AMPUTATION

Amputation is the removal of a limb by trauma, medical illness, or surgery. As a surgical measure, it
is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In
some cases, it is carried out on individuals as a preventative surgery for such problems. A special
case is that of congenital amputation, a congenital disorder, where fetal limbs have been cut off by
constrictive bands. In some countries, amputation of the hands, feet or other body parts is or was
used as a form of punishment for people who committed crimes.[1][2][3] Amputation has also been used
as a tactic in war and acts of terrorism; it may also occur as a war injury. In some cultures and
religions, minor amputations or mutilations are considered a ritual accomplishment.

CLINICAL MANIFESTATION OF AMPUTATION

The most common reason for amputation of a limb is peripheral artery
disease, or poor circulation. Peripheral arterial disease is a dangerous
hardening of arteries restricting blood flow putting you at risk for serious
complications. Without adequate blood flow, cells within the limb are
deprived of oxygen normally found within the bloodstream. Without this vital
nutrient, the deprived tissue begins to die and infection may set in. Additional
reasons for amputation could include:

 Severe injury or trauma

 Cancerous tumor
 Infection
 Neuroma or thickening of nerve tissue
 Frostbite

The Premier Surgical Limb Preservation Clinic is committed to the prompt

care of patients at risk of limb loss due to peripheral artery disease, diabetes,
and ischemia. An estimated 65% of amputations are considered preventable
and prevention is our primary goal. With early detection and rapid treatment
as critical steps to limb preservation the expert staff of Premier Surgical Limb
Preservation Clinic offers the following signs and symptoms to look for if
you have a condition putting you at risk for limb loss:

1. Intense pain or numbness in the limb while not moving

2. Sores or wounds unable to heal or heal very slowly
3. Gangrene
4. Shiny, smooth, dry skin on the limb
5. Thickening of toenails or nails
6. Absent or weakened pulse in the limb
 7. An infection in the limb unresponsive to antibiotics

If you have peripheral arterial disease or diabetes and begin to experience

symptoms listed above, seek treatment immediately. The sooner blood flow
can be restored to your limb, the more likely you will be to prevent
amputation.

“Our team works to develop and implement a timely and aggressive

treatment plan to all patients within the Limb Preservation Clinic,” says C.
Scott Callicutt, MD, FACS. “Life in general becomes much harder following
an amputation in regards to physical exertion and emotional state. In addition
the risk of death increases drastically if a lower extremity is amputated. We
are committed to saving limbs and more importantly saving lives by offering
immediate, state-of-the-art care from initial evaluation to rehabilitation.

NURSING MGT AFTER AMPUTATION

Richard L. Pullen, Jr., EdD, RN, replies: Lower extremity amputations are most commonly
performed because of advanced chronic peripheral arterial disease. Amputation can relieve signs
and symptoms, improve function, and maintain or improve the patient's quality of life.1 Most
postoperative nursing care priorities are the same as for any surgical patient: assessing and
maintaining the patient's airway, breathing, and circulation; monitoring vital signs; managing pain;
taking steps to prevent respiratory complications and venous thromboembolism; and watching for
signs and symptoms of hemorrhage.

After surgery, the patient will have a soft dressing or a rigid dressing made of fiberglass or plaster.
Assess the surgical dressing for integrity and drainage. Elevate the stump for the first 24 to 48
hours.2

Move and turn the patient gently and slowly to prevent severe muscle spasms. Reposition the
patient every 2 hours, turning the patient from side to side and prone, if possible. Lying prone helps
reduce hip flexion contractures.2 Avoid placing pillows between the patient's legs or under the
back.2

Unwrap the stump dressing every 4 to 6 hours for the first 2 days postoperatively as prescribed and
then at least once daily. Assess the stump for signs and symptoms of infection and skin irritation or
breakdown. Assess the color, temperature, and most proximal pulse on the stump before rewrapping
it, comparing findings to the contralateral extremity.

Before rewrapping the stump, provide periwound skin care as ordered, but avoid lotion. Wrap the
stump when it's elevated to prevent edema and vascular stasis. Follow your facility's policy for
replacing the bandage, such as every 2 to 4 days or sooner if it becomes soiled.
 Help the patient perform range-of-motion and muscle-strengthening exercises. Encourage the
patient to push the residual limb into a soft pillow, then into a firmer pillow, and finally against a hard
surface to prepare for prosthesis fitting and to reduce the incidence of phantom limb pain and
sensation.1

Encourage the patient to eat a well-balanced diet. Provide emotional support and patient teaching to
help your patient deal with altered body image and lifestyle changes. Help with the grieving process.

