AMPUTATION Table 9-1 Upper Limb Amputations by Site: 1993-2006

RELATED ANATOMY Percentage of Total Upper

SKIN
 Epidermis is the superficial layer of the skin,
consisting of epithelial tissue.
 Dermis - layer of connective tissue.
 Subcutaneous tissue, or hypodermis a layer of loose
connective tissue
MUSCLE
 Made up of numerous muscle fiber grouped into
bundles called fascicles.
 The entire muscle is covered by dense irregular
connective tissue called Epimysium.
 Each fascicle is surrounded by Perimysium
 Each muscle fiber is covered by Endomysium.
BONE
 Framework of the body,
 Support, protection, movement storage
o Tibia
 WB
o Fibula
 Mm and ligament attachment
MEDICAL BACKGROUND
AMPUTATION
 Removal of an extremity or appendage from the
body
 Acquired condition that results in the loss of the limb
from injury, disease or surgery
Disarticulation
Amputation through the joint
EPIDEMIOLOGY
- In US estimated 185,000 persons undergo an amputation of
the upper or lower limb each year.
- In 2008, estimated 1.9 million person were living with limb
loss in US
 500,000 — minor upper limb loss (fingers, hands)
 41,000 — major upper limb loss
Epidemiology
 5 of all combat — related major amputations involve
the upper limb
 Males - > 75% of those with upper limb loss
 More severe injuries are more likely occur in males
 185,000 new amputations are performed in U.S.
civilian hospitals each year
 The total population of veterans with amputations
being treated in VA medical centers annually has
increased from approximately 25,000 in 2000 to
more than 80,000 in 2016
Epidemiology of Amputation and the Influence of Ethnicity
 Male
 Increasing Age
 African American
 Nephropathy
 Hypertension
 Having Chronic Foot
 Diabetic Patients
 Elevated Triglyceride
 Ischemic Heart Disease
Epidemiology and Risk of Amputation in Patients With
Diabetes Mellitus and Peripheral Artery Disease
 Concomitant diagnoses of peripheral artery disease
and diabetes mellitus have a negative synergistic
effect, leaving patients at a higher risk for
amputation than either of the 2 diseases alone.
 Of those with peripheral artery disease, patients of
low socioeconomic status, those residing in rural
areas, and those of African-American or Native
American ethnicity are at the highest risk of
amputation
 Over the preceding two decades, the rates of
endovascular interventions have risen while
inexpensive and evidence-based measures—such as
hemoglobin Aic testing—are underused.
CAUSE OF AMPUTATION
1. Congenital Limb Deficiency
2. Acquired or Surgical Amputations
Congenital Limb Deficiency
 Largely unknown Apodia
 D/t teratogenic agents (eg. Thalidomide)
 Excessive exposure radiation
Genesis of limb deficiency MC during 1st trimester
Mesodermal formation of the limb = 26th day of Absence of foot
gestation until 8 weeks
MC risk factors:
 Maternal diabetes
 Thalidomide

ORIGINAL (CLASSIC) CLASSIFICATION (GB) COLLEGE OF

Amelia Absence of a limb SEs PHYSICAL THERAPY
Meromelia Partial absence of a limb
Hemimelia Absence of half a limb
Phocomelia Flipper-like appendage
attached to the trunk

NOMENCLATURE AND FUNCTIONAL LEVELS OF

AMPUTATIONS
Original Classification Scheme for Congenital Upper Limb
Reductions

Nomenclature and Functional Levels of Amputations

FRANTZ SYSTEM

ISPO CLASSIFICATION SYSTEM

 Preferred classification system
ORIGINAL (CLASSIC) VS FRANTZ VS ISPO  1 limb loss every 30s; 10x more common with DM
(WHO)
 4 per 1,000 pop’n with DM per year

Incidence and Characterization of Major Upper-Extremity

Amputations in the National Trauma Data Bank

MC congenital limb deficiency:

