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Rehabilitation of lower limb amputee

By : Dr.Hassan Hussien El- sharkawy

Definition of Amputation Statistics Reasons for Amputation Types of Amputation Psychological Support Preparation Types of Surgery, Pre-op, and Post-op Care Surgical Complications Amputation Complications Stump Care Rehabilitation and Prosthesis Case Study & Questions

Amputation: the surgical removal of a part of the body, a limb or part of a limb

Statistics
Canadians with diabetes are 23 times more likely to be hospitalized for a limb amputation than someone without diabetes More than 4,000 Canadians with diabetes had a limb amputated in 2006. 30% of Canadians with diabetes will die within one year of amputation. 69% of limb amputees with diabetes will not survive past five years Lower limb amputations are 4 times more common than upper limb (infection) .

While over 90% of amputations caused by vascular disease involve the lower limb, nearly 70% of amputations caused by trauma involve the upper limb

Statistics
For both males and females, risk of traumatic amputations increased steadily with age, reaching its highest level among people age 85 or older Limb amputations resulting from cancer most commonly involved the lower limb; above-knee and below-knee amputations alone accounted for more than a third (36 percent) of all cancer-related amputations. There were no notable differences by sex or race in the age-specific risk of cancer-related amputations, though rates of limb loss due to cancer were generally higher among individuals other than African Americans. In all age groups, the risk of dysfunctional vascular related amputation was highest among males and individuals who are African American

Causative Factors of Amputations


Peripheral arterial disease Diabetes Mellitus Gangrene (du to the complication

of # & plaster cast ) .


Trauma (crushing, frost bite, burns)

Congenital deformities
Chronic Osteomyelitis Malignant Tumor

Complications of diabetes that contribute to the increased risk of foot infection include: 1. Neuropathy a. Sensory b. Autonomic c. Motor 2. Peripheral vascular disease . 3. Immuno-compromise

High Risk Characteristics for Developing Foot Infections


Duration of diabetes more than 10 years
Age > 40 years History of smoking

Decreased peripheral pulses


Decreased sensation History of previous foot ulcers or amputation

Proper Foot Care for Diabetics


Check your sound foot and residual limb for sores, cuts, blisters or other problems every day. Check your shoes for pebbles and foreign objects. Wash your foot in warm, not hot, water. Dry it well, especially between the toes. Trim toenails straight across. Protect your foot from extreme hot or cold. If you are cold at night, wear socks. Never use heating pads or hot water to warm your foot/feet. Never go barefoot. Wear slippers or socks inside the house. Always wear your prosthesis or use a mobility aid. Hopping on your sound foot can lead to injury from overuse or by stubbing your toes or falling.

Pre-operative Assessment
Neurovascular and functional status of extremity Function and Condition of residual limb (in case of traumatic amputation) Circulatory status and function of unaffected limb Signs & Symptoms of infection (culture required) Nutritional Status Concurrent medical problems Current medications

Emotional reaction to amputation Circumstances surrounding amputation (ie. Traumatic versus surgical)

Occupational and social


Rehabilitation

Primary Amputation

Above the Knee Primary Amputation


Site of Amputation

Monitor for complications Pain management Education & support Promote mobility/ independent self-care Enhancing Body Image Promote wound healing

Wash at night Mild, fragrance free soap or antiseptic cleaner

Rinse well
Dry thoroughly General wound care

Hemorrhage Infection

Complication of Amputations
Joint contractures Energy issues

Phantom limb pain


Bony growth Skin Breakdown

What is PLP? The somatosensory homonculus

Acupuncture Exercise Anaesthetics Heat Biofeedback Magnetic Therapy Chiropractic Massage Cold Medications Cranial Sacral Therapy Psychotherapy Desensitization Shrinker Socks Dietary and Herbal Wearing Your Supplements Artificial Limb Electrical Stimulation

Levels of lower limb amputation

Prostheses
Devices to help shape and shrink the residual limb and help client readapt Wrapping of elastic bandages Individual fitting of the prosthesis; special care

Lower Limb Prosthesis


Types of lower limbs prostheses : Types of L.L. prostheses depend on different stages after amputation. There are three types: - Immediate postoperative prosthesis. - Temporary prosthesis - Definitive prosthesis.

