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02 Amputation

Jun 02, 2018

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    AMPUTATIONI. DEFINITION

    It is the surgical cutting of a limb or outgrowth of the body. The wordamputation is reserved for surgical, traumatic and disease created limbloses.

    TO !"#O$ %"TE&O$IE' OF "!()T"TION*+. "cuired "mputation- loss of part or all of an etremity as the direct result of

    trauma or by surgery. It is also done to revise acongenital limb amputation or alter a deformity secondaryto burns or trauma.

    /, %ongenital "mputation- loss of a limb in uterus and are believed to result from such stimuli as drug toicity. There is failure of formation or strangulation of limb buds by the umbilical cord.

    II. E(IDE!IO0O&1

    23*+ $atio of lower limb to upper limb amputees, ma4ority are men than women- 567 lower etremity- 37 partial foot and an8le- 367 below 8nee- 937 above the 8nee- : - +67 at the hip

    2 (eripheral ;ascular Disease -/37- :-+97 usually is associated with other medical problems

    such as cardiac dose and stro8e2 Trauma- :37 of acuired amputation in )E

    - primarily men aged +3-?3 yrs. Old- net most common cause for 0E amputation about /67 of which

    2 Disease and Tumors - responsible for about eual number of the remaining

    acuired )E amputations- in 0E, it accounts approimately :37 of all acuired

    amputations among >6 years and above- it is the most freuent cause of all amputation in both the

    )E and 0E among children aging +6-/6 yrs. oldIII. ETIO0O&1

    +. %ongenital "nomaly - refers to the absence or abnormality of a limb evident at birth or no etiology - i.e. polydactyl, congenital absence of a distal part

    /. (eripheral ;ascular Disease

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    - i.e. blast ins4uries?. Infection

    - i.e. chronic osteomyelitis, gas gangrene of high virulence3. Tumor

    - for primary malignant tumors not possible to resects or

    irradiate without heavy ris8s or recurrence or dysfunction2 without metastasis B amputation is curative2 with metastasis B it is palliative . Thermal, %hemical, Electrical In4uries- ecess of these creates severe tissue damage resorting to

    amputationI;. %$ITE$E" FO$ DI"&NO'I'

    2 &eneral Indications for "mputation+. Irreparable loss of blood supply in a disease or in4ured limb/. In4ury that is so severe that function would be better after "mputation9. To save life when infection is uncontrollable?. To remove part or all of a congenital abnormal limb for cosmoses or

    improving functions%O!(0I%"TION'

    +. %ontracturesLevel ofAmputation

    Typical Contracture Method ofPrevention

    "bove nee Etend

    "bduction

    Fleion

    hen supine in bed,

    the patient should bepositioned with sandbags to preventeternal rotationeercises are alsoindicated.$ange of motioneercises andresistive eercises tothe hip abductors areuseful.

    The patient spentlarge portions of eachday in the position.

    @elow nee ip Fleion !ethods of preventionare identical to thoselisted under above8nee "mputation.!ethods of preventionare identical to thoselisted under above8nee amputation.

    nee Fleion hen sitting, the legshould be positionedon board so that 8neeis in full etension

    /. Delayed ealing of 'tumpDelayed healing is board term used to describe a range ofsuperficial to deep s8in and tissue lesion that can be either

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    clean or infected. )nderlying causes of delayed on non Bhealing of the stump is*

    ;ascular insufficiency Eternal forces eternal on the stump 0oss of reduced s8in sensation

    'imple open stitches %omple open suture line

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    tissue, sympathetic, referred, residual limb changes.?. (roblem $elated to 'tump 'hape ". Edema

    The most common post - surgical problem is stump edema.Edema increases stump volume, decreases circulation, and

    conseuent slows wound healing. If not controlled, swelling canlead to secondary problems such as s8in brea8down, pittingedema, reduce s8in sensation, and can eventually develop intoverrucose hyperplasia. @. @ulbous 'oft Tissue

    If the distal is stump bulbous, stump entry into the soc8et isdifficult. @ulbous soft tissue can be the result of insufficientmyofascial flap contouring or distal edema caused by inadeuatesoft tissue supprt. %. $edundant Tissues

    This ecessive distal soft tissues are mobile and non functional.

