7

AMPUTATION
I.

DEFINITION
It is the surgical cutting of a limb or outgrowth of the body. The word
amputation is reserved for surgical, traumatic and disease created limb
loses.
TWO MAJOR CATEGORIES OF AMPUTATION:
1. Acquired Amputation
- loss of part or all of an extremity as the direct result of
trauma or by surgery. It is also done to revise a
congenital limb amputation or alter a deformity secondary
to burns or trauma.
2, Congenital Amputation
- loss of a limb in uterus and are believed to result from
such stimuli as drug toxicity. There is failure of formation
or strangulation of limb buds by the umbilical cord.
II.
EPIDEMIOLOGY
*5:1 Ratio of lower limb to upper limb amputees, majority are men
than women
- 90% lower extremity
- 5% partial foot and ankle
- 50% below knee
- 35% above the knee
- 7 - 10% at the hip
* Peripheral Vascular Disease (PVD)
- PVD without diabetes ranges 2-5% among individuals
- PVD with diabetes ranges 6-25%
- 7-13% usually is associated with other medical problems
such as cardiac dose and stroke
* Trauma
- 75% of acquired amputation in UE
- primarily men aged 15-45 yrs. Old
- next most common cause for LE amputation about 20%
of which
* Disease and Tumors
- responsible for about equal number of the remaining
acquired UE amputations
- in LE, it accounts approximately 75% of all acquired
amputations among 60 years and above
- it is the most frequent cause of all amputation in both the
UE and LE among children aging 10-20 yrs. old
III.
ETIOLOGY
1. Congenital Anomaly
- refers to the absence or abnormality of a limb evident at
birth or no etiology
- i.e. polydactyl, congenital absence of a distal part
2. Peripheral Vascular Disease (PVD)
- Bergers Disease or Arteriosclerosis
- Emboli or thrombus may cause a loss of blood supply to
extremity resulting to ischemia, ulceration, or
gangrene
requiring amputation
- Mostly involve lower limbs and the level of amputation
depends on the adequacy or remaining circulation
3. Trauma
- amputation is done where blood supply or tissues are so
destroyed, gangrene is inventible or reconstruction is
impossible

8
- i.e. blast insjuries
4. Infection
- i.e. chronic osteomyelitis, gas gangrene of high virulence
5. Tumor
- for primary malignant tumors not possible to resects or
irradiate without heavy risks or recurrence or dysfunction
* without metastasis amputation is curative
* with metastasis it is palliative (relieves pain; in acute or
chronic infections that cant be controlled by medical or
ordinary surgical treatment and has local or systemic sequelae
or prevents and pathological fracture; enhance chemotherapy;
improve systemic status)
6. Thermal, Chemical, Electrical Injuries
- excess of these creates severe tissue damage resorting to
amputation
IV.
CRITEREA FOR DIAGNOSIS
* General Indications for Amputation
1. Irreparable loss of blood supply in a disease or injured limb
2. Injury that is so severe that function would be better after Amputation
3. To save life when infection is uncontrollable
4. To remove part or all of a congenital abnormal limb for cosmoses or
improving functions
COMPLICATIONS
1. Contractures
Level of
Typical Contracture
Method of
Amputation
Prevention
Above Knee
Extend
When supine in bed,
the patient should be
positioned with sand
bags
to
prevent
external
rotation
exercises are also
indicated.
Abduction
Range
of
motion
exercises
and
resistive exercises to
the hip abductors are
useful.
Flexion
The patient spent
large portions of each
day in the position.
Below Knee
Hip Flexion
Methods of prevention
are identical to those
listed under above
knee Amputation.
Methods of prevention
are identical to those
listed under above
knee amputation.
Knee Flexion

When sitting, the leg

should be positioned
on board so that knee
is in full extension

2. Delayed Healing of Stump

Delayed healing is board term used to describe a range of
superficial to deep skin and tissue lesion that can be either

9
clean or infected. Underlying causes of delayed on non
healing of the stump is:
Vascular insufficiency
External forces external on the stump
Loss of reduced skin sensation
Simple open stitches
Complex open suture line (superficial, deep, infected),
sinus damage, ulceration, necrosis
3. Phantom Pain, Sensation and Residual Limb Pain
Phantom sensation: a non painful sensation or awareness of
the presence of the amputated part.
* Three Categories of Phantom Sensation:
1. Kinesthetic sensation posture length, volume
2. Kinetic sensation willed movement, spontaneous
movement, associate movement
3. Extroceptive sensation touch, temperature, pressure
Description of Sensation by the Amputee
Phantom Sensation Phantom Pain
Residual Limb Pain
Touch
Dull aching
Prosthetic
Pressure
Burning or shooting
Neuroma
Cold
Stabbing knife-like
Sympathetic
Wetness
Sticking
Referred
Itching
Squeezing or
Abnormal tissue
cramping
Formication
Electrical shocks
Joint pain
Fatigue
Leg is being pulled
Bone pain
off
General Pain
Trauma related pain
Soft tissue pain
Telescoping Limb
Pre-operative pain
Residual limb
change
Phantom Movement
Unnatural position
Wearing of
prosthesis ease the
phantom pain
Does not interfere Maybe localized or
with prosthetic
diffuse
Rehab
Responsive
to Maybe continuous or
external stimuli
intermittent
It may dissipate over Triggered by some
time or the person stimuli
may
have
it
throughout life
May
diminish
or
become permanent
Phantom Pain: if the sensation of the absent limb is painful
and disagreeable with strong paresthesias. The real cause is uncertain
and is usually experienced during the first week of several months later.
Stimuli that Relieve Pain
Stimuli that Provoke Pain
Using the prosthesis
Increase emotional stress
Stroking the stump
Exposure to cold
Heat
Local irritants to the stump
Distraction
Auriculotherapy
* Residual Limb Pain: pain arising in the residual limb from a
specific anatomical structure that can be identified.
Causes: prosthetic, neurogenic, abnormal residual limb

