Amputation, Causes, Symptoms, Diagnosis, Treatment

History

Hand dominance, occupation, time of injury, mechanism of injury, other associated injuries, comorbidities and NPO status.

Physical Exam

Level of amputation, structures involved, neurovascular status, function, and degree of contamination (if relevant).  It is vital to assess the amputated part and ultimately determine its suitability for replanting respective to the mechanism of injury (e.g., crush, guillotine-style, avulsion).

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.

Finger amputations classification is generally according to the level of amputation.  The Sebastian and Chung classification is outlined below[rx]:

Evaluation

Laboratory:(optional depending on clinical scenario)

• CBC (complete blood count) to assess for blood loss
• Coagulation studies (only if the patient is known to be on anticoagulants)

Imaging

• Plain radiograph of the affected finger/hand and amputated part; this allows assessment of bony injuries, bone quality and guide decisions regarding bony fixation methods. Angiograms are normally not requested unless it forms part of investigations for other injuries.

How Do I Get Ready For an Amputation

Ask your surgeon to tell you what you should do before your amputation. Below is a list of common steps that you may be asked to do:

• Your surgeon will explain the procedure and ask if you have any questions.
• You will be asked to sign a consent form that gives permission to do the procedure. Read the form carefully and ask
• questions if something is not clear.
• Along with a complete medical history, your surgeon may do a physical exam to ensure you are in otherwise good health. You may have blood or other tests.
• You will be asked to fast for 8 hours, generally after midnight.
• If you are pregnant or think you may be, tell your surgeon.
• Tell your surgeon if you are sensitive to or are allergic to any medicines, latex, tape, or local and general anesthesia.
• Tell your surgeon of all medicines (prescription and OTC) and herbal supplements that you are taking.
• Tell your surgeon if you have a history of bleeding disorders or if you are taking any blood-thinning (anticoagulant) medicines, aspirin, or other medicines that affect blood clotting. You may be told to stop these medicines before the procedure.
• You may be measured for an artificial limb.
• You may receive a sedative to help you relax.
• Based on your medical condition, your surgeon may request other specific preparation.

What Happens During an Amputation

Talk with your surgeon about what to expect during your procedure. An amputation requires a stay in a hospital. Procedures may vary depending on the type of amputation, your condition, and your surgeon’s practices.  An amputation may be done while you are asleep under general anesthesia, or while you are awake under spinal anesthesia. If spinal anesthesia is used, you will have no feeling from your waist down. Your surgeon will discuss this with you in advance.

Generally, an amputation follows this process

• You will be asked to remove any jewelry or other objects that may interfere with the procedure.
• You will be asked to remove your clothing and put on a gown.
• An IV line may be started in your arm or hand.
• You will be positioned on the operating table.
• The anesthesiologist will monitor your heart rate, blood pressure, breathing, and blood oxygen level during the procedure.
• A thin, narrow tube (catheter) may be inserted into your bladder to drain urine.
• he skin over the surgical site will be cleansed with an antiseptic solution.
• To determine how much tissue to remove, the surgeon will check for a pulse at a joint close to the site. Skin temperatures, color, and the presence of pain in the diseased limb will be compared with those in a healthy limb.
• After the incision, your surgeon may decide that more of the limb needs to be removed. The surgeon will keep as much of the functional stump length as possible. He or she will also leave as much healthy skin as possible to cover the stump area.
• If the amputation is due to injury, the crushed bone will be removed and smoothed out to help with the use of an artificial limb. If needed, temporary drains that will drain blood and other fluids may be inserted.
• After completely removing the dead tissue, the surgeon may decide to close the flaps. This is called a closed amputation. Or the surgeon may decide to leave the site open. This is called open flap amputation. In a closed amputation, the wound will be sutured shut right away. This is usually done if there is little risk of infection. In an open flap amputation, the skin will remain drawn back from the amputation site for several days so any infected tissue can be cleaned off. At a later time, once the stump tissue is clean and free of infection, the skin flaps will be sutured together to close the wound.
• A sterile bandage or dressing will be applied. The type of dressing used will depend on the type of surgery done.
• The surgeon may place a stocking over the amputation site to hold drainage tubes and wound dressings, or the limb may be placed in traction or a splint.