 UE: (L) TERMINAL TRANSRADIAL DEFICIENCY
 LE: BILATERAL FIBULAR LONGITUDINAL DEFICIENCY
CONGENITAL CONSTRICTING BAND SYNDROME
 AKA Constricting Rings, Amniotic Band Syndrome,
Intrauterine Amputation, Streeter Syndrome
 Subcutatneous tissue > hyperplastic collagenous &
elastic tissue
 Constricting annular bands —> do not extend to the
deep fascia but in some cases it extend up to
periosteum
 MC fingers & toes
Cause: probably from prenatal environment that produces
mesynchymal defect or rupture of the amnion
ACQUIRED/SURGICAL AMPUTATION
Indication:
 Irreparably damaged or deformed useless part of the
body
 When blood supply of the limb has been lost &
cannot be restored
 Permanent, irreparable loss on nerve supply
UPPER LIMB AMPUTATION
UPPER EXTREMITY AMPUTATION
Partial Hand Amputation
 Transphalangeal amputation (DIP, PIP or MCP levels)
 Carefully planned to ensure adequate residual
sensation & movement
 No salvaging if no metacarpals are present to
provide pinch
Transradial Amputation
 Aminimum of 5 cms proximal to the distal radius to
accommodate an externally powered terminal
device
Levels:
 Very short—residual limb length of less than 35%
 Short—residual limb length of 35% to 55%
 Long—residual limb length of 55% to 90%

CAUSES OF ACQUIRED AMPUTATION

 PVD: LE
 Trauma: UE
 Others:
o Tumors
o Infection
o Thermal/Electrical/Chemical injury
o Congenital defects

LIMB LOSS STATISTICS

 Vascular disease (including DM & PAD) — 54%
 Trauma — 45%
 Cancer & Malignancy — <2%
 4x more common among African-American than
white Americans
 Nearly half of the individuals who have an
amputation due to vascular disease will die within 5
years
 Person w/ DM who have LE amputation will require
amputation of the second leg within 2-3 years

Transhumeral Amputation
  Should be performed 7 to 10 cms proximal to the
distal humeral condyles to accommodate most of
the prosthetic elbow
Levels:
 Humeral neck—Residual limb length of <30%
[residual limb (humerus) length]
 Short transhumeral—Residual limb length of 30% to
50%
 Standard transhumeral—Residual limb length of 50%
to 90%
KRUKENBERG PROCEDURE
 Reconstructs the forearm & creates a sensate
prehensile surface for children with absent hands by
separating the ulna and the radius in the forearm
 transforms the residual ulna and radius into digits
 Indications: absent hands, visual impairment
SHOULDER DISARTICULATION
Performed in the following conditions:
 Severe electrical injuries
 Trauma cases
 Tumor surgery
Loss of anatomical shoulder necessitates use of an external
prosthetic shoulder joint
FOREQUARTER AMPUTATION
Rarely performed
Done in the following conditions:
 Severe trauma of the shoulder
 Malignant lesion involving the shoulder
Prosthetic use is UNCOMMON a due to absence of
suspension
HAND FUNCTION
 most important part of the hand is the opposable
thumb
 Phalangization - a reconstructive technique in which
the web space is deepened between the digits to
provide more mobile digits
 Pollicization - the process of moving a finger with its
nerve and blood supply to the site of the amputated
thumb, fine and gross grasp through opposition
 Wrist disarticulation - removal of the radius and ulna
to the styloid processes
 Krukenberg amputation - transforms the residual
ulna and radius into digits
LOWER LIMB AMPUTATION
Results: A total of 2,879 patients underwent a major lower
extremity amputation secondary to a trauma-related lower
limb injury, representing 0.18% of all NTDB trauma
admissions from 2011-2012. 80.4% were male and 67.6%
were white. The three most frequent definitive amputations
preformed included {trans-tibial (46%), trans-femoral (37.5%).
and through foot (7.6%). The average length of
hospitalization for all amputees was 22.7 days. Patients with
at least one revision amputation stayed in the hospital
approximately 5.5 days longer than patients not needing a
revision amputation. 1,204 patients (41.8%) required at least
one revision amputation. 27.5% of amputees experienced at
least one major post-surgical complication.
African Americans experienced a 49 percent increase in major
post-surgical complications and stayed, on average, 2.5 days
longer in the hospital compared to whites. Injury severity
score, age, hospital teaching status, presence of a crush
injury, fracture location, presence of compartment syndrome,
and experiencing a major post-surgical complication were all
significant predictors of revision amputation.
LOWER LIMB AMPUTATION
* Vascular conditions - 82%
* Trauma - 16% of amputations
* Malignancy - 0.9%
* Congenital deformity - 0.8%
* Smoking and hypertension
* Diabetes - 67% of all amputations, 18 to 28 times more than
that of persons without diabetes
* MC level of amputation — BKA, some literatures — toes
* Dysvascular, Men, Transtibial
* Hordacre, Birks, Quinn, Barr, Ptritti, & Crotty, 2012
* Moxey et al., 2011
SELECTION OF AMPUTATION LEVEL
 Tissue viability
 Prosthetic options
 Gait dynamics
 Cosmesis
 Biomechanics of the residual limb
 Objective: to determine the level at which healing
will occur and maximal function will be restored
after removal of all compromised or infected tissue
CATEGORIES
 Closed amputation — MC, arterial disease, skin flaps
are shaped for primary (sutured) closure
 Open amputations - only in instances of severe
trauma or overwhelming infection, allows for
appropriate drainage and observation of the wound
 Guillotine amputation - an open procedure in which
all the tissues are cut at the same level by a circular
incision, eventually requires a closed amputation
o Quick control of infection (e.g. gangrene)
TRANSTIBIAL AMPUTATION
 AKA below knee amputation (BKA)
 A long posterior flap meets a shorter anterior flap
allowing the soft gastroc-soleus muscles to dorm the
distal soft tissue
 Can fit prosthesis even if with short residual limb of
2.5 inches
 Distal tibiofibular synostosis Is better