    Distal tissue mobility ma8es it difficult to do the prosthesis since tissuemay result to pinching. It may also reduce position ease and decreaseprosthesis control during gait. D. '8in &rafts

    "lthough s8in should be avoided on 0E stumps they aresometimes necessary to retain stump length especially in burn ordegloving in4uries. &rafts are very sensitive and do not readily toleratestump soc8et pressures. (roblems can arise with graft re4ection andinfection around the graft side if weight activities are started too early. E. "dductor $oll

    This typical in transfer moral stump and is most commonly

    observed in elderly females. Epress adipose tissue may be prevented inthe adductor area and probably did no cause any difficulties prior toamputation. owever, during the prosthesis fitting this tissue bulges,interfering with stump placement into the soc8et brim and public ramus.The amputee sits too high in the prosthesis because the tissue bulgeprevent complete stump penetration into the soc8et, ma8ing the prosthesislong.

    !ost adductor rolls can be easily controlled by using stoc8inet topull this soft when donning the prosthesis. owever, roll always retainproblem free since the ecess s8in tends to perspire and causediscomfort.3. (roblem $elated to #oint $ange ". Etensive 'carring and "dhesions

    " stump with etensive burn scars may demonstrate soft tissue ands8in damage resulting in permanent stump shape in the stump areaavailable for weight bearing distribution.>. %omplications secondary to use (rosthesis". @listers

    These develop as a result of friction and pressure. Fluid developsunder the point of irritation. They came from edema B prone redundanttissues at the distal stump, over the patellar tendon, and at the pointwhere the proimal soc8et brim contacts the s8in. @. ;enous $estrictions

    This problem is primarily caused by circulatory restrictions at theposterior proimal stump level the long saphenous vein is compressedbecause pf weight B bearing on the ischial shelf. %. %ontact Dermatitis

    This localiGed dermatitis develops as a result of s8in reacting toagents. D. ;errucose yperplasia

    +6

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    It develops gradually and is visible at the distal end of the matureamputation stump. It is characteriGed as thic8ened s8in, Hpullydiscoloration, mushroom B li8e appearance, and dull sensation. E. 'ebaceous and Epidermoid %ysts

    These develop only on the stumps on active prosthetic users as a

    result of soc8et pressure, s8in friction, and perspiration. F. @one End 'ensitivityThe discomfort occurs as a complication during weight B bearing

    practice and if the bone end has minimal soft tissue coverage. &. @one 'purs

    It occurs in some shred of periosteum have remained in the softtissue following amputation surgery. If these forms of eostoses are s8insurface at the distal stump end, they can cause discomfort. . Neuroma

    If surrounding soft tissues does not protect neuroma, localiGed painis triggered by palpation.

    ;. ($O&NO'I'There are number of factors that may affect healing.(ostoperative infection, whether from eternal or internal sources is

    a ma4or concern. Individual with contaminated wounds, from in4ury,infected foot ulcers, or other causes are at greater ris8. $esearchindicates that smo8ing is ma4or deterrent to wound healing, with one studyreporting that cigarette smo8ers had a /*3 higher rate of infection andreamputation than non B smo8ers. There is some indication that failedattempts at limb revasculariGation may negatively influence healing atbelow B 8nee levels. Other factors influencing wound healing are theseverity of the vascular problems, diabetes, renal disease, and other

    physiologic problems such as cardiac disease.;I. !EDI%"0 J ')$&I%"0 !"N"&E!ENT". @asic 'urgical (rocedures of "mputation

    &eneral (rocedure*+. 'urgeon removes part or all of the limb

    - type of amputation is at the discretion of the surgeon andthe state of the etremity at the time of the amputation.

    /. "llow for + or / wound healing9. %onstruct a resident limb for optimum prosthetic fitting and

    function.TO)$NIK)ET B ecept in ischaemic limb, the sue of tourniuet is highlydesirable0E;E0 OF "!()T"TION B it should be through tissues that will healsatisfactory and at a level that will remove the abnormal or diseased part.The cardinal rule is to preserve all possible length consistent with goodsurgical 4udgment.!)'%0E' B they are 4ust distal to the level of the intended home sectionso that their ends will retract to that level. @eveling is done to obtain astump shape properly. !a4or muscles are stabiliGed by myofascial closure,myoplasty, myodesis, or tendesis, which allows maimum retention offunction.'IN F0"(' B the s8in at the end of the stump should be mobile and isnormally sensitive. The scar should be well healed, pliable, painless, andnon B adherent.@0OOD ;E''E0' B to achieve homeostasis, ma4or blood vessels shouldbe isolated, individually ligated. 0arger ones should be doubly ligated anda single ligatable or smaller vessels. @efore the amputation stump isclosed, the tourniuet should be released and all bleeding points shouldbe clamped and ligated.