PROSTHETICS Types of Prosthesis LOWER EXTREMITY

BELOW KNEE

KNEE DISARTICULATION

ABOVE KNEE

HIP DISARTICULATION

Prosthetics

There are 5 Stages of Rehabilitation: 1. Healing and Starting Physiotherapy 2. Visiting the Prosthetist

3. Choosing an Artificial Limb 4. Learning to Use your Artificial Limb

5. Life as a New Amputee

Rehabilitation of lower limb amputee :


Therapy plays an integral role in preparing a patient for a lower-extremity orthotic or prosthetic device and training them with that device once it has been fabricated. Once a patient receives a prosthetic or orthotic device, the therapist is then responsible for evaluating that patient with their device

Exercise After Amputation


ROM to prevent flexion contractures, particularly of the hip and knee Trapeze and overhead frame Firm mattress Prone position every 3 to 4 hours Elevation of lower-leg residual limb controversial

Case Study
John Rocke is a 45-year-old divorcee with no children. He has a history of type one diabetes mellitus and poor control of blood glu- cose levels. Mr. Rocke is unemployed and currently receives un- employment compensation. He lives alone in a second-floor apartment. Mr. Rocke had developed gangrene in the toe and failed to seek prompt medical attention; as a result, a left below- the-knee amputation was necessary.

What type of surgery did Mr. Rocke receive? A. Open B. Closed C. Congential D. Secondary

Case Study
Mr. Rocke is in his second postoperative day and his vital signs are stable. The stump is splinted and has a soft dressing. The wound is approximating well without signs of infection. He has not performed ROM exercises or turning since his surgery, com- plaining of severe crushing pain in his left foot? What type of pain is this? a. Fibromyalgia b. Somatic Pain c. Phantom limb pain d. Imaginary pain

Case Study
Which of the following post-operative complications would Mr. Rocke NOT experience? A. Hemmorrhage B. Joint Contractures C. Skin Breakdown D. Bony Overgrowth

Case Study
When the nurse goes into the room, he yells, "Get out! I dont want anyone to see me like this. What would be a priority nursing diagnosis for this situation?

Case Study
True or False: Mr. Rocke should receive a diet high in protein, vitamins and simple carbohydrates

Case Study
You are planning an education session to provide Mr. Rocke with information about the importance of stump care. Which of the following statements that Mr. Rocke repeats back to you best demonstrates his understanding of good stump care? A. I will wash my stump in the morning with cool water and Axe body wash. B. I will wash my stump at night with fragrance free soap and warm water. C. I will wash my stump in the morning with fragrance free soap and warm water D. I will never wash my stump.

References
Day, R.A., Paul, I., Williams, B., Smeltzer, S., Bare, B.G. (2009) Brunner and Suddarth's Textbook of

Canadian Medical-Surgical Nursing, 2nd ed. Lippincott Williams & Wilkins cawc.net/index.php/public/facts-stats-and-tools/statistics/

Canadian Association of Wound Care. (2011). Statistics on Diabetic Foot Ulcers. Retrieved from http://

Mosby. (2008). Mosby's Dictionary of Medicine, Nursing & Health Professions. 8th ed. A Mosby Title
National Limb Loss Information Center. (2008). Amputation Statistics by Cause Limb Loss in the United States. Retrieved from <http://www.amputeecoalition.org/fact_sheets/amp_stats_cause.html>
National Limb Loss Information Center. Statistics on Hand and Arm Loss. Retrieved from <http:// www.aboutonehandtyping.com/statistics.html> Net Wellness. (2011). Amputation Overview. Retrieved from <http://www.netwellness.org/ healthtopics/amputation/overview.cfm> War Amps (2009) Retrieved from <http://www.waramps.ca/CMSMasterHome.aspx?&LangType =1033>