10
tissue, sympathetic, referred, residual limb changes.
4. Problem Related to Stump Shape
A. Edema
The most common post - surgical problem is stump edema.
Edema increases stump volume, decreases circulation, and
consequent slows wound healing. If not controlled, swelling can
lead to secondary problems such as skin breakdown, pitting
edema, reduce skin sensation, and can eventually develop into
verrucose hyperplasia.
B. Bulbous Soft Tissue
If the distal is stump bulbous, stump entry into the socket is
difficult. Bulbous soft tissue can be the result of insufficient
myofascial flap contouring or distal edema caused by inadequate
soft tissue supprt.
C. Redundant Tissues
This excessive distal soft tissues are mobile and non functional.
Distal tissue mobility makes it difficult to do the prosthesis since tissue
may result to pinching. It may also reduce position ease and decrease
prosthesis control during gait.
D. Skin Grafts
Although skin should be avoided on LE stumps they are
sometimes necessary to retain stump length especially in burn or
degloving injuries. Grafts are very sensitive and do not readily tolerate
stump socket pressures. Problems can arise with graft rejection and
infection around the graft side if weight activities are started too early.
E. Adductor Roll
This typical in transfer moral stump and is most commonly
observed in elderly females. Express adipose tissue may be prevented in
the adductor area and probably did no cause any difficulties prior to
amputation. However, during the prosthesis fitting this tissue bulges,
interfering with stump placement into the socket brim and public ramus.
The amputee sits too high in the prosthesis because the tissue bulge
prevent complete stump penetration into the socket, making the prosthesis
long.
Most adductor rolls can be easily controlled by using stockinet to
pull this soft when donning the prosthesis. However, roll always retain
problem free since the excess skin tends to perspire and cause
discomfort.
5. Problem Related to Joint Range
A. Extensive Scarring and Adhesions
A stump with extensive burn scars may demonstrate soft tissue and
skin damage resulting in permanent stump shape in the stump area
available for weight bearing distribution.
6. Complications secondary to use Prosthesis
A. Blisters
These develop as a result of friction and pressure. Fluid develops
under the point of irritation. They came from edema prone redundant
tissues at the distal stump, over the patellar tendon, and at the point
where the proximal socket brim contacts the skin.
B. Venous Restrictions
This problem is primarily caused by circulatory restrictions at the
posterior proximal stump level the long saphenous vein is compressed
because pf weight bearing on the ischial shelf.
C. Contact Dermatitis
This localized dermatitis develops as a result of skin reacting to
agents.
D. Verrucose Hyperplasia

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V.

VI.

It develops gradually and is visible at the distal end of the mature

amputation stump. It is characterized as thickened skin, pully
discoloration, mushroom like appearance, and dull sensation.
E. Sebaceous and Epidermoid Cysts
These develop only on the stumps on active prosthetic users as a
result of socket pressure, skin friction, and perspiration.
F. Bone End Sensitivity
The discomfort occurs as a complication during weight bearing
practice and if the bone end has minimal soft tissue coverage.
G. Bone Spurs
It occurs in some shred of periosteum have remained in the soft
tissue following amputation surgery. If these forms of exostoses are skin
surface at the distal stump end, they can cause discomfort.
H. Neuroma
If surrounding soft tissues does not protect neuroma, localized pain
is triggered by palpation.
PROGNOSIS
There are number of factors that may affect healing.
Postoperative infection, whether from external or internal sources is
a major concern. Individual with contaminated wounds, from injury,
infected foot ulcers, or other causes are at greater risk. Research
indicates that smoking is major deterrent to wound healing, with one study
reporting that cigarette smokers had a 2:5 higher rate of infection and
reamputation than non smokers. There is some indication that failed
attempts at limb revascularization may negatively influence healing at
below knee levels. Other factors influencing wound healing are the
severity of the vascular problems, diabetes, renal disease, and other
physiologic problems such as cardiac disease.
MEDICAL / SURGICAL MANAGEMENT
A. Basic Surgical Procedures of Amputation
General Procedure:
1. Surgeon removes part or all of the limb
- type of amputation is at the discretion of the surgeon and
the state of the extremity at the time of the amputation.
2. Allow for 1 or 2 wound healing
3. Construct a resident limb for optimum prosthetic fitting and
function.
TOURNIQUET except in ischaemic limb, the sue of tourniquet is highly
desirable
LEVEL OF AMPUTATION it should be through tissues that will heal
satisfactory and at a level that will remove the abnormal or diseased part.
The cardinal rule is to preserve all possible length consistent with good
surgical judgment.
MUSCLES they are just distal to the level of the intended home section
so that their ends will retract to that level. Beveling is done to obtain a
stump shape properly. Major muscles are stabilized by myofascial closure,
myoplasty, myodesis, or tendesis, which allows maximum retention of
function.
SKIN FLAPS the skin at the end of the stump should be mobile and is
normally sensitive. The scar should be well healed, pliable, painless, and
non adherent.
BLOOD VESSELS to achieve homeostasis, major blood vessels should
be isolated, individually ligated. Larger ones should be doubly ligated and
a single ligatable or smaller vessels. Before the amputation stump is
closed, the tourniquet should be released and all bleeding points should
be clamped and ligated.