LOWER EXTREMITY AMPUTATION

¢ Partial Foot Amputation
¢ Transtibial Amputation
¢ Knee Disarticulation
¢ Transcondylar/Supracondylar Amputation
¢ Transfemoral Amputation
¢ Hip Disarticulation and Transpelvic Amputation
¢ Translumbar Amputation

PARTIAL FOOT AMPUTATION

TOE AMPUTATION
Excision of any part of one or more toes
TOE DISARTICULATION
Disarticulation at MTP jt.
RAY RESSECTION TRANSTIBIAL AMPUTATION LEVELS
Partial foot amputation Short BK
Resection of up to 3 or more MT (3 — 5) & digits ° <20% tibial length
TRANSMETATARSAL Medium Length BK
Proximal to the metatarsal heads ° 20-50% tibial length
LISFRANC Long BK
Tarsometatarsal disarticulation ° >50% tibial length
CHOPART
At midtarsal joint through the talonavicular and
calcaneocuboid joints
BOYD
Excision of all tarsals except the calcaneus
“aBOYD calcaneus”
PIROGOFF
Vertical calcaneal amputation
SYME
 Ankle disarticulation above malleoli 0.6 cm from
ankle
 Most satisfactory level in LE — walk for short
distances even without prosthesis
SARMIENTO
 Modified Syme
 Transection of the tibia & fibula ~1.3 cm proximal to
the ankle KNEE DISARTICULATION
 Excision of medial & lateral malleoli ¢ AKA through-knee amputation
VAS CONECELOS ¢ Removal of tibia and fibula at the knee
 Employed when the use of artificial limb Fibula is not ¢ Provides the capacity for partial end-weight bearing
anticipated
 Midtarsal amputation w/ tibiotalar & Subtalar
subtalar arthrodesis & section of inferior surface of
calcaneus
TRANSCONDYLAR/SUPRACONDYLAR AMPUTATION  Done in malignant tumors, major trauma or
 AKA Gritti-Stokes amputation uncontrolled infection
 Eliminates the bulbous prosthetic profile seen in
knee disarticulation
 Amputation through the femoral condyles
 Patella is attached over the cut end of the femur