    ++

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    @ONE END' B it should be covered good padding of soft tissue andphysiologically prepared for prosthetic wear. @one beveling is the processof smoothing the cut ends of bone to prevent rough edges and spurringthat interferes ambulation. @ones such as the fibula are often cut slightlyshorter for the same reason.

    D$"IN' B meticulous hemostasis should obtain before the amputationstump is closed. The Drain or tubes are removed ?9-:/ hours aftersurgery.@. Types of 'urgical "mputation+. Open "mputation

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    include removal of the medial and lateral malleoli anddistalJfibular flares

    - not done in vascular conditions as higher level isnecessary due to insufficient blood supply

    - allows good end B bearing, the heel pad being sutured

    into position over the distal end of the tibia and fibula- prosthesis is difficult in this typea?. @ody "mputation and (irgoff "mputation

    - amputation done which include tibio B calcaneal fusion- rarely don

    a3. (artial Toe- through the metatarsophalangeal 4oint

    a>. Toe Disarticulation- through the metatarsophalangeal 4oint

    a:. (artial Foot J $ay $esection- resection of 9rd, ?thand 3thmetatarsal and digits

    a. Transmetatarsal- through the midsection of all metatarsalsb. @elow nee "mputation

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    - method is carried out through the calcaneus bone ofsupracondylar region of the femur below the shaft

    - the uadriceps tendon which are included on the longanterior flap is cut close to its patellar attachment grownover the end sutured with full end bearing in all cases

    - symmetrical in contours from spurs and of maimumfunctional length c9. %allander "mputation

    - a supracondylar amputation with minimum tissuedissection

    - no muscle tissue is ecised- patella is removed from its bed in the uadriceps tendon

    leaving patellar ligaments intact and incorporated in thelong anterior s8in flap

    - the cut of the supracondylar is lower here than in ir8Aswhich is higher

    c?. $ogerAs "mputation- nee 4oint disarticulation with arthrodesis . 0ong "bove nee- amputation of more than >67 femoral length

    d. "bove nee "mputation

    - because patients 8nee 4oint is lost, it is etremelyimportant that stumps be long as possible to provide astrong lever arm for control of prosthesis. Theconventional, constant friction 8nee 4oint used in the most

    " prosthesis etends for 5 B +6 cm. distal to end ofprosthetic soc8et and the bone must be amputated thisfor proimal to the 8nee to allow room for the 4oint

    - transfemoral amputation most commonly seen in theelderly

    - ideal length is +6 -+/ inches below the greater trochanter

    - minimum stump length in which we can have control is ?inches below the tip of greater trochanter to fit and above8nee amputation

    - greater difficulty in learning to control his prosthesis andachieving good gait since proprioception from the 8nee

    4oint is lost and he bears weight at the ischial tuberosity- hip fleion contractures easily occurs unless prevented

    shorter stump B tend to become fleed and abducted

    due to the strong full of tensor fascia lata

    long above 8nee stump B tend to become fleed and

    abducted due to the intact abductor group which have

    a mechanical advantage over the pull of the shorttensor fascia latae. ip Disarticulation

    - amputation through the hip 4oint, pelvis intact- should be avoided because there is no substitute for

    anatomical 4ointf. emipelvectomy

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    soft tissues and chest cageg. emicorporectomy

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    Transphalangeal with involvement of sparing thumbThenar

    Transmetacarpal distal with involvement orsparing of the thumb

    Transmetacarpal proimal with thumb

    involvement sparingd. "mputation Throughout the rist- with adeuate palmar s8in, the carpal bones should be

    retained when possible to be useful for a patient with orwithout a prosthesis. The hand may be disarticulated atthe metacarpal 4oints or through carpus. %arpal bonesallow some fleion and etension of the distal stump andthis may be useful when a pressure is not used.(ronation and supination is preserved.