MEDICAL MANAGEMENT OF AMPUTATION

Amputation Overview
IN THIS ARTICLE

 Reasons for Amputation

 The Amputation Procedure
 Recovery From Amputation
Amputation is the surgical removal of all or part of a limb
or extremity such as an arm, leg, foot, hand, toe, or
finger.
About 1.8 million Americans are living with amputations.
Amputation of the leg -- either above or below the knee --
is the most common amputation surgery.

Reasons for Amputation

There are many reasons an amputation may be necessary.
The most common is poor circulation because of damage
or narrowing of the arteries, called peripheral arterial
disease. Without adequate blood flow, the body's cells
cannot get oxygen and nutrients they need from the
bloodstream. As a result, the affected tissue begins to die
and infection may set in.
Other causes for amputation may include:
  Severe injury (from a vehicle accident or serious burn,
for example)
 Cancerous tumor in the bone or muscle of the limb
 Serious infection that does not get better
with antibiotics or other treatment
 Thickening of nerve tissue, called a neuroma
 Frostbite
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The Amputation Procedure

An amputation usually requires a hospital stay of five to 14
days or more, depending on the surgery and
complications. The procedure itself may vary, depending
on the limb or extremity being amputated and the
patient's general health.
Amputation may be done under general anesthesia
(meaning the patient is asleep) or with spinal anesthesia,
which numbs the body from the waist down.
When performing an amputation, the surgeon removes all
damaged tissue while leaving as much healthy tissue as
possible.
A doctor may use several methods to determine where to
cut and how much tissue to remove. These include:

 Checking for a pulse close to where the surgeon is

planning to cut
 Comparing skin temperatures of the affected limb with
those of a healthy limb
 Looking for areas of reddened skin
 Checking to see if the skin near the site where the
surgeon is planning to cut is still sensitive to touch

During the procedure itself, the surgeon will:

 Remove the diseased tissue and any crushed bone

 Smooth uneven areas of bone
 Seal off blood vessels and nerves
 Cut and shape muscles so that the stump, or end of
the limb, will be able to have an artificial limb
(prosthesis) attached to it
The surgeon may choose to close the wound right away by sewing the skin
flaps (called a closed amputation). Or the surgeon may leave the site open for
several days in case there's a need to remove additional tissue.

The surgical team then places a sterile dressing on the wound and may place
a stocking over the stump to hold drainage tubes or bandages. The doctor
may place the limb in traction, in which a device holds it in position, or may
use a splint.

Recovery From Amputation

Recovery from amputation depends on the type of procedure and anesthesia
used.

In the hospital, the staff changes the dressings on the wound or teaches the
patient to change them. The doctor monitors wound healing and any
conditions that might interfere with healing, such as diabetes or hardening of
the arteries. The doctor prescribes medications to ease pain and help prevent
infection.

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If the patient has problems with phantom pain (a sense of pain in the
amputated limb) or grief over the lost limb, the doctor will prescribe
medication and/or counseling, as necessary.

Physical therapy, beginning with gentle, stretching exercises, often begins

soon after surgery. Practice with the artificial limb may begin as soon as 10 to
14 days after surgery.

Ideally, the wound should fully heal in about four to eight weeks. But the
physical and emotional adjustment to losing a limb can be a long process.
Long-term recovery and rehabilitation will include:

Exercises to improve muscle strength and control

Activities to help restore the ability to carry out daily activities and promote
independence

Use of artificial limbs and assistive devices

Emotional support, including counseling, to help with grief over the loss of
the limb and adjustment to the new body image

COMPLICATIONS OF AMPUTATION

Amputation
An amputation is the surgical removal of part of the body, such
as an arm or leg.
 This topic may be helpful if you or a member of your family has recently
had an amputation or is about to have one.

Why amputation may be needed

An amputation may be needed if:
 you have a severe infection in your limb
 your limb has been affected by gangrene (often as a result of peripheral
arterial disease)
 there's serious trauma to your limb, such as a crush or blast wound
 your limb is deformed and has limited movement and function

Assessment before surgery

Unless you need to have an emergency amputation, you'll be fully
assessed before surgery to identify the most suitable type of amputation
and any factors that may affect your rehabilitation.