What Happens After an Amputation

In the hospital

• After the procedure, you will be taken to the recovery room. Your recovery will vary depending on the type of procedure done and anesthesia used. The blood flow and feeling of the affected extremity will be checked. Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room.
• You will get pain medicines and antibiotics as needed. The dressing will be changed and watched closely.
• You will start physical therapy soon after your surgery. Rehabilitation is designed for your specific needs. It may include gentle stretching, special exercises, and help getting in and out of bed or a wheelchair. If you had a leg amputation, you will learn how to bear weight on your remaining limb.
• There are specialists who make and fit prosthetic devices. They will visit you soon after surgery and will instruct you how to use the prosthesis. You may begin to practice with your artificial limb as early as 10 to 14 days after your surgery, depending on your comfort and wound healing process.
• After amputation, you will stay in the hospital for several days. You will get instructions as to how to change your dressing. You will be discharged home when the healing process is going well and you are able to take care of yourself with assistance.
• After surgery, you may have emotional concerns. You may have grief over the lost limb or a physical condition known as phantom pain. This is pain or other feeling in your amputated limb. If this is the case, you may receive medicines or other types of nonsurgical treatments.

Treatment

The development of the science of microsurgery over last 40 years has provided several treatment options for a traumatic amputation, depending on the patient’s specific trauma and clinical situation:

• 1st choice – Surgical amputation – break – prosthesis
• 2nd choice – Surgical amputation – transplantation of other tissue – plastic reconstruction.
• 3rd choice – Replantation – reconnection – revascularisation of amputated limb, by microscope (after 1969)
• 4th choice –Transplantation of cadaveric hand (after 2000),^[rrx][rx]

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

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.

In addition to your primary care doctor and surgeon, other medical professionals involved in your treatment plan may include:

• An endocrinologist – who is a physician with special training in the treatment of diabetes and other hormone-related disorders
• A physical therapist – who will help you regain strength, balance and coordination and teach you how to use an artificial (prosthetic) limb, wheelchair or other devices to improve your mobility
• An occupational therapist – who specializes in therapy to improve everyday skills, including teaching you how to use adaptive products to help with everyday activities
• A mental health provider – such as a psychologist or psychiatrist, who can help you address your feelings or expectations related to the amputation or to cope with the reactions of other people
• A social worker – who can assist with accessing services and planning for changes in care

Complications

Complications classify according to the time of onset[rx]

Postoperative and Rehabilitation Care

Post-operative management:

• Maintain adequate hydration and circulation volume
• Analgesia
• Keep the affected limb elevated and warm
• Frequent monitoring of the replant capillary refill, color, and temperature
• Avoid dressings changes in the first 48 to 72 hours to minimize manipulation of the repair
• Consider anticoagulation
• In cases of artery-only replants, consider stab incision to the distal amputated tip and apply heparin soaked gauze to allow venous drainage or use leeches instead. This treatment can end once the finger becomes pink with normal capillary refill thus indicating adequate venous drainage

Some patients require further surgery to improve their function, such as tenolysis, bone grafting, tendon transfer, etc.[rx] On average, following upper limb amputations, patients return to work within 2 to 3 months after injury.[rx] Studies show that functional recovery is better in more distal injuries than proximal, both in terms of movement and power.[rx]

Deterrence and Patient Education

• Good health and safety regulations – to provide a safe working environment and reduce occupation-related injuries
• Public information leaflet/public awareness campaign – same objective as above, but to ensure a safe home environment for work and recreation, e.g., BBC News article in May 2018, warning the public of DIY and gardening accidents

Pearls and Other Issues

• Once a patient with an amputation injury arrives in hospital, a speedy but thorough assessment is essential to minimize the delay to definitive surgical management
• Often, amputated parts are brought to the emergency department (although sometimes forgotten at the scene or referring hospital) in inappropriate storage. As a specialist center, it is crucial to inform referring units of the best way to preserve the amputated part, to label it with the patient’s details and keep it with the patient to avoid loss
• Early involvement of specialists where possible

• Take account of patient factors, i.e., age, occupation, comorbidities, and also patient wishes – replantation requires long and complex surgery, hospital admission, the risk of complications, long rehabilitation, and risk of an incomplete return to normal function.

  • This may not be acceptable in some patients, especially in those who are self-employed and cannot take prolonged time off work
  • As such, terminalization of the affected finger may allow early return to work and normal function for the patient – if possible, the patient needs to understand their options and the potential outcome of each
• Good rehabilitation process – early involvement of hand therapists

Rehabilitation after amputation

Loss of a limb produces a permanent disability that can impact a patient’s self-image, self-care, and mobility (movement). Rehabilitation of the patient with an amputation begins after surgery during the acute treatment phase. As the patient’s condition improves, a more extensive rehabilitation program is often begun.

