Rehabilitation of lower limb amputee By : Dr.Hassan Hussien El- sharkawy

1. Rehabilitation of lower limb amputeeBy : Dr.HassanHussien El- sharkawy

2. Objectives Definition of Amputation Statistics Reasons for Amputation Types of Amputation Psychological Support Preparation Types of Surgery, Pre-op, and Post-op Care Surgical Complications Amputation Complications Stump Care Rehabilitation and Prosthesis Case Study & Questions

3. What is an Amputation? Amputation: the surgical removal of a part of the body, a limb or part of a limb

4. Statistics • Canadians with diabetes are 23 times more likely to be hospitalized for a limb amputation than someone without diabetes • More than 4,000 Canadians with diabetes had a limb amputated in 2006. • 30% of Canadians with diabetes will die within one year of amputation. 69% of limb amputees with diabetes will not survive past five years • Lower limb amputations are 4 times more common than upper limb (infection) . • While over 90% of amputations caused by vascular disease involve the lower limb, nearly 70% of amputations caused by trauma involve the upper limb

5. Statistics • For both males and females, risk of traumatic amputations increased steadily with age, reaching its highest level among people age 85 or older • Limb amputations resulting from cancer most commonly involved the lower limb; above-knee and below-knee amputations alone accounted for more than a third (36 percent) of all cancer-related amputations. • There were no notable differences by sex or race in the age-specific risk of cancer-related amputations, though rates of limb loss due to cancer were generally higher among individuals other than African Americans. • In all age groups, the risk of dysfunctional vascular related amputation was highest among males and individuals who are African American

6. Peripheral arterial disease • Diabetes Mellitus • Gangrene (du to the complication of # & plaster cast ) . • Trauma (crushing, frost bite, burns) • Congenital deformities • Chronic Osteomyelitis • Malignant Tumor Causative Factors of Amputations

7. Complications of diabetes that contribute to the increased risk of foot infection include: • Neuropathy • Sensory • Autonomic • Motor • Peripheral vascular disease . • Immuno-compromise Diabetes

8. High Risk Characteristics for Developing Foot Infections • Duration of diabetes more than 10 years • Age > 40 years • History of smoking • Decreased peripheral pulses • Decreased sensation • History of previous foot ulcers or amputation

9. ProperFoot Care for Diabetics • Check your sound foot and residual limb for sores, cuts, blisters or other problems every day. Check your shoes for pebbles and foreign objects. • Wash your foot in warm, not hot, water. Dry it well, especially between the toes. • Trim toenails straight across. • Protect your foot from extreme hot or cold. If you are cold at night, wear socks. • Never use heating pads or hot water to warm your foot/feet. • Never go barefoot. Wear slippers or socks inside the house. • Always wear your prosthesis or use amobility aid. Hopping on your sound foot can lead to injury from overuse or by stubbing your toes or falling.

10. Levels of Amputations

11. Pre-operative Assessment • Neurovascular and functional status of extremity • Function and Condition of residual limb (in case of traumatic amputation) • Circulatory status and function of unaffected limb • Signs & Symptoms of infection (culture required) • Nutritional Status • Concurrent medical problems • Current medications

12. Emotional reaction to amputation • Circumstances surrounding amputation (ie. Traumatic versus surgical) • Occupational and social Rehabilitation Psychological Support Preparation

13. Primary Amputation Above the Knee Primary Amputation Site of Amputation

14. AbovetheKnee

15. Post- Operative Interventions Monitor for complications Pain management Education & support Promote mobility/ independent self-care Enhancing Body Image Promote wound healing

16. Skin Care & Stump Hygiene Wash at night Mild, fragrance free soap or antiseptic cleaner Rinse well Dry thoroughly General wound care

17. Dressings

20. Surgical Complications Hemorrhage Infection “

21. Complication of Amputations • Joint contractures • Energy issues • Phantom limb pain • Bony growth • Skin Breakdown Blistering Necrosis

22. Phantom Limb Pain What is PLP? The somatosensory homonculus

23. Phantom Limb Pain: Coping Techniques Acupuncture Anaesthetics Biofeedback Chiropractic Cold Cranial Sacral Therapy Desensitization Dietary and Herbal Supplements Electrical Stimulation Exercise Heat Magnetic Therapy Massage Medications Psychotherapy Shrinker Socks Wearing Your Artificial Limb

24. Levels of lower limb amputation

25. Prostheses • Devices to help shape and shrink the residual limb and help client readapt • Wrapping of elastic bandages • Individual fitting of the prosthesis; special care

26. Lower Limb Prosthesis Types of lower limbs prostheses : • Types of L.L. prostheses depend on different stages after amputation. There are three types: - Immediate post- operative prosthesis. - Temporary prosthesis - Definitive prosthesis.

27. Types of Prosthesis

28. Prosthetics

29. Rehabilitation There are 5 Stages of Rehabilitation: Healing and Starting Physiotherapy Visiting the Prosthetist Choosing an Artificial Limb Learning to Use your Artificial Limb Life as a New Amputee

30. Rehabilitation of lower limb amputee :  Therapy plays an integral role in preparing a patient for a lower-extremity orthotic or prosthetic device and training them with that device once it has been fabricated. Once a patient receives a prosthetic or orthotic device, the therapist is then responsible for evaluating that patient with their device

31. Exercise After Amputation • ROM to prevent flexion contractures, particularly of the hip and knee • Trapeze and overhead frame • Firm mattress • Prone position every 3 to 4 hours • Elevation of lower-leg residual limb controversial

47. Case Study John Rocke is a 45-year-old divorcee with no children. He has a history of type one diabetes mellitus and poor control of blood glu- cose levels. Mr. Rocke is unemployed and currently receives un- employment compensation. He lives alone in a second-floor apartment. Mr. Rocke had developed gangrene in the toe and failed to seek prompt medical attention; as a result, a left below- the-knee amputation was necessary. What type of surgery did Mr. Rocke receive? Open Closed Congential Secondary

48. Case Study Mr. Rocke is in his second postoperative day and his vital signs are stable. The stump is splinted and has a soft dressing. The wound is approximating well without signs of infection. He has not performed ROM exercises or turning since his surgery, com- plaining of severe crushing pain in his left foot? What type of pain is this? Fibromyalgia Somatic Pain Phantom limb pain Imaginary pain

49. Case Study Which of the following post-operative complications would Mr. Rocke NOT experience? Hemmorrhage Joint Contractures Skin Breakdown Bony Overgrowth

50. Case Study When the nurse goes into the room, he yells, "Get out! I don’t want anyone to see me like this.” What would be a priority nursing diagnosis for this situation?