12
BONE ENDS it should be covered good padding of soft tissue and
physiologically prepared for prosthetic wear. Bone beveling is the process
of smoothing the cut ends of bone to prevent rough edges and spurring
that interferes ambulation. Bones such as the fibula are often cut slightly
shorter for the same reason.
DRAINS meticulous hemostasis should obtain before the amputation
stump is closed. The Drain or tubes are removed 43-72 hours after
surgery.
B. Types of Surgical Amputation
1. Open Amputation (Guillotine Amputation)
- often indicated for infection. The fact that the stump is not
closed over with a skin flap allows the free drainage of purulent
or infectious material. Patient undergoing an open amputation
require antibiotic therapy and the use of strict aseptic technique
whenever the incision is cleansed and the dressing is changed.
2. Closed Amputation (Flap Amputation)
- amputation in which the stump is closed or covered by a flap of
skin sutured over the bone end of the stump. This type of
amputation is preferred when there is no evidence of infection
and consequently no need for extensive open drainage.
3. Minor Amputation
- amputation done through or distal to the metacarpus or the
metatarsus.
4. Major Amputation
- amputation is done proximal to the metatarsal or metacarpal
bones and they are design to produce a stump suitable for an
artificial limb.
5. Joint Amputation
- amputation done at the joint.
* Surgical level for the amputation is one or the most important
decisions for the amputee. The pathological process dictates most
of the decision. The viability of the remaining tissues determines
the most of the decision. The viability of the remaining tissues
determines the most distal possible level. Functional considerations
determine whether to amputate more proximally.
C. Levels of Amputation
The classical sites of election are only guidelines to
indicate an ideal site in the segment of an extremity, which satisfies the
functional requirement and physical characteristic best adapted to the
simplest available conventional prosthesis. Modern prosthesis techniques
can fit amputation at any level.
1. Amputation of the Lower Extremities
- the surgical level may be classified on an anatomical or
functional basis
- objective: create a stump optimum for weight bearing
a. Foot and Ankle
a1. Lisfrancs Amputation / Distraction
- amputation through tarsometatarsal joint that allows
function of the foot distorts muscle balance of foot
creating intractable equinos deformity.
a2. Chopart Amputation
- through the talonavicular and calcaneocuboid joints
- equinos deformity of stump develops
- similar to a foot of the gorse ans is difficult to have a
satisfactory prosthesis
a3. Symes Amputation
- involves disarticulation at the ankle joints and may

13
include removal of the medial and lateral malleoli and
distal/fibular flares
- not done in vascular conditions as higher level is
necessary due to insufficient blood supply
- allows good end bearing, the heel pad being sutured
into position over the distal end of the tibia and fibula
- prosthesis is difficult in this type
a4. Body Amputation and Pirgoff Amputation
- amputation done which include tibio calcaneal fusion
- rarely don
a5. Partial Toe
- through the metatarsophalangeal joint
a6. Toe Disarticulation
- through the metatarsophalangeal joint
a7. Partial Foot / Ray Resection
- resection of 3rd, 4th and 5th metatarsal and digits
a8. Transmetatarsal
- through the midsection of all metatarsals
b. Below Knee Amputation (BKA)
- transtibial amputation
- best done at the junction of the middle and upper thirds
of the tibia, between 8 and 18 cm. Below the tibial
plateau
b1. Short Below Knee
- less than 20% of tibial length
b2. Long Below Knee
- more than 50% of tibial length
b3. Non ischemic Limb
- the ideal level for amputation below the knee is at the
musculo tendinous junction of the gastrocnemius
muscle. The distal third of the leg is not satisfactory
because there the tissues are relatively avascular and
soft tissue padding is scanty.
- In adults, the ideal bone length for a BKA stump is 12.5
to 17.5 cm. depending on the body height. A satisfactory
rule of thumb for selecting the level of bone section is to
allow 2.5 cm. of bone length for each 30 cm. of body
height. Usually the most tibial articular surface. A stump
under 12.5 cm. long is less efficient. In a very short sump
of 8.8 cm. or less in length, it is recommended that the
entire fibula together with some muscle bulk be removed
so that stump fir easily in the prosthetic limb.
b4. Ischemic limb
- amputations performed in ischemic limbs are customarily
at a higher level, for example 10 12.5 cm. distal to the
joint line, than are amputations in non ischemic limbs.
c. Amputation Through or Just Above the Knee Joint
c1. Gritti Strokes
- a supracondylar amputation
- the patella, after the removal of its articular cartilage, is
fastened with its attached quadriceps ligament surfaces
to the cut surface of the lower end of the femur
- this gives a very durable stump with full end bearing
- the best kind of amputation
c2. Kirks Amputation
- a supracondylar tendoplastic amputation

14
-

method is carried out through the calcaneus bone of

supracondylar region of the femur below the shaft
- the quadriceps tendon which are included on the long
anterior flap is cut close to its patellar attachment grown
over the end sutured with full end bearing in all cases
- symmetrical in contours from spurs and of maximum
functional length
c3. Callander Amputation
- a supracondylar amputation with minimum tissue
dissection
- no muscle tissue is excised
- patella is removed from its bed in the quadriceps tendon
leaving patellar ligaments intact and incorporated in the
long anterior skin flap
- the cut of the supracondylar is lower here than in Kirks
which is higher
c4. Rogers Amputation
- Knee joint disarticulation with arthrodesis (surgical fusion
Of the patella in anatomical position of the patella to the
front of femur)
- no cutting of any spracondylar
- no fibula if the length of the stump is 2 inches higher
c5. Knee Disarticulation
- through the knee joint
c6. Long Above Knee
- amputation of more than 60% femoral length
d. Above Knee Amputation
- because patients knee joint is lost, it is extremely
important that stumps be long as possible to provide a
strong lever arm for control of prosthesis. The
conventional, constant friction knee joint used in the most
AK prosthesis extends for 9 10 cm. distal to end of
prosthetic socket and the bone must be amputated this
for proximal to the knee to allow room for the joint
- transfemoral amputation most commonly seen in the
elderly
- ideal length is 10 -12 inches below the greater trochanter
-

minimum stump length in which we can have control is 4

inches below the tip of greater trochanter to fit and above
knee amputation
- greater difficulty in learning to control his prosthesis and
achieving good gait since proprioception from the knee
joint is lost and he bears weight at the ischial tuberosity
- hip flexion contractures easily occurs unless prevented
shorter stump tend to become flexed and abducted
due to the strong full of tensor fascia lata
long above knee stump tend to become flexed and
abducted due to the intact abductor group which have
a mechanical advantage over the pull of the short
tensor fascia lata
e. Hip Disarticulation
- amputation through the hip joint, pelvis intact
- should be avoided because there is no substitute for
anatomical joint
f. Hemipelvectomy (Hind Quarter Ablation)
- resection of lower half of the pelvis and bears weight on