TRANSFEMORAL AMPUTATION
 AKA above the knee amputation
 Equal anterior and posterior flaps
 Does not tolerate total end weight bearing
 Transects the following muscles:
o Quadriceps proximal to the patella TRANSLUMBAR AMPUTATION
o Adductor magnus from adductor tubercle  AKA Hemicorporectomy
o Smaller muscles 1 to 2 inches longer than  Amputation of both lower limbs & pelvis below L4-L5
bone cut level
 Done in patients with:
TRANSFEMORAL AMPUTATION LEVELS o Pelvic malignancy
o Intractable decubitus ulcers
o Infection or trauma
 Will also remove rectum and bladder

SURGICAL PROCESS
OPEN AMPUTATION
 GUILLOTINE
 OPEN CIRCUMFERENTIAL
 OPEN FLAPS
Initial open amputation helps to control the infection,
eliminate the bacteremia & provide a safer wound
environment for a definitive amputation at a later date

 Prone to hip flexion and abduction contracture
o Minimized to attach the adductor magnus
to the lateral aspect of the femur
o Hamstrings are able to assist in hip
extension
 Myodesis is better than myoplasty
HIP DISARTICULATION AND TRANSPELVIC AMPUTATION
True Hip Disarticulation
 Removal of the entire femur
 In practice, proximal femur is left to provide
prosthetic stabilization
Transpelvic Amputation
 AKA Hemipelvectomy
 Removal of the LE and part of the ilium (half of
pelvis)
GUILLOTINE AMPUTATION
 All the different tissues were transected at the same
level
 No flaps were fashioned, no muscle for myodesis
was retained & no fasciocutaneous closure was
planned
 Management includes application of skin traction,
daily dressing changes & prolonged wound care
Surgical procedure
- Amputation for vascular disease is generally considered an
elective procedure.
 the surgeon determines the level of amputation by
examining tissue viability through a variety of
measures.
o Doppler systolic blood pressure
measurement
o radioisotope or plethysmography
o arteriography
- Skin flaps
 healthy skin and tissue that is partly detached and
moved to cover a nearby wound
 broad as possible
 the scar should be pliable, painless, and non-
adherent.
 ERTL PROCEDURE
 Osteomyoplastic amputation
 Stops tib/fib motion > may lead to less pain
 Provides broader distal bone surface > may increase
end bearing
 Periosteal Flap used to cover end of tib & fib more
normal intra-osseous pressure
CLOSED AMPUTATION
 BURGESS TECHNIQUE
 FISHMOUTH TECHNIQUE
 SAGITTAL FLAPS
 SKEW FLAPS

BURGESS TECHNIQUE
 Classic technique
- Severed peripheral nerves form neuromas (a collection of  Long posterior flap
nerve cell ends) in the residual limb.  Dysvascular TRANSTIBIAL amputation
 Neuroma is surrounded by soft tissue so as not cause  Long Extended Posterior Flap
pain o Additional distal coverage and padding
 Surgeons identify the major nerves & pull them
down under some tension then cut them cleanly &
sharply & allow them to retract into soft tissue of the
residual limb
- Hemostasis is achieved by ligating major veins and arteries
- Cauterization is used only for small bleeders.
- Bones are sectioned at a length to allow wound closure
without excessive redundant tissue at the end of the residual
limb and without placing the incision under great tension.
- Sharp bone ends are smoothed and rounded
- Traumatic amputation, the surgeon attempts to save as
much bone length and viable skin as possible and preserve
proximal joints

