AMPUTATIONSFor Balakot rehabilitation centreHandicap International Pakistan

Please refer also to:- Disabled Village Children Chapter 27- Post Amputation Care Book- Exercise Sheets

Outline

- Definition - Multidisciplinary team - Causes - Classification - Assessment - Problem solving and analysis objectives

o Stump shapingo Desensitizationo Skin mobilityo Maintaining good range of motion, preventing or reducing

contractureso Strengtheningo Gait training or wheelchair mobility as appropriateo Prosthesis trainingo Instruct patient, caregiver and familyo Follow up visits to reassess prosthetic needs

- Patient and family education

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INTRODUCTION

How soon after the amputation will we begin to work with them?This depends on where you work and how soon the doctor wants to begin rehabilitation. If you are working in a hospital you will probably begin to work with them very soon after the amputation. In our center we begin when the patient came back home. Sometimes in the clinic you will see amputees (a person with an amputation) long after they have experienced the amputation.The objectives will be different depending on how healed is the stump, how physically and mentally is the patient.

Who else is on the team? What does working as a team mean? You will work along with the doctors and in hospital. In clinic, in Pakistan, a prosthetist if often the main team member to be involved if a patient would like to consider using a prosthesis (artificial limb). They are the professionals who help decide if a prosthesis would be helpful to a patient. They also decide what type of prosthesis would be best. We’ll talk more about how they do this later. Each of the team members has a different job. But, all of these jobs are important for the successful rehabilitation of the patient.

The doctor is responsible for coordinating the medical treatment when he is present in the clinic. He will determine when rehabilitation (for example, exercise, gait and transfer training) begins. The nurses are responsible for care of the healing wound and caring for any other medical problems.

The physical therapist will assess the patient, make a plan, and begin their part of the program when the doctor orders it. You will be working as the physical therapist, to progress the program.

A very important concept to understand:Some people may be more functional without a prosthesis. We’ll talk more about this.

Two more very important members of this team have not been mentioned. Can you think who they might be?

The patient and their family!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Communicating with them is very important as well!!!!!!!!!!!!!!!!!

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How do we interact as a team?The doctor, the nurses, the prosthetist, the physiotherapist or a technician will discuss about the general health of the patient, and other things that might affect the rehabilitation program. This will help you all plan your work. In PIPOS clinic, the physiotherapist is involved in the gait training if a patient would like to consider using a prosthesis (artificial limb). The physiotherapist will have to train the patient to walk with his prosthesis. He can also be involve in the several problems and objectives related to the patient

How do we begin to make our plans?You begin to problem solve. You will identify problems, possible solutions, and eventually your plan. You plan will involve deciding what your goals are for the patient and how you will help them reach these goals.

What the patient says? What do you see?

Analysis, identify problems: what do you think the problems are? What are my goals?

Plan: What will you do for each problem?

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A little bit of… theoryCAUSES OF AMPUTATION

Amputations may be congenital (present at birth) or acquired.

What is congenital amputation? Children may be born with partial or misshapen limbs. The limb has not been removed. It never developed fully.

What are acquired amputations? Acquired types of amputation happen when the limb is amputated during trauma, or a surgical amputation is intentionally done.Amputations may be necessary with severe infection of wounds caused by trauma,, diabetes, or poor circulation. The amputation must be done because the skin, muscle or bone are no longer healthy (viable). If not done a fatal infection will develop. Examples of acquired amputations:

o Traumatic Ex. motor vehicle accidents, violenceo Vascular deficiency (poor circulation) Ex. people with bad

circulationo Tumors Ex. Cancer of the boneo Infection Ex. Infected wound that won’t healo Disease Ex. Diabetes

We will also talk about this disease when we talk later about how to prevent amputations.

Discussion: What do you know about diabetes? Why could this be a cause of amputation?

CLASSIFICATION OF AMPUTATIONSAmputations are described or named by the site of the amputation.

Amputations can occur through the shaft of the bone. We can use a specific word to describe for example an amputation through the femur. We call this a ‘TRANS-femoral’ amputation. What does the prefix “trans” mean?

Amputations may also be done through a joint - a “disarticulation.” If a person has an amputation that separates the knee joint, leaving the femur but removing the tibia and fibula, we can say this person has a “disarticulation of the knee”, (or knee disarticulation). Let talk about the most frequent amputations you may see.

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The most frequent amputations are:

1) Above knee (A/K)- Trans femoral (across the femur)THIS IS AN A/K Picture

2) Below knee (B/K)- Trans tibial (across the tibia)

THIS IS AN B/K Picture

At the upper limb, we may see also:

Transhumeral (across the humerus)

Or forearm amputation (across the radius and ulna)

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Levels of amputation: Would you be able to name it?