    e. rist Disarticulation- although carpus disarticulation has occasionally been

    possible, this is not often practical. Disarticulation at theradio B carpal 4oint is the much more common site fortotal head amputation. The carpus is disarticulated at theradio B carpal wrist, this gas the advantage that theprosthesis is need not include the elbow 4oint and thepronration and supination are retained

    f. Forearm "mputation- as much length as possible should be preserved. If the

    wrist disarticulation cannot be done, the site of election inthe forearm is the function of the lower and middle +J9 ofthe elbow. This creates and adeuate level and

    preserves about /J9 of the available pronation andsupination. The usual prosthesis is hinged at the elbowand includes a forearm soc8et with a wrist unit to which aprosthetic handJhoo8 may be attached interchangeably.The goo8 is more useful than the hand. It can be openedby the pull of a cable attached to the harness about thepatients opposite shoulder and closed by rubber bandsabout its base.

    g. 'hort @elow Elbow "mputation- the most proimal useful stump measures +.3 below the

    insertion of the biceps tendon. The prosthesis for thisstump must be short to allow elbow fleion yet longenough to hold the stump securely. This may beaccompanied with a special prosthesis

    h. 0ong @elow Elbow "mputationi. Elbow Disarticulation

    - this is uncommon. hen the forearm is disarticulated atthe elbow or amputation occurs at a higher level, amechanical elbow 4oint is reuired to place the forearmand terminal device in use. This device must allow freevoluntary fleion and etension activated by shoulderharness.

    4. 'upracondylar "mputation- above elbow amputation are most satisfactory at

    this level, because above this functional efficiencybecomes less as shoulder ids approached and at least /of bone stump should remain below anterior aillary fold.

    "lthough amputation may be done through the condylesof the humerus, the most freuent site is about / or /.3above the 4oint line

    +>

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    8. 'hort "rm 'tump- amputation may be carried out within /.3 above the

    anterior aillary fold. In amputation at the shoulder, thehead and nec8 of the humerus should be preserved aspossible to minimiGe disfigurement

    l. Foreuarter or Interscapulothoracic "mputation- severe deforming procedure with removal of scapula andmost of clavicle reuired for treatment of malignantdisease

    m. %ineplastic "mputation- the power of one or more of the patientAs muscle

    transmitted by means of a small peg traversing a muscletunnel lined by the s8in used to activate prosthetic handmechanism

    D. "mputation in %hildren- children amputees ma8e up an interesting segment with

    great rehabilitation potential- every effort must be made to save the epiphyseal growthcenters

    - 'urgical ablation should be defend as possible since theamputated limb tends to at a slower rate than thecongenitally deformed limb

    %auses*- congenital- traumatic- neoplasticJtumor

    Ob4ectives of "mputation and (rosthesis

    - facilitate early function- enhance appearance- produce optimal stump for maturity

    %ompilation* bone overgrowth- this overgrowth leads to s8in performance and /nd

    degree low infection- often type in humerus, fibula or tibia and un8nown cause- usual treatment is revision of stump, traction at night in

    the prosthesis is an initial approach(rosthesis

    - standard type that is comfortable and simple- consider the growth factor

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    (ost B operative dressings are important for some sort of edemacontrol in ecessive edema in the residual limb, can compromise healingand cause pain.+. 'oft Dressings

    - the oldest method of post B surgical management and

    least edema control2 Two Types*a. Elastic wraps B a dressing is applied followed by a auGe pad and then the compression wrapb. Elastic shrin8er B soc8 B li8e garments of heavy rubber reinforced cotton

    Objective* (rovide protection, support and gradient pressureAdvantage* Ease of application, ability to inspect wound easily, provide

    alternative wound environment, inepensive, lightweight, available easily laundered.

    Disadvantage* (oor edema control, reuires s8ill in applicationfreuent reapplication, difficult to monitor moisture, temperature, sterility of wound surface under the dressing, may create tourniuet effect or

    varied pressure to the limb, slippage of the dressing, may create painand apprehension.

    /. 'emi B rigid and $igid dressings 'emi B rigid* )nna paste, felt, cotton, or polyurethane pads.