The assessment is likely to include:

 a thorough medical examination – assessing your physical condition,
nutritional status, bowel and bladder function, your cardiovascular
system (heart, blood and blood vessels) and your respiratory system
(lungs and airways)
 an assessment of the condition and function of your healthy limb –
removing one limb can place extra strain on the remaining limb, so it's
important to look after the healthy limb
 a psychological assessment – to determine how well you'll cope with the
psychological and emotional impact of amputation, and whether you'll
need additional support
 an assessment of your home, work and social environments – to
determine whether any additional provisions will need to be made to help
you cope

You'll also be introduced to a physiotherapist, who will be involved in

your post-operative care. A prosthetist (a specialist in prosthetic limbs)
will advise you about the type and function of prosthetic limbs or other
devices available.

If you're having a planned amputation, you might find it reassuring to talk

to someone who's had a similar type of amputation. A member of your
care team may be able to put you in touch with someone.

How amputations are carried out

Amputations can be carried out under general anaesthetic (where you're
unconscious) or using an epidural anaesthetic (which numbs the lower
half of the body).

Once the limb has been removed, a number of additional techniques can
be used to help improve the function of the remaining limb and reduce
the risk of complications.

These include shortening and smoothing the bone in your remaining limb
so it's covered by an adequate amount of soft tissue and muscle, and
stitching the remaining muscle to the bones to help strengthen your
remaining limb (a technique known as myodesis).

After the amputation, your wound will be sealed with stitches or surgical
staples. It will be covered with a bandage and a tube may be placed
under your skin to drain away any excess fluid. The bandage will usually
need to be kept in place for a few days to reduce the risk of infection.
Recovering after an amputation
After surgery, you'll usually be given oxygen through a mask and fluids
through a drip for the first few days while you recover on the ward.

A small flexible tube (a urinary catheter) may be placed in your bladder

during surgery to drain away urine. This means you won't need to worry
about going to the toilet for the first few days after surgery.

The site of the operation may be painful, so you'll be given painkillers if

you need them. Tell a member of your care team if the painkillers aren't
working, as you may need a larger dose or a stronger painkiller. A small
tube may be used to deliver local anaesthetic to the nerves in your
stump to help reduce pain.

Your physiotherapist will teach you some exercises to help prevent blood
clots and improve your blood supply while you're recovering in hospital.

Compression garments
You'll notice swelling (oedema) of your stump after surgery. This is
normal and it may continue after you've been discharged.

Using a compression garment will help with swelling and the shape of
the stump. It may also reduce phantom pain and help support the limb.

You'll be fitted with a compression garment once your wound has

healed. It should be worn every day, but taken off at bedtime. You
should be given at least two garments, which should be washed
regularly.

Rehabilitation
Physical rehabilitation is an important part of the recovery process. It can
be a long, difficult and frustrating process, but it's important to persevere.
After rehabilitation, you should be able to return to work and other
activities.

Your rehabilitation programme will be tailored to your individual needs

and requirements, and will aim to allow you to carry out as many of your
normal activities as possible.

You'll work closely with physiotherapists and occupational therapists who

will discuss with you what you'd like to achieve from rehabilitation so that
some realistic goals can be set.

Your rehabilitation programme will usually start within a few days of

surgery, beginning with some simple exercises you can do while lying
down or sitting. If you've had a leg amputation, you'll be encouraged to
move around as soon as possible using a wheelchair.

You'll also be taught "transfer techniques" to help you move around

more easily, such as how to get into a wheelchair from your bed.

Once your wound has started to heal, you may start working on an
exercise programme with a physiotherapist in the hospital gym to help
you maintain your mobility and muscle strength.

If you have a prosthetic limb fitted (see below), your physiotherapist will
teach you how to use it – for example, how to walk on a prosthetic leg or
grip with a prosthetic hand.

Going home and follow-up

The length of time it will take before you're ready to go home will depend
on the type of amputation you've had and your general state of health.
Before you're discharged from hospital, an occupational therapist may
arrange to visit you at home to see whether your home environment
needs to be adapted to make it more accessible.

For example, you may need a wheelchair ramp or a stairlift. If these

types of modifications are required, the issue can be referred to your
local social services department. Read about mobility, wheelchairs and
scooters and assessing your care and support needs.