15
soft tissues and chest cage
g. Hemicorporectomy (Humpty Dumpty)
- amputation of both lower limbs and pelvis below L4/L5
* Surgical Levels of Greatest Utility:
- vascular level is relatively good
- the lower the amputation, the less energy for ambulation
1. transmetatarsal, the Symes and the standard below
knee amputation
2. ultra short below the knee amputation next best level
2. Amputation of Upper Extremity
Levels of Amputation:
Upper extremity stumps are classified by level of amputation
using terminology form that used for congenital skeletal deficiency.
First, the length of the stump must be measured. Above elbow
stumps are measured form the tip of the acromion to the bone end;
This measurement is compared to the sound side distance form
arcomion to the lateral epicondyle and is expressed as a
percentage of normal side length. Below elbow measurement is
whichever is longer in the stump, and to the ulnar styloid tip on the
sound side.
% of N
Classification
Above elbow
0
Shoulder disarticulation
0 30
Humeral neck
30 50
Short above elbow
50 90
Long above elbow
90 100
Elbow disarticulation
Below Knee
0 35
Very short below elbow
35 55
Short below elbow
55 90
Long below elbow
90 100
Wrist disarticulation
In bilateral amputations, where no normal segment retains
for comparative measurement, the normal upper arm length is
estimated by multiplying the patients height by 0.19 and normal
forearm length is estimated by multiplying by 0.21.
Objective: preserve maximum length and function since
prosthesis offer a poor substitute and cosmesis is equally important
a. Forearm and Hand
- the optimal length is 7 inches below the tip of olecranon
and it shouldnt exceed it.
- Minimum length of below elbow amputation is 3.5 inches
b. Krukenberg Amputation
- the forearm stump after a below elbow amputation is
converted into a crude pinching mechanism by
separating the lower ends of radius and ulna and cover
them with soft tissues
- no prosthesis is used and not popular because of its
unsightliness
- best expedient in blind, bilateral below amputee since it
possess both tactile sensation and pinching function
* Disarticulation through elbow gives a poor stump for
prosthesis so it is discouraged
c. Partial Hand Amputation
- creates significance functional limitation and special
prosthetic and orthotic problems. Congenital hand
deficiencies occur in many forms. Levels of loss can be
classified as follows:

16

d.

e.

f.

g.

h.
i.

j.

Transphalangeal with involvement of sparing thumb

Thenar
Transmetacarpal distal with involvement or
sparing of the thumb
Transmetacarpal
proximal
with
thumb
involvement sparing
Amputation Throughout the Wrist
- with adequate palmar skin, the carpal bones should be
retained when possible to be useful for a patient with or
without a prosthesis. The hand may be disarticulated at
the metacarpal joints or through carpus. Carpal bones
allow some flexion and extension of the distal stump and
this may be useful when a pressure is not used.
Pronation and supination is preserved.
Wrist Disarticulation
- although carpus disarticulation has occasionally been
possible, this is not often practical. Disarticulation at the
radio carpal joint is the much more common site for
total head amputation. The carpus is disarticulated at the
radio carpal wrist, this gas the advantage that the
prosthesis is need not include the elbow joint and the
pronration and supination are retained
Forearm Amputation
- as much length as possible should be preserved. If the
wrist disarticulation cannot be done, the site of election in
the forearm is the function of the lower and middle 1/3 of
the elbow. This creates and adequate level and
preserves about 2/3 of the available pronation and
supination. The usual prosthesis is hinged at the elbow
and includes a forearm socket with a wrist unit to which a
prosthetic hand/hook may be attached interchangeably.
The gook is more useful than the hand. It can be opened
by the pull of a cable attached to the harness about the
patients opposite shoulder and closed by rubber bands
about its base.
Short Below Elbow Amputation
- the most proximal useful stump measures 1.5 below the
insertion of the biceps tendon. The prosthesis for this
stump must be short to allow elbow flexion yet long
enough to hold the stump securely. This may be
accompanied with a special prosthesis
Long Below Elbow Amputation
Elbow Disarticulation
- this is uncommon. When the forearm is disarticulated at
the elbow or amputation occurs at a higher level, a
mechanical elbow joint is required to place the forearm
and terminal device in use. This device must allow free
voluntary flexion and extension activated by shoulder
harness.
Supracondylar Amputation
- above elbow amputation are most satisfactory at
this level, because above this functional efficiency
becomes less as shoulder ids approached and at least 2
of bone stump should remain below anterior axillary fold.
Although amputation may be done through the condyles
of the humerus, the most frequent site is about 2 or 2.5
above the joint line

17
k.

Short Arm Stump

- amputation may be carried out within 2.5 above the
anterior axillary fold. In amputation at the shoulder, the
head and neck of the humerus should be preserved as
possible to minimize disfigurement
l.
Forequarter or Interscapulothoracic Amputation
- severe deforming procedure with removal of scapula and
most of clavicle required for treatment of malignant
disease
m. Cineplastic Amputation
- the power of one or more of the patients muscle
transmitted by means of a small peg traversing a muscle
tunnel lined by the skin used to activate prosthetic hand
mechanism
D. Amputation in Children
- children amputees make up an interesting segment with
great rehabilitation potential
- every effort must be made to save the epiphyseal growth
centers
- Surgical ablation should be defend as possible since the
amputated limb tends to at a slower rate than the
congenitally deformed limb
Causes:
- congenital
- traumatic
- neoplastic/tumor
Objectives of Amputation and Prosthesis
- facilitate early function
- enhance appearance
- produce optimal stump for maturity
Compilation: bone overgrowth
- this overgrowth leads to skin performance and 2nd
degree low infection
- often type in humerus, fibula or tibia and unknown cause
- usual treatment is revision of stump, traction at night in
the prosthesis is an initial approach
Prosthesis
- standard type that is comfortable and simple
- consider the growth factor (intellectual capacity and
neuromuscular maturation) in prosthesis needs frequent
readjustment in the first 2 years and the 2 nd major growth
spurt is between 11 13 in girls and 13 15 in boys
Upper Limb Amputees
- provide a mitten prosthesis as early as 6 months or at
the age of sitting
Lower Limb Amputees
- provide an artificial limb at 9 months (standing age) for
the child to develop an engram or circuitry
E. Immediate Post Operative Dressing
Dressing Selection Criteria:
- Level of Amputation
- Healing Requirements
- Physicians Preference
- Surgical Technique
- Patient Compliance