    $igids * (laster bandages, fiber glass casts, polymerplastics and felt, cotton and polyurethane pads.

    Objectives* (rovide a relatively dry, sterile environment with appropriate

    distal end pressure permitting adeuate tissue fluid echange. (reventecessive post B surgical edema.Advantages* &ood support to the surgical site, increase comfort andimprove wound environment. &reater confidence with movement by theamputee with less chance of in4ury to healing tissue. $eduction ofunnecessary wound inspection. $educe time for stump shrin8age, allowearlier ambulation and early fitting of a definitive prosthesis.Disadvantages* Improper application of the dressing fails to promoteadeuate circulation. Inability to uic8ly assess the wound to monitorhealing. $euire close supervision.2 "lternative rigid dressing*

    a. $igid dressing with a window B healing surgical sites that reuire freuent attention can be monitored with the inclusion of a cut

    out or Hwindow to the rigid dressingb. $emovable $igid Dressing B the cast is designed to protect the

    surgical site with the minimal amount of plaster and is securedby some form suspension

    c. @ivalve $igid Dressing B a full length rigid dressing that hasbeen split longitudinally for ease of removal and is secured by;elcro closures

    9. Immediate (ost B operative (rosthesis

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    Disadvantages* (otentially, places the physically unstable amputee atris8 for falls of in4ury. The limited weight bearing though the residuallimb could impair the healing site, and currently no research supportsthe notion that early ambulation assists in wound healing. "mbulationcould be permitted too soon. (roper application of the dressing to

    provide appropriate distribution of forces at the stumpJdressinginterface is freuently uestioned. Inability to access the wound tomonitor healing.

    Indications for rigid, semi B rigid or I(O( cast change - severe pain or ecessive tightness of cast - slippage, rotation or pistoning of the cast

    - damage to the cast - febrile patient or an odor associated with infection

    ?. (neumatic DevicesMaterials* double walled, clear long leg air splint with a controlled pressure

    of /3 mm&. 'terile gauGe, lambAs wool and stump soc8 cover the surgicalsite.Objectives* provide compression, early bipedal with a clear splint to monitorthe residual limb. The splint may be inflated or deflated easilyAdvantages* problems associated with these splints include* air lea8age,variations in pressure and buc8ling of the splint if too much force is eerted.The splints can be bul8y and difficult to maneuver in bed and duringtransfers. (erspiration and heat concern towards the healing environment.

    3. %ontrolled Environment Treatment

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    ischial tuberosity to the end of the bone and note the hip 4oint

    position. ?. $esidual 0imb 'hape

    a. cylindrical, conical, bulbous

    b. abnormalities

    b. Other etremities

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    nurse, (T, OT, orthosist and later prosthesist, psychologist, social wor8er nutritionist, etc.=

    - general medical care

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    ice bags on the proposed level of amputation andmay reuire use of mild narcotics.

    /. "cute (ost-Operative %are(rimary &oal* healing without complications

    This is the period between the amputations and the

    removal of sutures for as long as +?-/+ days.The goals of treatment during this phase of care include*a. reduce pain and edemab. prevent contractures and secondary problemsc. prevent cardiopulmonary and general body conditioningd. educate the patient and familye. provide psychological support

    During this time nursing staff and therapist will initiate a program whichmay include*

    a. (ositioning to prevent edema and contracture- proper bed positioning with stumps always being

    parallel to the unaffected leg in etension- there should be no pillow under the stump orbetween the legs

    b. Transfer training wheelchair mobility training and early gaittraining

    c. )pper etremity strengthening, particularly of shoulderdepressors and elbow etensors

    d. @ed mobility with precautions for trauma to the residual limb- mat eercises- bridging and rolling can be commenced on the

    first day

    - balance eercisee. Functional activitiesf. Isometric eercise to all muscle groupsg. "ctive range of motion eercise of all 4ointsh. (rophylactic respiratory care including deep breathing and

    coughingi. %ardiac monitoring and rehabilitation procedures for all patients

    at ris8s4. Education of the patient about s8in care and protection of both

    the residual limb and limbs with peripheral vascular disease8. Encouraging discussing possible future rehabilitation plans by

    the patient and family to raise uestions, epress fearsl. $esponding to signs of severe emotional response to

    amputation@. (rosthetic (rescription, %hec8ing-out and Training

    The prosthesis must balance the amputeesA need for stability,safety, mobility, durability and cosmetics. The availability must beconsidered. Input from the medical team especially from the patient resultsin the most appropriate prosthetics prescription.

