a "soft" liner to provide a cushioning effect.

and allowing it to harden. the prosthetist usually begins by wrapping the stump with plaster-of-Paris bandages to obtain a negative mold. The first one is usually a test. socket made of a transparent plastic to determine if further modifications are needed. After modification of the model to provide the proper characteristics to the finished socket. The endoskeletal type uses carved foam rubber over the supporting pylon and the entire prosthesis is encased in a either a latex or fabric stocking. A new method being used by many prosthetists for obtaining a modified model of the stump involves use of a computer and automatic machinery. a plastic socket is formed over it. The socket is mounted on an adjustable leg for walking trials. Known a CAD/CAM (Computer-Aided-Design/Computer-Aided-Manufacturing). or check. A positive model is made by filling the negative mold with a mixture of plaster-of-Paris and water. the limb is ready for the finishing procedures.Fabrication of a Below-Knee Prosthesis Whether the prosthesis is to be crustacean or endoskeletal (often called "modular") type. this method permits prosthetists to modify the model more easily since it does not require making and carving an actual plaster model. The exoskeletal shank may be of plastic-covered wood or all plastic. and when both the prosthetist and the amputee are satisfied. Steps in the fabrication of a plastic prosthesis for a below-knee (trans-tibial) amputee: .

The clear plastic socket is tried on to make sure that it fits properly. . C. H. D. A negative mold of the stump is made by wrapping it with a wet plaster-ofParis bandage. F. The socket to be used on the definitive prosthesis is formed over the model by using either a mixture of plastic resin and cloth or by forming a heated sheet of plastic over the model. E. a test. A positive model of the stump is made by filling the cast with a mixture of plaster of Paris and water. The definitive socket is attached to a pylon that can be adjusted for alignment and walking trials can be made.A. or check socket. A new positive model is made by filling the clear socket with a mixture of plaster of Paris and water. B. The finished prosthesis maybe either exoskeletal or endoskeletal. After modifications have been made to the model by the prosthetist to make sure that the pressures m the socket will be correct. G. is made by forming a heated sheet of clear plastic over the model.

The thicknesses generally available are designated 3-ply. humid weather. Use of detergents should be avoided at all times. and should be replaced daily with newly laundered ones. Some amputees have found that use of a one-ply cotton filler sock provides a satisfactory way to obtain a still finer adjustment in thickness. Manufacturers recommend that socks be rotated on at least a three. One 3-ply + one 5-ply = 8 plies One 6-ply sock can be used instead of two 3-ply socks.Care of the Stump The stump must be washed daily to avoid irritations and infection. it should be removed and reapplied. the prosthetist should be consulted. Mild soap and warm water are recommended.or four-day schedule to allow the fibers to retain their original position. They should be washed in warm water with a mild soap. Prosthetic socks are woven especially for their intended use and are available inthree thicknesses and a variety of sizes. If the amputee has trouble in obtaining comfort by a combination of prosthetic socks. Frequent adjustments are often required in the first year. With this combination. he should consult his prosthetist immediately. If discomfort persists. Some amputees have found a hair dryer to be useful in drying the stump and preparing the socket for donning. Reductions in the size of the stump can be accommodated by adding one or more prosthetic socks. Prosthetic socks must be applied carefully to avoid wrinkles. The interior of plastic sockets also must be kept clean by washing daily with warm water and a mild soap. When the prosthesis does not feel comfortable during standing and walking. more often in warm. various thicknesses can be obtained as follows: One 3-ply = 3 plies One 5-ply = 5 plies Two 3-ply = 6 plies. . 5-ply. and 6-ply.