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GENERAL GOALS OF THERAPY

Before we can make a plan and set individual goals for a patient with an amputation we need to talk with them. The first thing you will do is talk with them to find out about themselves as a person. You will want to talk gently about what has happened to them, how they are feeling about this situation, and what they are hoping to be able to do when they finish their therapy. Remember that they may not want to talk about any of this at all at first. Especially if it is very soon after the amputation. Gaining trust and establishing communication begins the first time that you meet a patient.

The patient will need to be assessed. We will talk soon about how we assess an amputee, what we have to write in his file…

We assess the patient to identify problems, consider solutions, and to establish goals.

POSSIBLE THERAPY PATIENT PO SOLUTIONS PROBLEM PLAN

PATIENT’s GOALS

We will establish therapy goals for this individual. We will also talk about how to record this information as an assessment, and in the written progress notes.

What could be complications or problems that could be observed after an amputation?

P __ __ __E __ __ __ __N __ __ __ __ __ __SCAR A__ __ __ __ __ __ __ __BONY S __ __ __C __ __ __ __ __ __ __ __ __ __ W __ __ __ __ __ __ __SCAR I __ __ __ __ __ __ __ __

Let try to find appropriate treatment solutions to these problems….

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Along with individual goals, there are general goals that are important.What are these?

The therapy goals following amputation are:1. Stump shaping2. Desensitization3. Skin mobility4. Maintaining good range of motion, preventing or reducing

contractures5. Strengthening6. Gait training or wheelchair mobility as appropriate7. Prothesthetic training8. Instruct patient, caregiver and family9. Follow up visits to reassess prosthetic needs

Let’s look at each of these goals.

Stump shaping

What is a stump? The stump is the bone and surrounding muscle tissue left after the amputation. Another term is residual limb

The length of the stump is determined by the length of the bone where the cut is made, and the quantity of skin and muscle tissue left to cover and protect the end of the bone. . The remaining stump may be of any length (e.g. close to knee or closer to ankle), but a longer stump is preferable as it offers more leverage and more surface for prosthetic attachment.

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What does this mean? A prosthesis is an artificial limb. The stump fits down inside the prosthesis. Generally, if a stump is too short it is difficult to hold it snuggly inside the prosthesis. It will also be difficult to control the prosthesis during walking or using an upper extremity prosthesis. We’ll talk more about this later.

Yes!

Femoral prosthesis Tibial prosthesis

Arm prosthesis

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It is important to shape the stump into a conical form. Why? To fit better into a prosthesis.

How do we do stump shaping? We begin by teaching the patient to use elastic wraps. By wrapping in a certain way we are able to encourage the tissues to form correctly around the bone. We demonstrate first, and then assist them and their family in becoming independent and consistent in keeping the stump wrapped.

What happens if they don’t do this correctly or every day?If unwrapped or wrapped circumferentially (in circles instead of diagonally) the stump will become bulbous (get a knob on the end) or heal with “dog-ears” on the ends. This makes it difficult to successfully wear a prosthesis. Not wrapping the stump every day will result in these same things happening.

Bulbous Cone Dog-ears

When do we begin wrapping?Wrapping should begin on day one after the surgery or as soon after as possible. We must be very careful to not wrap it directly on the wound if it is not healed. This may cause infection!!!!! The wound should be protected by a clean bandage Then the wrapping is done over this. Wrapping may be needed daily for years.

Do we wrap upper and lower extremity stumps differently? Wrapping upper and lower extremities are very similar.

How do we keep the wrapping from slipping off of the stump? Wrapping requires an extra step to “anchor” the wrap around the joint above. This keeps them securely on the stump!!!!!

What kind of wraps do we use?Elastic wraps work best. Use 4” wide (10 cm) Ace (elastic) wraps for the arm or below knee stumps and 6” wide (15 cm) Ace (elastic) wraps for above knee stumps. Sometimes if a patient is large you may need to use two lengths of bandages sewn together end to end.

Wrapping Guidelines

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1. Always wrap at an angle. This prevents constricting (cutting off) circulation.

2. Apply with firm even pressure. Provide firmest pressure at the bottom. Decrease pressure on the wrap as you work towards the top

3. For below knee amputation, make a wrap above the knee to finish and secure.

4. For above the knee amputations, make a wrap around the waist to finish and secure.

5. For above elbow amputation, make a wrap around the chest to finish and secure.

6. For below elbow amputations, make a wrap above the elbow to finish and secure.

7. The final securing wraps around the joint passes behind the hip (above knee amputation), in front of the knee (below knee amputation), behind the shoulder (above elbow amputation), and behind the elbow (below elbow amputation). Why?