18
Post operative dressings are important for some sort of edema
control in excessive edema in the residual limb, can compromise healing
and cause pain.
1. Soft Dressings
the oldest method of post surgical management and
least edema control
* Two Types:
a. Elastic wraps a dressing is applied
followed by a qauze pad and then the
compression wrap
b. Elastic shrinker sock like garments of
heavy rubber reinforced cotton
Objective: Provide protection, support and gradient pressure
Advantage: Ease of application, ability to inspect wound easily, provide
alternative wound environment, inexpensive, lightweight, available easily
laundered.
Disadvantage: Poor edema control, requires skill in application
frequent reapplication, difficult to monitor moisture, temperature, sterility
of wound surface under the dressing, may create tourniquet effect or
varied pressure to the limb, slippage of the dressing, may create pain
and apprehension.
2. Semi rigid and Rigid dressings
Semi rigid: Unna paste, felt, cotton, or polyurethane pads.
Rigids
: Plaster bandages, fiber glass casts, polymer
plastics and felt, cotton and polyurethane pads.
Objectives: Provide a relatively dry, sterile environment with appropriate
distal end pressure permitting adequate tissue fluid exchange. Prevent
excessive post surgical edema.
Advantages: Good support to the surgical site, increase comfort and
improve wound environment. Greater confidence with movement by the
amputee with less chance of injury to healing tissue. Reduction of
unnecessary wound inspection. Reduce time for stump shrinkage, allow
earlier ambulation and early fitting of a definitive prosthesis.
Disadvantages: Improper application of the dressing fails to promote
adequate circulation. Inability to quickly assess the wound to monitor
healing. Require close supervision.
* Alternative rigid dressing:
a. Rigid dressing with a window healing surgical sites that require
frequent attention can be monitored with the inclusion of a cut
out or window to the rigid dressing
b. Removable Rigid Dressing the cast is designed to protect the
surgical site with the minimal amount of plaster and is secured
by some form suspension
c. Bivalve Rigid Dressing a full length rigid dressing that has
been split longitudinally for ease of removal and is secured by
Velcro closures
3. Immediate Post operative Prosthesis (IPOP)
Materials: Unna Paste, plaster bandages, fiberglass casting material,
copolymer plastics and polyurethane foams, Prosthetic components
include an attachment plate for the pylon, an aluminum, steel, PVC or
plastic pylon and inexpensive foot/ankle assembly (SACH foot)
Objectives: Reduce the time without bipedal ambulation to a minimum
Advantages: Provides a socket and temporary prosthesis with the
psychological and physiological benefits attributed to walking.
Potentially, shorter hospital length of stay and a reduction in the
severity of phantom pain.

19
Disadvantages: Potentially, places the physically unstable amputee at
risk for falls of injury. The limited weight bearing though the residual
limb could impair the healing site, and currently no research supports
the notion that early ambulation assists in wound healing. Ambulation
could be permitted too soon. Proper application of the dressing to
provide appropriate distribution of forces at the stump/dressing
interface is frequently questioned. Inability to access the wound to
monitor healing.
Indications for rigid, semi rigid or IPOP cast change
severe pain or excessive tightness of cast
slippage, rotation or pistoning of the cast
damage to the cast
febrile patient or an odor associated with infection
4. Pneumatic Devices
Materials: double walled, clear long leg air splint with a controlled pressure
of 25 mmHG. Sterile gauze, lambs wool and stump sock cover the surgical
site.
Objectives: provide compression, early bipedal with a clear splint to monitor
the residual limb. The splint may be inflated or deflated easily
Advantages: problems associated with these splints include: air leakage,
variations in pressure and buckling of the splint if too much force is exerted.
The splints can be bulky and difficult to maneuver in bed and during
transfers. Perspiration and heat concern towards the healing environment.
5. Controlled Environment Treatment (CET)
- composed of a console that controls pressure, temperature and humidity
and sterilizes the air in the unit; and a polyvinyl transparent bag that
encases the residual limb. The bags flexibility allows active exercises of
the involved extremity as well as standing at bedside, but the hose and
machine limit bed mobility and ambulation
VII.
PT ASSESSMENT
A. Pre prosthetic Assessment Guide
1. General Medical Information
a. cause of amputation
b. associated diseases and symptoms
c. current physiological state (post-surgical cardiopulmonary
status, vital signs, duration of time out of bed, pain)
d. medications
2. Skin
a. scar (healed, invaginated, flat)
b. other lessons (size, shape, open, scar tissue)
c. moisture (moist, dry, scaly)
d. sensation (absent, diminished, hyperesthesia)
e. grafts (locations, type, healing)
f. dermatologic (psoriases, eczema, cysts)
3. Residual Limb Shape
a. bone length (below knee limbs measured from medial tibial
plateau, above knee limbs measured from ischial tuberosity or
greater trochanter)
b. soft tissue length (note redundant tissue)
c. circumferential measurements (taken as soon as dressing
allows and then taken regularly throughout the pre prosthetic
period. In below knee or Symes residual limb, measure every
5 8 cm. from the medial tibial plateau. AKA or thorough knee
amputee, measure every 8 10 cm. from greater trochanter or

20
ischial tuberosity to the end of the bone and note the hip joint

VIII.

