AMPUTATION PROSTHESIS AND REHABILITATION

DEFINITION

Amputation is the partial or complete removal of an affected body part usually an extremity

CLINICAL INDICATIONS

• Diabetes mellitus resulting in gas gangrene
• Trauma especially crush injuries, thermal Injuries like Burns & electric burns
• Chronic osteomyelitis
• Malignant tumor of the bone
• Circulatory Impairment like Peripheral vascular diseases
• Congenital deformities of the bone especially in the extremities
• Infarction(Decreased Oxygen supply)
• Accidents resulting in problems with vascular and neuronal supply
• Uncontrolled or wide spread Infection in the extremity like gas gangrene, Osteomyelitis

LEVELS OF AMPUTATION

IN UPPER EXTREMITY

• Shoulder Disarticulation: It is removal of the upper extremity from the shoulder Joint.
• Above Elbow Amputation: It is removal of the upper extremity from the upper arm at the level above the elbow Joint.
• Elbow disarticulation: It is the removal of the upper extremity from the elbow joint.
• Below elbow Amputation: It is removal of the extremity at the level below the elbow Joint.
• Wrist disarticulation: It is removal of the wrist from the wrist Joint.
• Ray Amputation: It is removal of fingers in the hands

IN LOWER EXTREMITY

• Hip Disarticulation: It is removal of the lower extremity at the level of hip joint.
• Above knee amputation: It is the removal of the limb at the level anywhere above the knee joint.
• Knee Disarticulation: It is the removal of the limb at the level of Knee Joint.
• Below knee amputation : It is the removal of the limb at the level anywhere below the knee joint.
• Syme amputation: It is  the removal of the legs at the level of ankle Joint also called as modified ankle disarticulation. It is performed in extensive foot trauma and produces painless durable extremity and can withstand full weight bearing.
• Trans-metatarsal Amputation: It is removal of the toes in the foot

CLINICAL MANIFESTATIONS/ COMPLICATIONS OF AMPUTATION:

• Loss of Sensation
• Pallor
• Inadequate Circulation leading to cyanosis & Ischemia or necrosis
• Local & Systemic Manifestations like redness, ulceration, pus etc.
• Phantom limb pain : numbness and painful sensation in the area severed of by the peripheral nerves.
• Hemorrhage
• Infection
• Skin breakdown
• Joint contractures

DIAGNOSTIC FINDINGS TO ASSESS THE NEED FOR AMPUTATION

• History regarding crush/ Sport Injuries, Accidents, Infection, Gangrene etc.
• Physical Examination to assess the color changes, skin temperature & Sensory function of the affected Extremity
• Peripheral pulses Monitoring to determine the circulation in the affected Extremity
• Arteriography: to monitor the blood flow in the arteries
• Venography: It is done to determine the venous drainage in the affected extremity
• Plethysmography: It is done to measure the changes in the blood flow to an organ or extremity

PRE-OPERATIVE MANAGEMENT:

• Provide psychological support to client & family members
• Obtain Informed Consent from the client or significant caregivers
• Do all Investigations like blood test & Imaging studies as per the surgeon or Anesthetist prescription
• Obtain Anesthetic consent prior to the surgery
• Teach the client on the need for prosthesis after amputation & information is provided about mobility training exercises
• Identify & inform the the client about the level of amputation that is required
• Teach all post operative exercises to be performed according to the client's level of Amputation
• Provide Information on positioning of the residual limb & support and care that will be needed in the post-operative period
• Inform the client that phantom limb sensation will be present post-operatively and will subside ad the recover progresses
• Make sure all care is provided as per the pre-operative checklist and recorded accurately

POST-OPERATIVE MANAGEMENT

• Assess & Monitor the vital signs & hemodynamic parameters continuously and dressings are checked frequently for soakage & excessive bleeding
• Careful Attention is needed in practicing aseptic technique during handling the operated site while performing surgical dressing
• Monitor the Surgical site for Infection, color changes, sensation & pus formation etc.
• Rigid plaster bandage supported with plaster must be used for dressing post-operatively
• Teach the patient on the need for prosthesis & it must be applied only after complete healing of the amputated limb
• Provide Information that weight bearing can be done using the prosthesis
• Advice the client to wear compression bandage every time except during exercise
• Physical therapy has to be started earlier to prevent contractures of the limb
• Advice the client to avoid dangling of the residual limb when in bed to prevent Edema
• Crutch walking is demonstrated and made to practice as soon as patient is physically stable
• Encourage the client to do exercises at the same time give Information that initial periods of Exercise should not exceed 5 minutes to avoid disruption in the tissue healing process.
• Provide careful Information to the client and significant caregivers regarding the residual limb care, ambulation, prevention of contractures and follow up care

NURSING MANAGEMENT

• Assess the site for infection, bleeding and edema.
• Assess the vital signs of the patient.
• Do an doppler ultrasound of the extremity to assess the extremity for circulation.
• Monitor for drain tubes for the amount of bleeding.
• Remove the drain tubes if present within 24-48 hrs.
• Do not place pillow below the stump as it may cause flexion deformity of the hip.
• Help the client for early mobilization with crutches and fitting artificial limbs.
• Remove the skin sutures in 10th day.
• Meet all the hygienic needs of the patient.
• Perform all procedures at the bedside of the patient.
• Provide psychological support to the patient and teach the patient on the various prosthesis available to support the extremity.
• Teach the patient on home care management like preventing infections, preventing edema and use of soft compressive dressings.