It can take several months before you're fitted with a prosthetic limb (if
you're a suitable for one), so you may be given a wheelchair to help you
get around if you've had a lower limb amputation.

You'll probably need to attend a follow-up appointment a few weeks after

being discharged to discuss how well you're coping at home and
whether you require additional help, support or equipment.

At your appointment, you may also be given details of your nearest

amputee support group, made up of both healthcare professionals and
people living with an amputation.

Prosthetics
After an amputation, you may be able to have a prosthetic limb fitted.

Prosthetic limbs aren't suitable for everyone who's had an amputation

because an extensive course of physiotherapy and rehabilitation is
required (see below).

Adjusting to life with a prosthetic limb takes a considerable amount of

energy because you have to compensate for the loss of muscle and
bone in the amputated limb.

This is why frail people or those with a serious health condition, such
as heart disease, may not be suitable for a prosthetic limb.
 If you're able to have a prosthetic limb, the type of limb that's
recommended for you will depend on:
 the type of amputation you had
 the amount of muscle strength in the remaining section of the limb
 your general state of health
 tasks the prosthetic limb will be expected to perform
 whether you want the limb to look as real as possible or whether you're
more concerned with function

If it's thought that you would find it difficult to withstand the strain of using
a prosthetic limb, a purely cosmetic limb may be recommended. This is a
limb that looks like a real limb, but can't be used.

It's possible to have a prosthetic limb that's both physically realistic and
functional, but there may have to be an element of compromise between
the two.

Preparing to have a prosthetic limb fitted

If a prosthetic limb is suitable for you, you'll begin a programme of
activities while still in hospital to prepare for the prosthetic.

Before a prosthetic limb is fitted, the skin covering your stump may be
made less sensitive (known as desensitisation). This will make the
prosthetic more comfortable to wear.

Skin desensitisation involves the following steps:

 gently tapping the skin with a face cloth
 using compression bandages to help reduce swelling and prevent a
build-up of fluid inside and around your stump
 rubbing and pulling the skin around your bone to prevent excessive
scarring
 Your physiotherapist will teach you a range of exercises to strengthen
the muscles in your remaining limb and improve your general energy
levels, so you're able to cope better with the demands of an artificial
limb.

Depending on what's available in your local area, it can be several

months before you get your first appointment with a prosthetist
(specialist in prosthetic limbs).

Stump care
It's very important to keep the skin on the surface of your stump clean to
reduce the risk of it becoming irritated or infected.

Gently wash your stump at least once a day (more frequently in hot
weather) with mild unscented soap and warm water, and dry it carefully.

If you have a prosthetic limb, you should also regularly clean the socket
using soap and warm water.

When taking a bath, avoid leaving your stump submerged in water for
long periods because the water will soften the skin on your stump,
making it more vulnerable to injury.

If your skin becomes dry, use a moisturising cream before bedtime or

when you're not wearing your prosthesis.

Some people find wearing one or more socks around their stump helps
absorb sweat and reduces skin irritation. The size of your stump may
change as the swelling goes down, so the number of socks you need
to use may vary. You should change the socks every day.

Check your stump carefully every day for signs of infection, such as:
 warm, red and tender skin
 discharge of fluid or pus
 increasing swelling

Contact your care team for advice if you think you may be developing a
skin infection.

Caring for your remaining limb

After having a leg or foot amputated, it's very important to avoid injuring
your remaining "good" leg and foot, particularly if your amputation was
needed because of diabetes. Your remaining leg and foot may also be at
risk.

Avoid wearing poorly fitting footwear and ensure that an appropriately

trained healthcare professional, such as a podiatrist, is involved in the
care of your remaining foot. You should also be offered a regular review
of your foot by the foot care team.

Read more about diabetes and foot care.

Complications
Like any type of surgery, an amputation carries a risk of complications. It
also carries a risk of additional problems directly related to the loss of a
limb.

There are a number of factors that influence the risk of complications

from amputation, such as your age, the type of amputation you've had,
and your general health.

The risk of serious complications is lower in planned amputations than in

emergency amputations.