8. Rewrap if the bandage loosens.

9. Unwrap and inspect the stump several times a day.

10.Launder bandages when soiled and dry them completely.

11.Sometimes a stump “shrinker” is used in place of wrapping after the incision is well healed. What is a stump shrinker? A sturdy elastic cone shaped sock that pulls on over the stump and applies pressure. It replaces the elastic wrappings.

Does the stump change size and shape as it heals?YES! Over time the stump changes size and shape. The stump is no longer as wide as it was. Girth is the word used to describe the distance around the stump. So, it decreases in girth. Length may decrease a little as the tissue at the distal end of the stump forms into a cone shape.

What happens if the stump is not wrapped?The stump will not heal into a cone shape. This is why we use the wrapping. Wrapping also helps to decrease swelling.

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Does the stump continue to change size over time even after the incision is healed and the swelling decreases?? OFTEN. Minimal change is expected. But a gain or loss of weight in a patient’s body causes the same changes in their stump.

What happens? A smaller or larger stump shrinker may be needed.If a person is using prosthesis this will require adjustment of the prosthesis to fit the stump. We’ll talk about this later.

We will practice wrapping in a laboratory. You have in the appendum the pictures related to it.

Desensitization

What do we mean by desensitization? Decreasing and lessening sensitivity: The stump often is very sensitive following surgery. We can help decrease this with several techniques.

Why would we want to do this? The stump can remain sensitive for a long time. This can interfere with the ability to wear a prosthesis.

Why?The stump surface must be able to tolerate the pressure of walking and also able to tolerate the contact of the prosthetic socket.

What is phantom limb? What is phantom pain? When someone has an acquired amputation (trauma, surgery, etc.), it often happens that he or she feels the absent limb. We call that the phantom limb. This is normal. The patient will probably keep this sensation for many years, and many patients for their life. It could be distressing. For example, sometimes the patient will stand up on his absent foot and fall. You have to be particularly careful in the first weeks to prevent these kinds of falls.

The phantom limb sensation is different that the phantom pain sensation. Phantom pain occurs often also when someone has an acquired amputation and often when he or she had a lot of pain before and during the amputation. The pain is located at the absent foot, leg or hand. It could be a little pain (scratching, tickling, pressure) or very significant pain (being crushed or smashed). This pain is often greater in the first days and weeks. You or your patient need to talk about it with the doctor if it distresses them too much. There are medications that can help. The phantom pain usually stays during the first one or two years but becomes lessened with time. However, in some people it can continue all of their life.

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What are some desensitization techniques?At the beginning, it may be very painful when someone or something touches the stump. It is not used to being touched. By doing desensitization techniques, it will become less irritable. At the beginning you can tell your patient to gently touch their stump, to do this with gentle but firm pressure just after the amputation. (Take care that they don’t put their hands directly on the wound. If it is not healed this may infect the wound. A bandage or a dressing may be placed over the incision before beginning the desensitization techniques.)Next once they can tolerate the gentle touching you can try brushing with a soft cloth. Pressure can increase as the patient can tolerate it.When they can tolerate gentle brushing with a soft cloth you may then begin gentle tapping and patting of the skin. Intensity can increase as the patient can tolerate it.

You can do these at first, and then encourage the patient and family to do this themselves.

Talk with a doctor about medication that the patient might take before beginning desensitization if it is very painful. This may also help them before beginning exercise as well. Exercise may cause them pain when they first begin to use the stump again.

Wearing the prosthesis also helps to gradually decrease this sensitivity.

Caution:Be careful not to compromise (interfere with) the healing in the acute (early) phase before stitches are removed and the incision is completely healed. Begin after this phase.

Skin mobility

We are talking about the skin around and over the incision. We also are talking about the skin over the bones of the stump. It is important not to allow this skin to become stuck by scar tissue to the underlying bone. This restricts normal skin movement over this underlying bone. Why is this a problem? This causes abnormal pressure and rubbing of this skin and bone against the inside of the socket of the prosthesis.

Example: This is like a foot inside of a tight shoe. The foot can’t move freely and the skin begins to rub. The result is an abrasion or blister of the skin that forms on your bony heel or toes. The same thing happens when the skin doesn’t move freely inside of the prosthesis.