PROSTHESIS

DEFINITION

Prosthesis is an artificial extension that replaces a missing body part. It is the science of fusing mechanical devices with human muscles, skeleton etc.

TYPES OF PROSTHESIS:

• Trans radial prosthesis: It is an artificial limb that replaces the missing arm below the elbow. These prosthetics are also available with myoelectric arms. These work by sensing via electrodes when the muscles in the upper arm moves, causing an artificial hand to close or open.
• Trans humeral prosthesis: It is an artificial limb that replaces the arm missing above the elbow.
• Trans tibial prosthesis: It is an artificial limb that replaces a leg missing below the knee. These are usually able to regain normal movement more readily due to the large part to retaining the knee which allows for easier movement.
• Transfemoral prosthesis: This is an artificial limb that replaces the leg missing above the knee. These patients have difficult maintaining normal movements due to complexities in movement associated with the knee.

CARE OF PROSTHESIS

• Instruct client that the prosthesis must be selected suitably by matching with the patient's age, General health, Intelligence, Occupation & finances and the prosthesis will be fitted by the prosthetist who will also train the client to use it.
• While applying prosthesis, the edges should be lubricated or fabricated to prevent friction & rubbing between the residual limb & prosthesis socket
• The residual limb can be subject to perspiration so advice the patients to sprinkle some baking soda on the residual limb to prevent odors and skin problems.
• Use a mild anti-bacterial soap to clean the residual limb, rinse thoroughly with clean water and gently dry with towel.
• When bathing advice the patient to carefully examine the limb for redness, tenderness, any type of abrasions or blisters.
• Clean the artificial limb (socket) with antibacterial soap and water or by rubbing it with alcohol, if alcohol is used then again wipe with wet towel to remove alcohol from the socket.

REHABILITATION

• Rehabilitation is the process of restoring the near normal functioning of the patient after undergoing an amputation or transplant surgeries.

GOALS OF REHABILITATION

The goal of rehabilitation after an amputation is to help the client return to the highest level of function and independence possible, while improving the overall quality of life physically, emotionally, and socially.

STAGES OF REHABILITATION

• Pre operative Assessment: Regarding the medical condition, patient education, discussion with the client on the need for surgical management and functional expectations.
• Amputation surgery/dressing: determine the residual limb length Rigid application of dressings Limb reconstruction Determining the soft tissue coverage.
• Acute post Surgical care: Wound healing by following strict aseptic technique. Pain control using analgesics Helping in mobility Providing psychological and emotional support Teaching the client on phantom limb sensation
• Pre prosthetic phase: Shaping the residual limb by rigid dressings Increasing muscle strength by passive exercises Restoring the patient sense of control by psychological support .
• Prosthetic training phase: Teach the patient on the need for wearing the prosthetics Teach the patient on prosthetic care like cleaning with soap and water to prevent odors.
• Physical rehabilitation: Teach the patient on active and passive exercises. Help the client in ambulation using prosthetic limb .
• Vocational rehabilitation: Assess the clients ability to do vocational activities like art crafts, paintings etc. Teach the client on modification of life style with the use of prosthetics. Teach the patient on the need for job modifications.
• Community Integration:
  • Assess the functional ability of the patient
  • Help the patient in resuming the family roles
  • develop healthy coping strategies with the use of prosthetics
  • Indulge the client on recreational activities .
  • Provide emotional support to the patients.
  • Follow all the treatment protocol as prescribed to improve wound healing and stump care
  • Perform Activities to help improve motor skills, restore activities of daily living (ADLs), and help the patient reach maximum independence
  • Demonstrate Exercises that promote muscle strength, endurance, and control
  • As per the prosthetist advice find a Fitting artificial limbs (prosthesis) and practice use of  prostheses
  • Administer Analgesics as prescribed for both post-operative and phantom pain (a sensation of pain that occurs below the level of the amputation)
  • Emotional support to help during the grieving period and with readjustment to a new body image
  • Nutritional counseling to promote healing and health
  • Vocational counseling is provided to practice use of Assistive devices in order to maintain the near normal Independent life
  • Adapting the home environment for ease of function, safety, accessibility, and mobility
  • Follow up - teach the patient on the need for life long use of prosthetics and prosthetic care.