TRANSTIBIAL AMPUTATION
 Posterior Flap is typically considered Standard
 Cylindrical shape
 Tolerates total contact type fit FISHMOUTH TECHNIQUE
 More durable  Equal anterior & posterior flap
SKIN FLAPS
 TRANSFEMORAL amputation
 Pedicle flap: A flap in which a local muscle inclusive
 Nondysvascular TRANSTIBIAL amputation
of the overlying skin is moved over with its own
blood supply to fill a large defect.
 Microvascular free flap: A flap in which the donor is
not local and the microvasculature of the donor
muscle is anastomosed to the available vessels at
the defect site.
SKEW FLAPS
MUSCLE STABILIZATION MAY BE ACHIEVED BY:
 Angular medial — lateral incision
1. myofascial closure (mm to fascia closure)
 Places the scar away from bony prominences
2. Myoplasty (mm to mm closure)
3. Myodesis (mm attached to periosteum or bone)
4. Tenodesis (tendon attached to bone)

END WEIGHT BEARING AMPUTATIONS

 OSTEOMYOPLASTY
 ERTLPROCEDURE

gastrocs retained
SKEW FLAPS
SAGITTAL FLAPS
TYPE OF INCISION FOR BELOW KNEE AMPUTATION
There is no evidence to show a benefit of one type of incision
over another. However, in the presence of wet gangrene a
two-stage procedure leads to better primary stump healing
compared to a one-stage procedure. The choice of
amputation technique can, therefore, be a matter of surgeon
preference taking into account factors such as previous
experience of a particular technique, the extent of non- viable
tissue, and the location of pre-existing surgical scars.
TRANSTIBIAL AMPUTATION
 MC level of amputation 2° PVD
 Prosthetic rehab is more successful
 Lower postoperative mortality
 Reamputation of the C/L limb increased over time
and was fairly high for individuals with diabetes.
 Longer RL — better control — smoother gait —
reduce energy required
 Highest Level?
 fibula is cut about 1 cm shorter than the tibia
TRANSFEMORAL AMPUTATION
 Ambulation requires considerable energy
 Indicated if gangrene has extended to the knee or
the patient's circulatory status precludes healing at
the transtibial level.
 The adductor magnus maintain normal adduction
COMMON PROBLEMS & COMPLICATIONS
¢ Phantom Sensation
¢ Phantom Pain
¢ Stump Pain
¢ Edema
¢ Joint Contractures
¢ Dermatologic Problems
¢ Bone Problems
¢ Choke Stump Syndrome
PHANTOM LIMB SENSATION
 Normal occurrence after amputation
 Awareness of a non-painful sensation in the
amputated part (distal to the site of amputation)
 Usually diminishes with time but could persist
throughout amputee’s life
 Telescoping Phenomenon of Phantom Sensation
PHANTOM PAIN
 Awareness of pain in the portion of the extremity
that has been amputated
 It may accompany phantom sensation, localizing in
the phantom limb rather than in the residual limb
 Usually cramping, aching, burning, and, occasionally
lancinating type of pain
 Etiology: neuron deafferentation hyperexcitability
STUMP PAIN
 Pain arising on the residual part of the body
 It is commonly sharp, sticking, or pressure feeling,
usually localized at the end of the stump
 Normal result after surgery & subsides quickly during
healing
Causes:
 Prosthogenic- improper fitting of prosthesis
 Neurogenic- formation of neuroma
 Arthrogenic- pain on the adjacent jt. or surrounding
tissues
 Symphatogenic- associated c the ANS, pain is
sometimes called Causalgia or Reflex Symphatetic
Dystrophy
 Referred- may come from the joints & muscle
 Abnormal Stump Tissues- bony exostosis,
heterotropic ossification, adherent scar, or sepsis
(infection)
JOINT CONTRACTURES
 May occur usually before or immediately after an
amputation
 Result of muscle imbalance or fascial tightness,
improper positioning of the residual limb
 TT: Knee flexion contracture
 TF: Hip flexion & abduction
EDEMA CHARACTERISTICS OF IDEAL STUMP
 Occurs immediately after amputation  No dog ears — usually caused by bad bandaging
 May be caused by:  Intact sensation
o Bad bandaging  No tenderness
o Trauma of operation  No phanton pain
o Joint problems  No open wound
o Loss of muscle pump  No LOM
o Arterial dse.  No contracture (<15° knee flexion contracture is
o Poor venous return acceptable)
o Associated disorders (DM & Kidney  Good to Normal MMT
problems)  Ideal Shape
 Causes — interstitial pressure imbalance — edema  Transtibial — cylindrical
—> fitting difficulties & delayed healing — pain —  Transfemoral — conical
DELAYED REHABILITATION
CHOKE STUMP SYNDROME ANTHROPOMETRICS
Proximal constriction of the stump results in obstruction of ¢ LGM
the venous outflow > edema of the distal residual limb ¢ Surgical wound
Signs: ¢ Stump circumference
 Brawny edema ¢ Stump length: measure (B) LE
 Induration
 Skin discoloration of the distal stump in a circular STUMP LENGTH
shape