Complications associated with having an amputation include:

 heart complications – such as heart attack
 deep vein thrombosis (DVT)
 slow wound healing and wound infection
 pneumonia
 stump and "phantom limb" pain

In some cases, further surgery may be needed to correct problems that

develop or to help relieve pain. For example, if neuromas (thickened
nerve tissue) are thought to be causing pain, the affected cluster of
nerves may need to be removed.

Stump and "phantom limb" pain

Many people who have an amputation experience some degree of
stump pain or "phantom limb" pain.

Phantom limb sensations are sensations that seem to be coming from

the amputated limb. Occasionally, these can be painful (phantom limb
pain).

The term "phantom" doesn't mean the painful symptoms are imaginary.
Phantom limb pain is a real phenomenon, which has been confirmed
using brain imaging scans to study how nerve signals are transmitted to
the brain.

The symptoms of phantom limb pain can range from mild to severe.
Some people have described brief "flashes" of mild pain, similar to an
electric shock, that last for a few seconds. Others have described
constant severe pain.

Stump pain can have many different causes, including rubbing or sores
where the stump touches a prosthetic limb, nerve damage during
surgery and the development of neuromas.

Treating stump and phantom limb pain

 Stump and phantom limb pain will usually improve over time, but
treatments are available to help relieve the symptoms.

Medications

Medications that may be used to help relieve pain include:

 non-steroidal anti-inflammatory drugs (NSAIDs) – such as ibuprofen
 anticonvulsants – such as carbamazepine or gabapentin
 antidepressants – such as amitriptyline or nortriptyline (these
medications work directly on the nerves in your leg)
 opioids – such as codeine or morphine
 corticosteroid or local anaesthetic injections

Self-help measures and complementary therapy

There are several non-invasive techniques that may help relieve pain in
some people. They include:
 checking the fit of your prosthesis and making adjustments to make it
feel more comfortable
 applying heat or cold to your limb, such as using heat or ice packs, rubs
and creams
 massage – to increase circulation and stimulate muscles
 acupuncture – thought to stimulate the nervous system and relieve pain
 transcutaneous electrical nerve stimulation (TENS) – where a small,
battery-operated device is used to deliver electrical impulses to the
affected area of your body, to block or reduce pain signals
 mental imagery (see below)

Research has shown that people who spend 40 minutes a day imagining
using their phantom limb, such as stretching out their "fingers" or
bunching up their "toes", experience a reduction in pain symptoms.
 This may be related to the central theory of phantom limb pain (that the
brain is looking to receive feedback from the amputated limb), and these
mental exercises may provide an effective substitution for this missing
feedback.

Another technique, known as mirror visual feedback, involves using a

mirror to create a reflection of the other limb. Some people find that
exercising and moving their other limb can help relieve the pain from a
phantom limb.

Psychological impact of amputation

The loss of a limb can have a considerable psychological impact. Many
people who've had an amputation report feeling emotions such as grief
and bereavement, similar to experiencing the death of a loved one.

Coming to terms with the psychological impact of an amputation is

therefore often as important as coping with the physical demands.

Having an amputation can have a considerable psychological impact for

three main reasons:
 you have to cope with the loss of sensation from your amputated limb
 you have to cope with the loss of function from your amputated limb
 your sense of body image, and other people's perception of your body
image, has changed

Negative thoughts and emotions are common after an amputation. This

is particularly true in people who've had an emergency amputation
because they don't have time to mentally prepare for the effects of
surgery.

Common negative emotions and thoughts experienced by people after

an amputation include:
 depression
 anxiety
 denial (refusing to accept that they need to make changes, such as
having physiotherapy, to adapt to life with an amputation)
 grief
 feeling suicidal

People who've had an amputation as a result of trauma (particularly

members of the armed forces) also have an increased risk of
developing post-traumatic stress disorder (PTSD).

Talk to your care team about your thoughts and feelings, particularly if
you're feeling depressed or suicidal. You may need additional treatment,
such as antidepressants or counselling, to improve your ability to cope
after having an amputation.

Help and support

Being told you need to have a limb amputated can be a devastating and
frightening experience. Adjusting to life after an amputation can be
challenging, but many people enjoy a good quality of life once they have
managed to adapt.

You may find it useful to contact a support group for people living with
amputations. The Limbless Association can provide you with information
and advice, as well as the details of various local support groups. Its
phone number is 0800 644 0185 (Monday to Friday, 9am to 5pm).

You may also find the Douglas Bader Foundation (DBF) a useful source
of information and advice.