    2 (robable (rosthetic %andidates*+. readable cardiovascular reserve/. adeuate healing and s8in coverage9. good range of motion and muscle strength?. adeuate motor control and learning ability

    2 (rosthetic Training"fter completing the final prosthetic evaluation, a period of gait

    training using the prosthesis is reuired. &ait training of course on an out-patient basis from + wee8 to + month or more with 3-3 visits per wee8. Themore proimal levels of amputation reuire lengthy training than distal

    //

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    levels, longer training for upper limb than lower limb amputees, forbilateral than unilateral amputees, for adults than for children.

    Treatment &oalsa. reduce edema and shaped limb for prosthetic fir. B

    commonly the rehabilitation team can employ several methods to

    achieve goal including +. intermittent compression pump therapy /.elevation with active eercise 9. elastic wrapping of their residuallimb ?. commercially made stump shrin8ers.

    Elastic bandages will not only help control edema but alsoshrin8 the bandage, a figure-eight wrap usually incorporates theproimal 4oint closest to the stump. rapping from the distal toproimal site should provide distal compression. The stump shouldbe wrapped every ? hours or whenever the bandages loosen, slipsor bunches. "n elastic stump shrin8er may be used if elasticwrapping is impractical.

    b. Instruct the patient in stump hygiene.

    - @efore the inclusion is completely headed a whirlpool often ishelpful in slowly healing limbs or wounds that are draining.'chedule hydrotherapy for /6 to 96 minutes once or twice daily. "detergent or antiseptic additive such as betadine may be helpful forcleansing. %losely monitor the water temperatures to avoidscalding, especially if there is a vascular disease. In this case, 8eepthe water temperature below 56LF.

    "fter the incision is healed, soften the s8in with a watersoluble cream or lanolin preparation three times daily. &entlemassage of the distal soft tissue helps 8eep them mobile over theend of the bone. Tapping the scar and distal soft tissue four times a

    day often helps desensitiGe these areas prior to wearing theprosthesis. Tap with the finger tips, starting slightly and increasingpressure for about 3 minutes until mild discomfort is produced.

    &ood s8in hygiene should be taught, using mild soap to wor8on a lather and ten raising with lu8ewarm water. The s8in should bepatted, not rubbed dry. %leansing is recommended in the evening.

    c. Increase strength of all etremities and trun8. !aintainrange of motion and prevent contractures.- "ll patients should be continued on the positioning and eercisesschedule developed in acute postsurgical care. Eercise for targetmuscle may be achieved by a number of approaches such as* +.dynamic stump eercise, 9. proprioceptive neuromuscularfacilitation, and ?. sling suspension techniues. 'uch techniue hasits own advantages and a combined approach is usually mosthelpful.

    Dynamic 'tump Eercises B are a series of eercises withfunctional emphasis. Each eercise is intended to stimulate aparticular functional activity or group of activities. The eercises areespecially demanding and stress the cardiovascular system.

    For each eercise, activity is progressed from easiest tomore difficult using principles of therapeutic eercise. Initially, archof motion may be allowed to assistC the movements are performedwithout addition of eternal resistance and the arch of motionreuired is decreased. "s s8ill and strength improve, theseparameters are altered ma8ing eercise more difficult. Theseeercises often employ stools and sandbags in graduated siGes toincrease difficulty.2 Target !uscles to be 'tressed in Training "bove and @elow nee

    "mputation*"bove-8nee "mputation

    /9

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    +. iliopsoas/. gluteus maumus9. eternal hip rotators?. internal hip rotators3. gluteus medius

    >. abductor comple:. pelvic and trun8 rotators. abdominal muscles5. shoulder depressors and elbow etensors

