Rehabilitation of lower limb

amputee

By : Dr.Hassan Hussien El- sharkawy

Objectives 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

What is an Amputation?

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 AmputationsPeripheral arterial diseaseDiabetes MellitusGangrene (du to the

complication of # & plaster

cast ) .Trauma (crushing, frost bite,

burns)Congenital deformitiesChronic OsteomyelitisMalignant Tumor

DiabetesComplications 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.

Levels of Amputation

s

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

Psychological Support Preparation

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

Above the Knee

Post- Operative Interventions

Monitor for complications Pain management Education & supportPromote mobility/ independent self-careEnhancing Body ImagePromote wound healing

Skin Care & Stump Hygiene

Wash at night

Mild, fragrance free soap or antiseptic cleaner

Rinse well

Dry thoroughly

General wound care

Dressings

Hemorrhage

Infection

“

Surgical Complications

Complication of Amputations

Joint contractures

Energy issues

Phantom limb pain

Bony growth

Skin Breakdown

Blistering

Necrosis

Phantom Limb Pain

What is PLP?The somatosensory homonculus

Phantom Limb Pain: Coping Techniques

AcupunctureAnaestheticsBiofeedbackChiropracticColdCranial Sacral Therapy

DesensitizationDietary and Herbal Supplements

Electrical StimulationExerciseHeatMagnetic TherapyMassageMedicationsPsychotherapyShrinker SocksWearing Your Artificial Limb

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 post- operative prosthesis. - Temporary prosthesis

- Definitive prosthesis.

Types of Prosthesis

BELOW KNEEKNEE

DISARTICULATION ABOVE KNEEHIP

DISARTICULATION

PROSTHETICSLOWER EXTREMITY

Prosthetics

RehabilitationThere 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 StudyJohn 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. OpenB. ClosedC. CongentialD. Secondary

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. Fibromyalgiab. Somatic Painc. Phantom limb paind. Imaginary pain

Case Study

Which of the following post-operative complications would Mr. Rocke NOT experience?A. HemmorrhageB. Joint ContracturesC. Skin BreakdownD. Bony Overgrowth

Case Study

When the nurse goes into the room, he yells, "Get out! I don’t 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 waterD.I will never wash my stump.

Case Study

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

Canadian Association of Wound Care. (2011). Statistics on Diabetic Foot Ulcers. Retrieved from http:// cawc.net/index.php/public/facts-stats-and-tools/statistics/

Mosby. (2008). Mosby's Dictionary of Medicine, Nursing & Health Professions. 8th ed. A Mosby Title

National Limb Loss Information Center. (2008). Amputation Statistics by CauseLimb Loss in the United States. Retrieved from <http://www.amputee-

coalition.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>

References