1. Failure of total contact of stump in distal socket wall

2. Distal stump choking
3. If untreated for a long period
4. VERRUCOUS HYPERPLASIA

OTHER PROBLEMS
LEVEL OF AMPUTATION:
 Dermatologic problems
 Neuromas
 Ulceration- maceration, increase pressure over
prolonged period of time, friction & shear forces, & THINGS TO REMEMBER
stress concentration Bilateral Amputees
 Scoliosis- wc borne  Upper Arm Length: px’s ht. x .19
 Forearm Length: px’s ht. x .21
HEALING PROCESS
Risk Factors: REHABILITATIVE MANAGEMENT
Infection Stages:
* greatest postoperative concerns  Pre-operative
Smoking  Post-operative
* 2.5% higher rate of infection and reamputation than  Prosthetic Training
nonsmokers PRE-OPERATIVE STAGE
Severity of the vascular problems, diabetes, renal disease,  Psychological support
and other physiological problems such as cardiac disease  Strengthen crutch walking muscles
 Isometric for affected Extremity
EVALUATION AND ASSESSMENT  Maintain ROM of unaffected & proximal jts. to
LOA affected
LOC  Maintain good respiratory fxn
Inspection
 Maintain independence in ADL’s
 Stump shape
 Dressing/s
 Surgical wound
o Draining or non-draining, type of closure
POST-OPERATIVE STAGE Post-operative Dressings
Immediate Postamputation Period Goals Rigid Dressings
 Promote wound healing  Immediate postoperative fitting of Plaster of Paris
 Control pain socket (IPOP)
 Control edema Semirigid Dressing
 Prevent contracture  Unna’s Dressing — gauze impregnated with zinc
 Initiate remobilization and preprosthetic training oxide, gelatin, glycerin & calamine
 Manage expectations through supportive  Air Splint — plastic double wall bag that is pumped
counseling. to the desired level of rigidity
 Continue education, including orientation to Soft Dressing
prosthetic  Elastic Wraps — a dressing is applied to the incision
Postsurgical General Goals followed by some form of gauze pad then the
- Healing residual limb compression wrap
- Protect remaining limb (if dysvascular)  Elastic Shrinkers — socklike garments knitted of
- Independent in transfers and mobility heavy rubber reinforced cotton
- Demonstrate proper positioning
- Begin psychological adjustment
- Understand the process of prosthetic rehabilitation

FACTORS INFLUENCING FUNCTIONAL GOALS

1. Premorbid activity level
2. Preprosthetic activity level
3. Level of amputation
4. Comorbidities affecting balance and endurance POST-OPERATIVE CARE
5. Extent of disease or injury leading to amputation Edema
6. Financial situation  Elastic bandaging & shrinkers
7. Relationship of prosthetic components to functional o Should wear a shrinkage device 24-hours a
abilities day except for bathing
8. Presence of moderate to severe hip flexion  Removal rigid dressings
contractures  Intermittent Compression Unit- promotes stump
shaping
POST-OPERATIVE STAGE Phantom Pain
 ROM exercise
 Heating Modalities
 Ultrasound, TENS
 Massage
 Pharmacologic: Tricyclic antidepressant
Contractures
 ROM exercises
 PNF exercises
 Stretching
GENERAL PLAN OF INTERVENTIONS  Positioning
 For correction- serial casting, passive or dynamic
splinting
 Contractures are easy to prevent but difficult to
correct.