The success of rehabilitation depends on many variables, including the following:

• Level and type of amputation
• Type and degree of any resulting impairments and disabilities
• Overall health of the patient
  Family support

It is important to focus on maximizing the patient’s capabilities at home and in the community. Positive reinforcement helps recovery by improving self-esteem and promoting independence. The rehabilitation program is designed to meet the needs of the individual patient. Active involvement of the patient and family is vital to the success of the program.

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

In order to help reach these goals, amputation rehabilitation programs may include the following:

• Treatments to help improve wound healing and stump care
• Activities to help improve motor skills, restore activities of daily living (ADLs), and help the patient reach maximum independence
• Exercises that promote muscle strength, endurance, and control
• Fitting and use of artificial limbs (prostheses)
• Pain management for both postoperative 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
• Use of assistive devices
• Nutritional counseling to promote healing and health
• Vocational counseling
• Adapting the home environment for ease of function, safety, accessibility, and mobility
• Patient and family education

The amputation rehabilitation team

Rehabilitation programs for patients with amputations can be conducted on an inpatient or outpatient basis. Many skilled professionals are part of the amputation rehabilitation team, including any or all of the following:

• Orthopedists/orthopedic surgeons
• Physiatrist
• Internist
• Other specialty doctors
• Rehabilitation specialists
• Physical therapist
• Occupational therapist
• Orthotist
• Prosthetist
• Social worker
• Psychologist/psychiatrist
• Recreational therapist
• Case manager
• Chaplain
• Vocational counselor

Types of Rehabilitation Programs for Amputations

There are a variety of treatment programs, including the following:

• Acute rehabilitation programs
• Outpatient rehabilitation programs
• Day-treatment programs
• Vocational rehabilitation programs

Preventing foot ulcers

The best strategy for preventing complications of diabetes — including foot ulcers — is proper diabetes management with a healthy diet, regular exercise, blood sugar monitoring and adherence to a prescribed medication regimen.

Proper foot care will help prevent problems with your feet and ensure prompt medical care when problems occur. Tips for proper foot care include the following:

• Inspect your feet daily – Check your feet once a day for blisters, cuts, cracks, sores, redness, tenderness or swelling. If you have trouble reaching your feet, use a hand mirror to see the bottoms of your feet. Place the mirror on the floor if it’s too difficult to hold, or ask someone to help you.
• Wash your feet daily – Wash your feet in lukewarm (not hot) water once a day. Dry them gently, especially between the toes. Use a pumice stone to gently rub the skin where calluses easily form. Sprinkle talcum powder or cornstarch between your toes to keep the skin dry. Use a moisturizing cream or lotion on the tops and bottoms of your feet to keep the skin soft. Preventing cracks in dry skin helps keep bacteria from getting in.
• Don’t remove calluses or other foot lesions yourself – To avoid injury to your skin, don’t use a nail file, nail clipper or scissors on calluses, corns, bunions or warts. Don’t use chemical wart removers. See your doctor or foot specialist (podiatrist) for removal of any of these lesions.
• Trim your toenails carefully – Trim your nails straight across. Carefully file sharp ends with an emery board. Ask for assistance from a caregiver if you are unable to trim your nails yourself.
• Don’t go barefoot – To prevent injury to your feet, don’t go barefoot, even around the house.
• Wear clean, dry socks –  Wear socks made of fibers that pull sweat away from your skin, such as cotton and special acrylic fibers — not nylon. Avoid socks with tight elastic bands that reduce circulation or socks with seams that could irritate your skin.
• Buy shoes that fit properly – Buy comfortable shoes that provide support and cushioning for the heel, arch and ball of the foot. Avoid tightfitting shoes and high heels or narrow shoes that crowd your toes.If one foot is bigger than the other, buy shoes in the larger size. Your doctor may recommend specially designed shoes (orthopedic shoes) that fit the exact shape of your feet, cushion your feet and evenly distribute weight on your feet.
• Don’t smok –  Smoking impairs circulation and reduces the amount of oxygen in your blood. These circulatory problems can result in more-severe wounds and poor healing. Talk to your doctor if you need help to quit smoking.
• Schedule regular foot checkups  Your doctor or podiatrist can inspect your feet for early signs of nerve damage, poor circulation or other foot problems. Schedule foot exams at least once a year or more often if recommended by your doctor.