    @elow-8nee "mputation"ll muscles listed under above-8nee amputations,

    plus hamstrings and uadriceps.d. Teach independence in ambulation

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    )ltraviolet irradiation* ultra violet rays gave aphysiological effect on the s8in. Depending on the dosagethey increase circulation cause erythema, and 8ill bacterialgrowth. &rowth of epithelial cells, antibiotic effects onsurface. )se E+ progressed daily around wound or E9JE? on

    wound unprogress.hirlpool bath* whirlpool bath immersion is used to*'timulate stump circulationelp desensitiGe the tender-stamp(rovide gently rinsing debridement of thewoundDisinfect the wound%ontribute to a general feeling of well being

    ound taping* this techniue of wound support isindicated for suture line splits and small open wounds. Itensures that the amputee can proceed ambulate it on and

    stabiliGe the surrounding stump tissues.'tump immobiliGation* in early post-operative stages,when it becomes evident that healing will not occur byprimary intention. The rigid dressing is reapplied. This is non-weight-bearing resting cast promotes healing by protectingthe wound from eternal trauma, controlling edema andprevention tissue mobility temperature is 99-9>L%, etremityis immerse, agitators turn on giving heat, massage anddebridement.

    Topical medication can be used to further stimulatewound healing andJor oral antibiotics to combat any infection

    that may be present. 'ome common topical medications thatmay be used are*+6.ygeol

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    h. many neurosurgical procedure have beenadvocated but none is permanent. "nterolateralcordotomy had been the best reported results.

    i. (sychiatric treatment may be necessary in some4. hen any procedures relieves the pain,

    resumed the prescribed eercises, massage anduse of prosthesis to decrease li8elihood ofrecurrence

    ?. !anagement related to 'tump shape problemsa. Edema B for control, apply bandaging

    techniues, shrin8ers soc8s, intermittentcompression pumping, and pneumatic wal8ingaid

    b. '8in grafts B treatment aims towardsmaintenance of the grafted tissue and preventionof s8in contractures. 'mall blisters can be 8ept

    clean treated topically.c. "dductor roll B application of bandagingtechniues, and in rare occasions, surgicalremoval is indicated

    3. !anagement related to #oint $ange (roblema. Etensive 'carring and "dhesions B treatment

    include prophylais, pain relief, manual stretchtechniue, active eercise, ambulation andsplinting

    >. !anagement related to (rosthetic (roblemsa. @listers B physical therapy measures include

    dressing thic8ness, soc8et ad4ustments,restriction pf weight bearing progression by8eeping the amputee on the parallel bars, andstop weight bearing activities for patient withsevere

    b. ;enous $estriction B soc8et alterations areindicated

    c. %ontact Dermatitis B alleviated by the eliminationof the source of the irritant

    d. ;errucose yperplasia B improved by providingdistal contact accompanied by some weightbearing

    e. 'ebacous %ysts, Epidermoid %ysts B treatmentinclude surgical management by incision anddrainage, antibiotic therapy, ); radiation

    f. @one 'purs B revision or filling of the bone endmaybe necessary to allow pain-free ambulation

    g. Neuroma B conservative treatment includeapplication of TEN' and )'

    2 Factors to %onsider for a 'uccessful $ehabilitation&ood and ideal stumpFunctional well fitted prosthesis(roper training'ound psychological 4udgment

    2 Functional %lassification of "mputees%lass + B Full $estoration* the individual is

    functionally euivalent to normalC he is an essentiallydisabled individual, but can do his former 4ob with norestrictionC he also can compete in sports and return toformer social life.

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    Transtibio-fubular %lassification

    6-/6 ;ery short transtibio-fibular stump

    /6-36 'hort transtibio-fibular stump

    36-+66 0ong transtibio-fibular stump

    2 measurementTransfemoral stump normal measurement* periunium to medial

    femolar condyleTranstibio-fibular stump normal measurement* medial tibial

    plateau to medial malleolus7age length of residual limb +66

    length of sound limb0evels of Impairment

    )pper Etremity 7age of impairment

    Thumb //7

    Inde finger +?7

    !iddle finger ++7$ingJlittle finger 37

    rist 3?7

    Elbow 3:7

    'houlder >67

    Fore

    uarter :67

    "ll fingers ecept thumb 9/7

    0ower Etremity 7age of impairment

    @ig toe 37

    Other toes /7

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    ?= 'ubserves the physiological ualities of heat or burning B the most commonualities of phantom pain. The brain processes that underlie the body

    self areHbuilt in genetic specification, although this can be modified.

    /5