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What happens then? The patient must stop wearing the prosthesis to allow this abrasion or blister to heal. Possible solutions include increasing skin mobility or having the prosthetist adjust the prosthesis. This is very costly in terms of time lost for the patient in learning to walk with the prosthesis. Also, it can be difficult and expensive to get the prosthesis adjusted.

How do you keep the skin mobile?

Over the bone:Use your thumbs to press down gently but firmly and move the skin in small circles over the underlying bone. Move the skin over the bone. Be certain that you are not just rubbing over the skin!!!

Around an incision:Use your thumbs, one on each side of the incision, and move the skin side to side, and around in circles, making sure to move the skin over the tissue underneath. Make certain that you are not just rubbing the skin!!!!You can also use the second and third fingertips of one hand. Place them, one on each side of the incision, and move like instructed above. We’ll practice in lab. (LAB 2)

Caution: Do not begin before the incision is healed Do not push too hard.This can be done only when the wound is closed and well closed!! You do not want to open it.!!!! It is usually healed three or four weeks after the surgery. Ask the doctor if your are not sure.

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Maintaining Good Range of Motion, Preventing or Reducing Contractures

Group discussion: 1) What is a contracture? 2) Why do you think this might happen?3) Where do these develop most frequently?

4) Discuss about the following positions:

Hip: What positions would cause a 1) Hip flexion contracture

2) Hip abduction contracture

Knee: What positions would cause: 1) Knee flexion contracture

Elbow: What positions would cause: 1) elbow flexion contracture

5) Why are contractures a problem for an amputee?Contractures make it difficult to be fitted for a prosthesis. They also make it more difficult to walk effectively. More on this when we talk about gait training.

6) How can we help the patient prevent contractures?

7) How can we help them reduce contractures they may have already developed?

8)How can we do this in addition to exercise and stretching?

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Contracture Prevention/Positioning

What are the causes of contractures?People who have an amputation are at risk to develop contractures. Remember when we discussed about contractures in Basic Procedures. We said that a contracture happens when tissues around an articulation become stiff. It could be the muscles, joint capsule, tendons, skin, etc. Like we also mentioned, different things can cause this problem. Pain may prevent patient from moving and may cause patients to adopt bad postures. By staying too often, and spending too much time in a position, the articulation is not able to move well after awhile. A good example is when a patient with an above knee amputation keeps his limb flexed on a pillow to protect it. He can have difficulty to extend his hip later.

Another cause of contracture is an imbalance in muscles strength. Because some muscles are cut during the amputation, those muscles can become weaker and stronger muscles can then pull harder and keep the limb always in an abnormal and tightened position For example, if the hip adductors are weakened, the hip abductors may pull the leg into a resting position of abduction more easily. Also if an amputee rests always in a position, he can develop a contracture. You have to be aware of all these causes.

Your role will be to PREVENT contractures, and TO TREAT any contractures that are already present.

Why is this important?Mobility of the joints is important in daily life activities. To transfer, to sit, to use the residual limb, or if it is possible to walk with a prosthesis. You never know if a patient will have the opportunities to get a prosthesis, and it is important to act as if he will be a candidate for it. Another reason will be to reduce pain (incision and phantom pain). When a patient is free in his movements, it reduces pain.

Let’s look briefly at movements that we need to be able to walk. Remember the two phases in human gait. Support and swing.

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When stance (support) phase begins, the knee is extending. We need a full extension of the knee to walk. Now, as we enter mid stance (support), the knee and hip continue to extend. We

also need a full hip extension. Now the plantar flexors push off powerfully raising the heel from the floor and pushing from the ball of the foot. moving the body forward. Stance (support) phase ends.

Swing phase begins when the entire foot is lifted from the ground. To clear the ground the dorsiflexors begin their work again to lift the toes off of the ground. The knee flexors (hamstrings) bend the knee while the hip flexors (iliopsoas) bend the hip, lifting the leg off of the ground and swinging it forward in front of the body and the opposite leg. So we also need flexion of the hip and the knee. Now the cycle begins to repeat itself as the knee and hip begin to extend and the heel strikes the ground.

The legs take turns alternating these phases. While one is in stance (support) phase the other is in swing phase.

Question: What happens when someone is not able to do a full extension of his knee? Try it. And then, try to walk without any hip extension.)

We also need to be able to adduct the leg at least to the middle line of the body. What happens if someone is not able to do an adduction at the support phase? Could you demonstrate it?

Which are the most common contractures seen?

Following amputations contractures can develop in the remaining joints and muscles of the limb.