position.
4. Residual Limb Shape
a. cylindrical, conical, bulbous
b. abnormalities (dog ears, etc.)
5. Vascularity (both limbs if amputation cause is vascular)
a. pulses (e.g. femoral, popliteal, dorsalis pedis, posterior tibial)
b. color (e.g. red, cyanotic)
c. temperature
d. edema (circumference measurement, water displacement
measurement, caliper, measures)
e. pain (type, location, duration)
f. trophic changes
6. Range of Motion
a. residual limb (specific goniometric measurements are
necessary. In BKA, hip FE, abdadd measurements are taken
early in the post-op phase. Knee F-E are taken if dressing
allows and some incisional healing occurred. In AKA, hip F-E
abd-add measurements done several days after surgery and
when dressing allows. Hip internal-external rotation is
unnecessary if there is no pathology.
b. Other extremities (gross for major joints)
7. Muscle Strength (MMT)
a. residual limb (MMT for the involved LE will wait until most healing
occurred. In BKA, good strength in hip extensors and abductors,
knee extensors and abductors are much used
b. Other extremities (gross MMT of UE and uninvolved LE is done
early post-op)
8. Neurologic
a. pain (phantom)
b. neuropathy
c. cognitive status (alert, oriented, confused)
d. emotional status (acceptance, body image)
9. Functional Status
a. transfers (e.g. bed to chair)
b. mobility (ancillary support, supervision)
c. ADLs
d. Instrumental ADL (e.g. cooking, cleaning)
PHYSICAL THERAPY MANAGEMENT
The interaction of the health care team working with the patient to
achieve the goal of prosthetic restoration and rehabilitation can be
referred to as prosthetic management. Prosthetic management can be
divided into 2 distinct segments:
A. Pre-Prosthetic Management
- further subdivided into the pre-operative care,
acute post surgical care and pre-prosthetic
prescription, check outing and training
- typically can last 6-10 weeks for the dysvascular
lower extremely amputee, shorter period forth
etraumatic LE amputee and 3-6 weeks for UE
amputee
1. Pre Operative Care
Primary goal: education and prevention of further adversity
a. Entry into the Medical System
- introduction to the medical team (physician,

21
nurse, PT, OT, orthosist and later prosthesist,
psychologist, social worker nutritionist, etc.)
- general medical care (hygiene safeguards,
medications, vital signs, and health monitoring)
- sounds limb care (protection, prevention, skin
integrity)
- reinforce supportive services available to the
amputee (family, relationships, support, group,
social work)
b. Assessment and Preparation
- Pre amputee assessment is necessary for
optimum of care to be provided
* Psychological preparation
* Physical Assessment
- sensation, ROM, strength, mobility
ambulation, cardiopulmonary function, coordination,
positioning of the residual functional assessment
ADLs and self-care skills
Teach Therapy Programs
- the therapist should teach the patient on relaxation
techniques transfer skills and proper bed limb and
conditioning exercises that improves cardiovascular
endurance should be included. The patient can be
instructed in the various stump wrapping
procedures and teach family members appropriate
assistance
Depending upon the available and general
conditions of patient, the following should be
included
- strengthening and mobilizing exercises for the lower
trunk
- rolling, sitting-up and walking to standing if possible
- strengthening of the unaffected leg for crutch
walking
The patient should also be instructed in the use of crutches
or walker and any gait to be used after surgery.
Instruct deep breathing and coughing techniques and
introduced to various respiratory equipment that may be necessary
after surgery. Introduce to the patient his post-surgical and
rehabilitation plan of care.
*The patient is often more able to absorb and comply with a
therapy program during the pre-operative period when incisional
pain, medication or apprehension are not yet present.
*Principles of surgery by Schwarts, Shires, etc., include that:
1. leg is usually kept in slightly dependent position, and
Buergers exercise may be supplied to improve the
Circulation
2. intense heat and soaks are contraindicated, and if no
infection is apparent and there is dry gangrene, wet
dressing should not be used.
3. refrigeration may be used preliminary to amputation to
improve the condition of the patient by decreasing the
metallic by-products and infectious material.
Refrigeration also relieves pain but the technique
should be employed if there is any hope of salvaging
the extremity. The techniques involve the placement

22
ice bags on the proposed level of amputation and
may require use of mild narcotics.
2. Acute Post-Operative Care
Primary Goal: healing without complications
This is the period between the amputations and the
removal of sutures for as long as 14-21 days.
The goals of treatment during this phase of care include:
a. reduce pain and edema
b. prevent contractures and secondary problems
c. prevent cardiopulmonary and general body conditioning
d. educate the patient and family
e. provide psychological support
During this time nursing staff and therapist will initiate a program which
may include:
a. Positioning to prevent edema and contracture
- proper bed positioning with stumps always being
parallel to the unaffected leg in extension
- there should be no pillow under the stump or
between the legs
b. Transfer training wheelchair mobility training and early gait
training
c. Upper extremity strengthening, particularly of shoulder
depressors and elbow extensors
d. Bed mobility with precautions for trauma to the residual limb
- mat exercises
bridging and rolling can be commenced on the
first day
- balance exercise
e. Functional activities
f. Isometric exercise to all muscle groups
g. Active range of motion exercise of all joints
h. Prophylactic respiratory care including deep breathing and
coughing
i. Cardiac monitoring and rehabilitation procedures for all patients
at risks
j. Education of the patient about skin care and protection of both
the residual limb and limbs with peripheral vascular disease
k. Encouraging discussing possible future rehabilitation plans by
the patient and family to raise questions, express fears
l. Responding to signs of severe emotional response to
amputation
B. Prosthetic Prescription, Checking-out and Training
The prosthesis must balance the amputees need for stability,
safety, mobility, durability and cosmetics. The availability must be
considered. Input from the medical team especially from the patient results
in the most appropriate prosthetics prescription.
* Probable Prosthetic Candidates:
1. readable cardiovascular reserve
2. adequate healing and skin coverage
3. good range of motion and muscle strength
4. adequate motor control and learning ability
* Prosthetic Training
After completing the final prosthetic evaluation, a period of gait
training using the prosthesis is required. Gait training of course on an outpatient basis from 1 week to 1 month or more with 5-5 visits per week. The
more proximal levels of amputation require lengthy training than distal