PRE-PROSTHETIC STAGE
¢ Gait Training
¢ Desensitization training- start with partial weight training
POST-OPERATIVE DRESSINGS ¢ Shadow training
Use to control excessive edema of the residual limb ¢ Crutch ambulation
Types:
¢ Rigid Dressings
¢ Semirigid Dressing
¢ Soft Dressing
  Crutch walking: requires more energy than walking PRESSURE TOLERANT
with a prosthesis
 Muscles that need strengthening in preparation for
crutch walking:
o Latissimus dorsi
o Triceps
o Biceps
o Quads
o Hip Extensors
o Hip Abductors PRESSURE SENSITIVE
PROSTHETIC TRAINING
Temporary Prosthesis
 Prosthesis is not fitted unless residual limb is free
form edema & soft tissue has shrunk
 Limited to w/c & crutch or walker
 Once fitted with prosthesis, residual limb continues
to change in size, shape & second prosthesis is often TIMING FOR PROSTHETIC FITTING IN CHILDREN
required within first 2 years  Above below elbow is 3 to 6 months
Advantages:  Below above knee joint is 8 to 10 months
 Shrinks residual limb more effectively  Active Terminal Device is 2 y/o
 Allows early bipedal ambulation  Elbow Unit is 2 to 3 y/o
 Some individuals can return to work  Functional Hand - 3 y/o
 Means of evaluating rehabilitation potentials  Actively Controlled Knee jt.— 3-4 y/o or when stair
 Serves as a positive motivating factor climbing
 Reduces the need for complex exercise PROSTHESIS REPLACEMENT
PROSTHETIC REPLACEMENT FREQUENCY IN THE PEDIATRIC
 Can be used by individuals who may have difficulty
AMPUTEE
obtaining payment for definitive prosthesis
First 5 years of age Yearly
Permanent Prosthesis
Ages 5-12 Every 18 months
The first prosthesis in intended to:
Ages 12-21 Every 2 years
 Promote residual limb maturation & desensitization
 Build up wearing tolerance
 Allow patient to become functional user
PRESSURE TOLERANT

PRESSURE SENSITIVE
AMPUTATION OUTCOMES
Functional Prognosis
Medicare Functional Classification Level (MFCL) Descriptions
and Prosthetic Component Recommendations for Each Level

INCREASE ENERGY COST OF AMPUTEE AMBULATION

OUTCOMES - UE  Single AKA -65%
Amputation of all fingers at level of MCP  Double AKA - 110%
* 100% loss of hand function  1 AKA and 1 BKA - 75%
* 90% loss of UE function  Single BKA_ - 10-40%
* 54% loss of function man’s entire body  Double BKA - 41%
Below Elbow — 95% loss of UE function  Crutches without prosthesis — 60%
Above Elbow  Wheelchair Ambulation - 9%
* 100% loss of UE function  Trivia — set rear wheel backward 1 ½ to 2 inches for
* 60% loss of function man’s entire body bilateral
 AKA for increase stability

ENERGY COST OF AMPUTEE AMBULATION

 Wheelchair Ambulation - 9%
 Crutches without prosthesis — 60%
 Single BKA - 10-40%
 Double BKA- 41%
 Single AKA - 65%
 Double AKA - 110%
 1 AKA and 1 BKA- 75%
 Trivia—set rear wheel backward 1 % to 2 inches for
bilateral AKA for increase stability
ENERGY EXPENDITURE
Amputation Energy level

SPEED OF WALKING
GRIEF, DYING & DEATH
 Dying — process
 Death — event
 Grief — response

KINDS OF LOSSES
 Personal possessions
 Familiar environment.
 Significant other
 Life itself
 Part of self- limb, sight, hearing, psychological
function, memory, self-confidence, respect, love
ENGLE’S 3 PROCESS OF GRIEF WORK
 Shock & disbelief
 Developing awareness of the loss
 Acknowledging the loss
KUBLER-ROSS’ STAGES OF GRIEF & LOSS
 Denial
 Anger
 Bargaining
 Depression
 Acceptance