Hip Flexion contracture: Hip flexion contractures develop often in both above knee and below knee amputation. The patient protects his limb by keeping it close to him. Also the hip flexors are often stronger that the extensors. This can cause patients to not be able to lock the prosthetic knee joint for weight bearing. With above knee amputations the prosthetic knee (if it bends) is spring loaded but must be fully extended to lock and bear weight.

Hip Abduction contracture: Again, this is a common contracture. The abductor muscles of the hip pull the hip in abduction and patients are comfortable relaxing their limb out to the side. This will lead to a circumducting gait where the leg is held out to the side, which makes walking more difficult and less energy efficient. Any walking pattern that is abnormal, even something simple such as a limp will increase energy consumption.

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Knee Flexion contracture (below knee amputation): The knee may develop a flexion contracture when it is held for long periods in a flexed position. The sitting position is often causes the knee to be held in a flexed position. This causes a knee flexion contracture to develop. The patient is then unable to place the foot of a prosthesis flat on the floor. They walk with a crouched or bent knee position.

Prevention and treatmentWe will practice this lab. We will however look together now with position we should encourage patients to avoid contracture. We prevent and treat contracture by the ways:: positioning and stretching.

Positioning

Lying Down

The leg has to be extended and adducted at the mid line (not abducted)To prevent flexion we will avoid putting any pillow or cushion under the knee or the thigh.

We will also avoid any pillow between the legs to avoid abduction.

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A good position to encourage is to lying down prone. Some patient will be able, some not, particularly the older ones that have lung or heart problems, or that have overweight. They can be uncomfortable.

Sitting

We will encourage patients to not stay for a long period of time sitting down. When sitting the leg should point in front of them (not abducted), and the knee should be kept straight.

Standing

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Encourage them to keep the hip and knee straight and to not rest their stump on their crutch.

Who should be taught about positioning?

Teaching the patient and their family is really important. By explaining why it is important, you will get more of their collaboration. Put energy into teaching the family and get their participation in the treatment. It will help the patient to accept his new disability and will give responsibility to the family as well as the patient. This will help in the process of acceptance.

Notes:

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Stretching We will stretch the articulations to avoid the common contractures. Is someone able to remember which are the most common contractures?

How do we stretch?

Performing stretching

1) Explain what is to be done and why. Prepare the patient to preserve modesty.

2) Support the extremity or joint to be stretched. Move the joint slowly to just beyond the point where resistance is felt. Hold the body part in this position for 30 seconds. Do not bounce the joint as you stretch.

3) Positions for stretching each joint or muscle are the same as for performing range of motion.

4) Some muscles cross over more than one joint. When you stretch them you will use special positions to insure that you stretch them completely. We will practice this in lab. Examples are the hamstrings and the gastrocnemius,

5) Sometimes the patient’s body position can be used to assist with prolonged stretching. EXAMPLE: If someone has tightened hip flexor muscles you may ask them to lie on their stomach for short periods to passively stretch the hip flexor muscles and the hip joint itself. Try this. Lie on your stomach, pretend that your hip flexor muscles are tight. Now, see how gravity and your body weight stretch them out so that you are lying flat with your hips on the table.

We will practice these different ways of stretching in lab.

You have to find one way to stretch each of these muscle groups with: 1) the help of a rehab aide 2) without help (the patient has to stretch himself) 3) by using positioning

Stretching the hip flexors.Stretching the knee flexors Stretching the hip abductors.Stretching the elbow flexors.

How often should we perform the stretching?

Stretching exercises should be done twice daily. Patients will have to stretch their limb for the rest of their lives. (Why?)

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Strengthening

Strength decreases after amputation because of lack of activity. Not only do the muscles of the legs get weaker, but also the muscles of the arms and trunk. Endurance decreases as well.

Why would we need to be concerned about the non-involved (non-amputated leg) and the arms and trunk? Or endurance? Because all of those muscles are used in transfers, moving about in bed, and walking with assistive devices.

Why do we worry about endurance? Walking with assistive devices is very tiring. Walking with a prosthesis, or using an upper extremity prosthesis requires additional energy.

What other factors do we need to consider? Patients may have illnesses such as diabetes, heart disease, high blood pressure or pulmonary problems. They may have been immobilized or inactive a long time before the decision was made to amputate the limb.

When should exercises begin? The doctor should advise when you can begin. What type of exercise would you use first to strengthen the amputated leg? Isometrics would work well. Why? No movement occurs but the muscles can still strengthen. How would you progress their exercise? You would want to avoid resisted exercise with the stump until the incision had healed. Then, progress first with no resistance and increase resistance according to patient tolerance. Remember to use different exercise positions and try to use different everyday activities for strengthening as well. Can you think of any?