23
levels, longer training for upper limb than lower limb amputees, for
bilateral than unilateral amputees, for adults than for children.
Treatment Goals
a. reduce edema and shaped limb for prosthetic fir.
commonly the rehabilitation team can employ several methods to
achieve goal including 1. intermittent compression pump therapy 2.
elevation with active exercise 3. elastic wrapping of their residual
limb 4. commercially made stump shrinkers.
Elastic bandages will not only help control edema but also
shrink the bandage, a figure-eight wrap usually incorporates the
proximal joint closest to the stump. Wrapping from the distal to
proximal site should provide distal compression. The stump should
be wrapped every 4 hours or whenever the bandages loosen, slips
or bunches. An elastic stump shrinker may be used if elastic
wrapping is impractical.
b. Instruct the patient in stump hygiene.
- Before the inclusion is completely headed a whirlpool often is
helpful in slowly healing limbs or wounds that are draining.
Schedule hydrotherapy for 20 to 30 minutes once or twice daily. A
detergent or antiseptic additive such as betadine may be helpful for
cleansing. Closely monitor the water temperatures to avoid
scalding, especially if there is a vascular disease. In this case, keep
the water temperature below 90F.
After the incision is healed, soften the skin with a water
soluble cream or lanolin preparation three times daily. Gentle
massage of the distal soft tissue helps keep them mobile over the
end of the bone. Tapping the scar and distal soft tissue four times a
day often helps desensitize these areas prior to wearing the
prosthesis. Tap with the finger tips, starting slightly and increasing
pressure for about 5 minutes until mild discomfort is produced.
Good skin hygiene should be taught, using mild soap to work
on a lather and ten raising with lukewarm water. The skin should be
patted, not rubbed dry. Cleansing is recommended in the evening.
c. Increase strength of all extremities and trunk. Maintain
range of motion and prevent contractures.
- All patients should be continued on the positioning and exercises
schedule developed in acute postsurgical care. Exercise for target
muscle may be achieved by a number of approaches such as: 1.
dynamic stump exercise, 3. proprioceptive neuromuscular
facilitation, and 4. sling suspension techniques. Such technique has
its own advantages and a combined approach is usually most
helpful.
Dynamic Stump Exercises are a series of exercises with
functional emphasis. Each exercise is intended to stimulate a
particular functional activity or group of activities. The exercises are
especially demanding and stress the cardiovascular system.
For each exercise, activity is progressed from easiest to
more difficult using principles of therapeutic exercise. Initially, arch
of motion may be allowed to assist; the movements are performed
without addition of external resistance and the arch of motion
required is decreased. As skill and strength improve, these
parameters are altered making exercise more difficult. These
exercises often employ stools and sandbags in graduated sizes to
increase difficulty.
* Target Muscles to be Stressed in Training Above and Below Knee
Amputation:
Above-knee Amputation

24
1. iliopsoas
2. gluteus maxumus
3. external hip rotators
4. internal hip rotators
5. gluteus medius
6. abductor complex
7. pelvic and trunk rotators
8. abdominal muscles
9. shoulder depressors and elbow extensors
Below-knee Amputation
All muscles listed under above-knee amputations,
plus hamstrings and quadriceps.
d.
Teach independence in ambulation (without
prosthesis). It is one of the most critical to the patient
because it develops the pre-requisite skills for
prosthetic usage. It may also serve as the terminal
phase of treatment for patients who will be discharged
ambulatory without prosthesis.
The preprosthetic ambulation program has its
objectives development of an independent gait
without prosthesis. The approach utilized by the
physical therapist includes:
1. a mat program including activities that are preparatory
to standing in the parallel bars.
2. Gait training progressing from parallel bars to
crutches or walker.
to crutches or walker.
The patient with a unilateral leg amputation usually can
begin walking before prosthesis is fitted by balancing on
one leg with the support of the forearm crutches. The
bilateral amputee is trained in wheel chair transfers
* Physical Therapy Management
1. Management of Contractures
While sutures are still in place, encourage the
patient to do active ROM exercise of the proximal
joints.
Patients with upper extremity amputation will
benefit from the following exercises involving the shoulder
complex:
a. Scapular abduction: reach as far forward as possible with
both arms
b. Humeral Flexion: lift the arms as far forward above the
head as possible
c. Shoulder elevation: try to pinch the spine with both
sapulae
d. Humeral Extension: with the arms at the side, reach as far
backward as possible
e. Humeral rotation: rotate the humerus inward and outward
Hold each exercise for a slow count of five. These
exercises should be done every few hours in repition of ten,
with deliberate extension, forearm pronation, and supination
exercises.
2. Management of Stump Complications
Conservative
physical
therapeutic
treatment
techniques used to treat stump would aim toward increasing
circulation and thereby promoting healing. These include:

25
Ultraviolet irradiation: ultra violet rays gave a
physiological effect on the skin. Depending on the dosage
they increase circulation cause erythema, and kill bacterial
growth. Growth of epithelial cells, antibiotic effects on
surface. Use E1 progressed daily around wound or E3/E4 on
wound unprogress.
Whirlpool bath: whirlpool bath immersion is used to:
Stimulate stump circulation
Help desensitize the tender-stamp
Provide gently rinsing debridement of the
wound
Disinfect the wound
Contribute to a general feeling of well being
Wound taping: this technique of wound support is
indicated for suture line splits and small open wounds. It
ensures that the amputee can proceed ambulate it on and
stabilize the surrounding stump tissues.
Stump immobilization: in early post-operative stages,
when it becomes evident that healing will not occur by
primary intention. The rigid dressing is reapplied. This is nonweight-bearing resting cast promotes healing by protecting
the wound from external trauma, controlling edema and
prevention tissue mobility temperature is 33-36C, extremity
is immerse, agitators turn on giving heat, massage and
debridement.
Topical medication can be used to further stimulate
wound healing and/or oral antibiotics to combat any infection
that may be present. Some common topical medications that
may be used are:
10. Hygeol (dilute NaCl solution 1%)
11. Saylon (chlorohexidine gluconate-centrimide)
12. Providine Betadine
13. Hydrogen peroxide
14. Cicatrin
3. Management of patient with Phantom pain
a. pre-operatively, inform patient about the
phantom sensation which is normal and not
harmful
b. post-operatively,
examine
the
stumps
appearance, sensation and function
c. observe proper post-operative care
d. for a healed stump wound, instruct patient to
massage it with an emollient lotion and apply
tincture of benzion afterward to toughen the skin.
Patient can also do gentle pounding or slapping
of the stump or use chemical vibrator without
traumatizing the scar
e. exercise the stump muscles through imaginary
movement of phantom limb
f. provide a functional as well as cosmetic
prosthesis as soon as possible to reduce or
relieve phantom pain
g. a number of measures may block neural
conduction and relieve the phantom pain: e.g.
ethyl chloride spray