You will want to strengthen the rest of the body as well. What will be very important muscle groups to strengthen in the upper extremities, and why?

Stretching exercises should be done twice daily. Early isometric and beginning active exercise can also be done daily. Once a regular resistive strengthening program begins it should be done three days per week. The patient will also be doing gait training and transfer training as well.

Which muscles are important to allow the functional use of a prosthesis for lower limb amputees?When someone has an amputation, the muscles of the articulations above in that limb, the muscles in the non-amputated leg, and the arms and trunk have to be really strong to compensate for the missing articulations. So each muscle group is important.

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Which are the principal muscle groups at the hip? ______________________________________________________________________________________________________________________________

Which are the principal muscle groups at the knee? __________________________________________

Which are the principal muscle groups at the elbow?___________________________________________________________________________________

And the shoulder joint?______________________________________________________________________________________________________________________________ We will look together at each of them and how we can do isometric and isotonic strengthening for these muscles in lab.

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Transfers (Transfers? They begin as soon as the patient can move about. They will be very important to the amputee’s mobility.

The first time the patient will put down his residual limb it may be painful. The blood goes down and may increase the pain. This is normal and it will decrease with time and practice. Don’t neglect to ask the patient to take their anti-pain medication before they exercise if it is really painful.

We will practice transfers in lab. Don’t forget the safety rules we learned in Basic Procedures about transfers. Do you remember? Wheelchair training They will need to learn to get around in the wheelchair. What skills should they learn? We will practice it in lab also.

Gait training \

Pre ambulation training What are some pre ambulation activities that you can do? Things that will prepare the patient to begin walking with crutches or a walker?

Begin in a supported setting, like parallel bars or at a railing. Gradually introduce the most stable device. For some that will be a walker, others may be able to begin with crutches. What factors would you consider when deciding which device to begin with?

What other activities would you have them practice other than walking around the therapy gym?

Exercise/Transfers/Gait training program

Progression Stretching exercises should be done twice daily. Early isometric and beginning active exercise can also be done daily. Once a regular resistive strengthening program begins it should be done three days per week. The patient will also be doing gait training and transfer training daily at first, then three times a week.

If you work in a hospital you will see the patient while they are there. They may then go to an outside physical therapy clinic once they are discharged from the hospital. Some hospitals have programs for the patients to return there for their therapy.

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Prosthetic training The decision as to when and if a prosthesis is made for a patient is often a team decision. The doctor and other members of the rehabilitation team will often discuss the issue among themselves and with the patient. Factors such as age, medical problems, and the type of amputation will be considered.

Walking usually begins with a lot of assist, e.g. parallel bars, progressing to mobile support – crutches, walker, etc. as able, then eventually to walking without support if possible.

Prosthesis What is the difference between an orthosis and a prosthesis? An orthosis (brace) is made to support a limb, to help it if it is weak or stiff. We learned in Basic Procedures about different kinds of orthoses.The prosthesis (artificial limb) is made to take the place of a missing limb. Amputees may or may not be candidates for a prosthesis (not an orthsis).

A prosthesis An orthosis

You will see below two kinds of prosthetic limbs: the tibial (below knee) prosthesis and the femoral (above knee) prosthesis. There are others that you may see like a upper extremity prosthesis (above or below elbow) or a foot prosthesis.

If you look closely at a femoral prosthesis, you can separate it into a few components: 1) the belt or pelvic band (Ceinture) to secure it to the stump, 2) the socket, 3) the knee joint, Belt, 4) the tibial segment, and 5) the foot.

Socket

Knee Tibial segment Foot

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Some femoral prostheses have a hip joint. Some femoral prostheses will not have any belt. They attach to the residual limb (stump) by a suction system. It will be easier for you to catch it by seeing a real one.

The tibial prostheses will have 1) a belt of some sort, or use suction, to secure it to the stump, 2) the socket, 3) the tibial segment and 4) the foot.

Belt------------------------

Socket---- Tibial segment---------------

Foot---------

The tibial segment may be done in two formats: ones are called exoskeletal prosthesis and the other endoskeletal. Exo means ‘external’ and it is a prothesis that is done to look as a limb: the center of the prosthesis is empty between the heel and the socket. The picture above is a exoskeletal prosthesis. It is also called a conventional prosthesis.

The endoskeletal means inside and it is the prosthesis in metal tube which rely the feet to the socket. This tube will be easily adjustable and finally it will be recovered of rebury foam. This last one is also called modular prosthesis.

The socket is the part of the prosthesis directly applied to the stump. The stump fits down inside of the socket. The skin of the stump is not directly in contact with the socket. We will have some special stump sock or lining to avoid friction.

The stump will have to bear the person’s weight. It is important to remember that the weight is not placed, on the distal end of the stump.

Sockets are built to have certain bony landmarks be cushioned and come in contact with them to help bear and distribute some of the weight and pressure. Bony landmarks that bear weight include the ischial tuberosity (above knee or femoral prosthesis) and the tibial tuberosity and it’s attached strong and fibrous patellar tendon (below knee or tibial prosthesis). The residual limb is “suspended” inside of the socket.

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Look at the following picture. It is a side view of a residual limb suspended in a femoral (above knee) prosthesis.

Front Behind (posterior) (anterior) ischial tuberosity

Prosthesis (shelf built to support the ischial tuberosity)

If we look at the upper side of the socket:Behind (on the posterior side of) the socket, you can see that the ischial tuberosity is sitting down on the prosthesis. There is a little shelf built into the socket where the ischial tuberosity rests. This is an important point of weight bearing. The socket also has an adductor space where the adductor tendons have to pass comfortably on the inner medial side of the socket. In some patients the adductor tendons and excess skin and tissue in this area form an “adductor roll”. You have to make sure the socket does not compress this. It can hurt the skin and prevent the patient being able to tolerate wearing the prosthesis.

Adductor space Socket

Anterior view

At the bottom of the socket, you will see a valve or a hole. to take out air or to take out a “stockinet”. The stockinet in a long sock put on over the other socks and that will help to insert the stump (for better fit to pull the stump deeper) in the socket. Let do a demonstration with a real prosthesis!!

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valve knee

The knee is an artificial articulation. Some can be locked in extension, some will mimic the real flexion of a knee. The locks ones can usually be unlocked when the patient sits down.

The tibial (below knee) prosthesis will not have any knee joint. The patient’s real knee joint is still working. The prosthesis will also have particular weight bearing spots. The end of the stump is more conical (like a cone) so it cannot bear all of the weight on its end. The sock (cuissard) will help to distribute the weight but the principal area of weight bearing is the patellar tendon (under- rotulien) tendon. It has an angle between the socket and the tendon as you can see on this picture below.

Angle between The socket and the patellar tendon

Why is it important to know the weight bearing points?Your patients will be more susceptible to be hurt at these points. You have to be aware of it. Some patients cannot feel well when they hurt themselves because they have decreased sensation. (for example, our diabetes patients). You have to show them to inspect these important points.

Watch stump for tolerance and fit of prosthesis.

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When a patient complains of sensitivity or pain in the stump while learning to use the prosthesis it must be checked immediately and often.

Why? The skin on the stump should be examined for areas that are damaged – reddened, abrasions, or blisters.

What causes this? Learning to walk with a prosthesis is a little like wearing a new pair of shoes. If they fit well and you gradually increase the time that you wear them you have few problems. You may have a little reddening where the bone is closest to the skin - your heel or toes. You take off the shoe. Soon the redness leaves. You put the shoe back on and the next day there is less redness as your skin adjusts. If the shoes are too tight , you feel pain. If you continue to wear them you will develop abrasions, or even worse, blisters, on the skin over the bones of the heel and toes. You will not be able to continue to wear the shoes. The same thing can happen if the shoes are too big. They will rub your foot and cause these same problems.

How do we adjust the prosthesis if it is not fitting correctly?

A socket can be too big or too small. A prosthesis can be too short or too long. The knee joint may not work smoothly. All of these things can be adjusted. Things that a patient can try is adding or taking of stump socks (they should always wear at least one (some special prosthesis may not require one, but they are rare). If this does not help you will need to notify the prosthetist to have them look at it and make adjustments.

Is a stump sock like a regular sock that you use on your foot? NO!!!!!!!!! They are made of fabric that prevents friction and absorbs sweat, and they are shaped like the stump.

Do not allow the patient to continue to wear a prosthesis that is causing them pain or skin breakdown.

IT MAY TAKE MANY ADJUSTMENTS BEFORE THE PROSTHESIS FITS CORRECTLY. THIS IS NORMAL. And, after first learning to use the prosthesis the stump continues to shrink some changes may need to be made to the socket. Or for example, in a growing child, if they outgrow the prosthesis they will need to have new ones made.

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You must also look at any abnormality of the gait pattern when the person is walking. Why? For several reasons.

1) to avoid abnormal stress on the patient’s stump, 2) to be sure the prosthesis fits well and is not causing them to limp3) to achieve as normal a gait pattern with the prosthesis as possible

Why is it important for them to have as normal a gait pattern as possible? For several reasons again: 1) When you begin to walk abnormally, the rest of the body begins to suffer.