26
h. many neurosurgical procedure have been
advocated but none is permanent. Anterolateral
cordotomy had been the best reported results.
i. Psychiatric treatment may be necessary in some
j. When any procedures relieves the pain,
resumed the prescribed exercises, massage and
use of prosthesis to decrease likelihood of
recurrence
4. Management related to Stump shape problems
a. Edema for control, apply bandaging
techniques,
shrinkers
socks,
intermittent
compression pumping, and pneumatic walking
aid
b. Skin grafts treatment aims towards
maintenance of the grafted tissue and prevention
of skin contractures. Small blisters can be kept
clean treated topically.
c. Adductor roll application of bandaging
techniques, and in rare occasions, surgical
removal is indicated
5. Management related to Joint Range Problem
a. Extensive Scarring and Adhesions treatment
include prophylaxis, pain relief, manual stretch
technique, active exercise, ambulation and
splinting
6. Management related to Prosthetic Problems
a. Blisters physical therapy measures include
dressing
thickness,
socket
adjustments,
restriction pf weight bearing progression by
keeping the amputee on the parallel bars, and
stop weight bearing activities for patient with
severe
b. Venous Restriction socket alterations are
indicated
c. Contact Dermatitis alleviated by the elimination
of the source of the irritant
d. Verrucose Hyperplasia improved by providing
distal contact accompanied by some weight
bearing
e. Sebacous Cysts, Epidermoid Cysts treatment
include surgical management by incision and
drainage, antibiotic therapy, UV radiation
f. Bone Spurs revision or filling of the bone end
maybe necessary to allow pain-free ambulation
g. Neuroma conservative treatment include
application of TENS and US
* Factors to Consider for a Successful Rehabilitation
Good and ideal stump
Functional well fitted prosthesis
Proper training
Sound psychological judgment
* Functional Classification of Amputees
Class 1 Full Restoration: the individual is
functionally equivalent to normal; he is an essentially
disabled individual, but can do his former job with no
restriction; he also can compete in sports and return to
former social life.

27
Class 2 Partial Restoration: the artificial limb makes
the individual completely functional; he is able to work and
engage in sports and social activities but on selective basis
Class 3 Self-care Plus: here the individual is disable
and has physical limitations because they cant endure long
standing and too much walking. This class requires frequent
adjustment of their prosthesis.
Class 4 Self Care Minus: this needs the help from
others because this is reversely disable individual, cannot go
up and down the stairs without the assistance of other
people or crutch.
Class 5 Cosmetic Plus: the amputee is better off
with a prosthesis, however, he values this for personal
reasons, for example, appearance, because he wishes to
meet the public even though he requires considerable help.
Class 6 Not Feasible: here, the amputee does not
have prosthesis because it is not prescribed to him.
However, he should be trained to do so as they can form a
wheelchair in the way of self care activities.
Formulae for the levels of Amputation:
A. Upper extremity
if unilateral:
Percentage from normal
a)
Transhumeral
Classification
0
Shoulder disarticulation
0-30
Humeral neck
30-50
Short transhumeral stump
50-90
Long transhumeral stump
Elbow disarticulation
b)
Transaradio-ulnar
Classification
0-35
Very short transradio-ulnar
stump
35-55
Short transradio-ulnar stump
55-90
Transradio-ulnar stump
90-100
Wrist disarticulation
100
Transcarpal
* measurement
Transhumeral stump normal measurement from tip of the
acromion process to the lateral epicondyle
Transradio-ulnar stump normal measurement: from the
medial epicondyle to ulnar styloid
%age = length of the residual limb x 100%
length of the sound limb
if bilateral, then:
Upper arm = patients height in cm. X 0.19
Forearm = patients height in cm. X 0.21
B. Lower Extremity
Percentage from normal
a)
Transfemoral
Classification
0-35
Short transfemoral stump
35-60
Medium transfemoral stump
60-100
Long transfemoral stump
b)

28
Transtibio-fubular
0-20
20-50
50-100

Classification
Very short transtibio-fibular
stump
Short transtibio-fibular stump
Long transtibio-fibular stump

* measurement
Transfemoral stump = normal measurement: periunium to medial
femolar condyle
Transtibio-fibular stump = normal measurement: medial tibial
plateau to medial malleolus
%age = length of residual limb x 100
length of sound limb
Levels of Impairment
Upper Extremity
%age of impairment
Thumb
22%
Index finger
14%
Middle finger
11%
Ring/little finger
5%
Wrist
54%
Elbow
57%
Shoulder
60%
Forequarter
70%
All fingers except thumb
32%
Lower Extremity
Big toe
Other toes
Choparts Amputation
Symes Amputation
Energy Requirements:
Type of Amputation
Unilateral trsntibio-fibular
Bilateral transtibio-fibular
Unilateral transfemoral
Bilateral transfemoral
Unilateral transfemoral/unilateral
transtibio-fibular

%age of impairment
5%
2% (each)
21%
28%
METS (% greater from normal)
10-40%
41%
65%
110%
75%

THEORIES ON ETIOLOGY OF PHANTOM SENSATION OR PHANTOM PAIN

NEUROMATRIX THEORY: Melzacks four premises for the neuromatrix theory of
phantom sensation:
1) A network of neutrons that extends throughout the widespread areas of the
brain, composing the anatomical substrate of physical self. The body we
normally feel is subserved by the same neuronal process in the brain. These
processes in the brain can act in the absence of any input.
2) A genetically determined substrate that is modified by sensory experience. All
sensation that we normally feel can be felt in the absence of any input from the
body. Origins of the patterns lie within the neuronal network of the brain and
the quality of the patterns are dependent on the quality of experienced.
3) Laws of modulating input from limb or body causes the neuromatrix to produce
abnormal signature patterns created by patterns that flow through the
neuromatrix. The body is perceived as a unit and is identified as the self,
distinct from other people.

29
4) Subserves the physiological qualities of heat or burning the most common
qualities of phantom pain. The brain processes that underlie the body
self are
built in genetic specification, although this can be modified.