Your other joints begin to have extra work to do and they begin to have problems too.

2) The prosthesis is built to work best when the patient is ambulating correctly.

3) Patients want to walk as normally as possible. It is good for their confidence. (LAB 10)

What are some things that we look at when checking fit of the prosthesis?

1) Are the legs the same length? How can we check this? Check the height of their iliac crests. What can cause this? The prosthesis is too long, or the stump is not going down far enough into the prosthesis.

2) Is the stump down into the socket and resting correctly on the bony landmarks?

3) Is the person circumducting the prosthesis when they walk? What would this look like? What might cause this? The prosthesis is too long. Or it is pinching the adductor roll.

4) Is the foot of the prosthesis rotated excessively – to the inside or the outside? Is it because they are rotating their hip too much? They need to adjust their gait. Or because the foot of the prosthesis is actually turned too much? If so, an adjustment needs to be made to the prosthesis itself.

4) Is the person is vaulting. What does this look like and what can cause this? The prosthesis is too long or an adjustment needs to be made in the foot.

5) Are they “pistoning” in the socket? This means that the stump has too much room in the socket. Add stump socks, or the socket may need to be given additional lining by the prosthetist.

5) Are they hyperextending, or excessively flexed, at the hip?6) Is the prosthesis making a lot of noise.7) Is the patient complaining of pain when wearing the prosthesis? They may

need to adjust the number of socks that they are wearing.

If walking is commenced soon after the amputation, the brain better “remembers” the normal walking pattern. The sooner they begin, the easier the adjustment and the greater chance of success for a normal gait pattern

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When you teach a patient to walk with his prosthesis:

Look at walking patterns:

1. Look at the alignment of hip over lower extremity joints (patient may be reluctant to trust the prosthetic limb and weight shift normally onto that side and instead, they hold the leg out of normal alignment)). The hip joint when standing should be over the knee and ankle joints. Look from both in front of and from the side of the patient.

2. Is swing-through straight with no circumduction. Circumduction may be caused by reluctance to let the prosthetic knee flex for fear that it will collapse or by prosthesisbeing too long.

3. Discourage “whipping” of prosthetic knee joint into extension. Patientsoften do this because they do not trust that the mechanical knee jointwill lock and support them.

4. Weight shifts should be equal over both legs.5. Equal step lengths should be taken with each leg.6. Encourage them to keep their pelvis level and straight. May need

more abduction strengthening – this may be practiced in standing –hiking hip up.

7. Encourage spending equal time on each limb (clapping or music may help with pattern)

8. Walk slowly and correctly, and then increase speed. .

Use of a mirror is helpful to self-monitor.

PATIENT AND FAMILY EDUCATION

It will be important for the patient and family to realize that some changes will occur after an amputation. It will be a period of adjustment as the patients’ body image changes and their mobility decreases. Patients may continue to experience phantom limb and phantom pain. This is normal.Their family will be important partners in their exercise routine and if possible, eventual training in using a prosthesis. Skin care becomes very important. They must pay close attention to how their prosthesis is fitting.

Families are adjusting also to the changes in the family itself. Your job will be to help ease the transition back to a normal life.

How can I tell if I have ‘poor circulation’?

Pay attention to your feet! You may have poor circulation:- If they hurt while walking or resting.

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- If they lack sensation (feeling) in them.- It they are cold, pale, blue or swollen.- If they have sores that don’t heal.- If the skin is thick, dry, scaly, calloused or

cracked.

Eleven steps to prevent problem of poor circulation that can lead to amputation

1. Daily wash and dry your feetUse mild soap. Wash with warm water (not hot). Test temperature first with your hand. Dry well, but no hard rubbing. Be sure to dry well between toes. Get help if you cannot reach your toes

2. Daily inspection and lubrication3. Get attention if there is sign of infection4. Take care of toenails

Use clean nail clippers, not scissors. Cut straight across. Do not use sharp instruments to poke our dig around corners. Do not to cut their nails too short, or cut their cuticles, or let them get too long. Do not use razor blades to trim calluses.

5. Wear proper shoes and socks6. Avoid damaging or 7. Bumping the skin on the feet and legs8. Maintain a good activity level9. Follow a good diet10.Take your medication 11.Make regular visits to your doctor and nurse.

Hygiene and inspection of the skin is the best way to prevent wound infection that can lead to amputation.

Why are diet and activity important with people who have poor circulation? (See Amputee Care Booklet)

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