Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Amputation


Specialists

  • General Surgeon
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Vascular Surgeon

Comorbid Conditions

  • Cardiovascular disease
  • Diabetes mellitus
  • Other body parts injured by the trauma that caused the amputation
  • Peripheral vascular disease

Factors Influencing Duration

Presence of underlying disease such as diabetes or PVD in the retained limb(s), and atherosclerosis in other areas (coronary artery disease, cerebrovascular disease) will influence recovery time and an individual’s return to ambulation and activities. Additionally, the presence of complications, the particular limb or digit amputated, whether an amputated upper limb is the dominant limb, the individual's psychological status, whether or not a prosthesis will be used, the individual’s adaptation to the prosthesis, and the individual's job requirements may influence length of disability.

Medical Codes

ICD-9-CM:
84.00 - Upper Limb Amputation, Not Otherwise Specified; Closed Flap Amputation of Upper Limb NOS; Kineplastic Amputation of Upper Limb NOS; Open or Guillotine Amputation of Upper Limb NOS; Revision of Current Traumatic Amputation of Upper Limb, NOS
84.01 - Amputation and Disarticulation of Finger
84.02 - Amputation and Disarticulation of Thumb
84.03 - Amputation through Hand; Amputation through Carpals
84.04 - Disarticulation of Wrist
84.05 - Amputation Through Forearm; Forearm Amputation
84.06 - Disarticulation of Elbow
84.07 - Amputation Through Humerus; Upper Arm Amputation
84.08 - Disarticulation of Shoulder
84.10 - Lower Limb Amputation, NOS; Closed Flap Amputation of Upper Limb NOS; Kineplastic Amputation of Upper Limb NOS; Open or Guillotine Amputation of Upper Limb NOS; Revision of Current Traumatic Amputation of Upper Limb, NOS
84.11 - Amputation of Toe; Amputation through Metatarsophalangeal Joint; Disarticulation of Toe; Metatarsal Head Amputation; Ray Amputation of Foot (Disarticulation of the Metatarsal Head of the Toe Extending Across the Forefoot just Proximal to the Metatarsophalangeal Crease)
84.12 - Amputation Through Foot; Amputation of Forefoot; Amputation through Middle of Foot; Choparts Amputation; Midtarsal Amputation; Transmetatarsal Amputation (Amputation of the Forefoot, Including All the Toes)
84.14 - Amputation of Ankle through Malleoli of Tibia and Fibula
84.15 - Amputation below Knee, Other; Amputation of Leg through Tibia and Fibula NOS
84.16 - Disarticulation of Knee; Batch, Spitler, and McFaddin Amputation; Mazet Amputation; S.P. Rogers Amputation
84.17 - Amputation above Knee; Amputation of Leg through Femur; Amputation of Thigh; Conversion of Below-Knee Amputation into Above-Knee Amputation; Supracondylar Above-Knee Amputation
84.18 - Disarticulation of Hip
84.19 - Abdominopelvic Amputation; Hemipelvectomy; Hindquarter Amputation
84.3 - Revision of Amputation Stump; Reamputation of Stump; Secondary Closure of Stump; Trimming of Stump

Overview

Amputation is the calculated surgical removal of all or part of an extremity when its blood supply is irreversibly compromised by disease or severe injury. By contrast, traumatic amputation is the accidental severing of the body part (See Amputation Foot, Traumatic, and Amputation Leg, Traumatic). The same general principles apply to both forms of amputation, especially regarding wound closure, rehabilitation, and use of artificial limbs (prosthetics). The aim is to remove diseased or damaged tissue, relieve pain, and to prepare a site for a prosthesis, helping the individual return to the most comfortable and functional life possible.

Amputations may be performed at any level in the upper extremities such as the digits, the hand, or the arm, or in the lower extremities such as the toes, the foot, or the leg. The point at which the limb or digit is incised and removed is known as the amputation level; surgeons determine the amputation level by measuring blood flow in the area, determining where complete healing is most likely to occur with least risk of complications, and evaluating which level would permit the greatest function and most efficient use of a prosthesis following rehabilitation. Optimum function may be gained when the amputation level is closer to the diseased or damaged part of a limb (distal amputation), while the risk of complications is reduced when the amputation level is higher and a greater portion of the limb is removed (proximal amputation). Amputation levels are referred to by site as upper extremity (UE), above elbow (AE), below elbow (BE), lower extremity (LE), above the knee (AK), below the knee (BK), or through the knee (TK). More recent terminology classes the amputation by the major bone transected, e.g., transtibial means below knee, transradial means below elbow, and transfemoral means above knee.

Source: Medical Disability Advisor



Reason for Procedure

Surgical amputation is performed most often to remove a limb or digit when blood supply is irreversibly compromised by disease or uncontrolled infection; it may also be performed to treat an injured extremity, such as a crushed or partially severed limb or digit, or to remove or prevent spreading (metastases) of malignant tumors such as bone or skin cancer (melanoma). Disease is the most common indication for amputation in adults age 50 or older; trauma is the usual cause of amputation in younger individuals. The majority of amputations, approximately 90%, are performed as a result of peripheral vascular disease or PVD (Bowker). In PVD, waxy build-up (plaque) on blood vessel walls narrows arteries and arterioles and thus compromises blood flow in the limb, causing local anemia (ischemia), especially in lower extremities. Half of individuals undergoing amputations as a result of PVD have concomitant diabetes. When any diseased or traumatized limb is deprived of blood supply, cells and tissue in the limb will be deprived of oxygen (hypoxia), resulting in the death of cells and ultimately tissue (ischemic necrosis or gangrene), and requiring amputation.

Individuals with blood coagulation problems that can cause formation of blood clots in arteries (thrombosis) are at high risk for amputation; before amputation is performed on an individual with blockage of blood flow by an arterial blood clot (embolism or thrombosis), consultation with a vascular surgeon is recommended to determine if revascularization of the compromised limb is an option.

Uncontrollable acute or chronic infection that has not responded to antibiotic treatment may require amputation as a life-saving measure. For example, infection by gas-forming organisms (Clostridia, anaerobic streptococci, Bacteroides) can occur in contaminated wounds derived from farm injuries, automobile accidents, or gunshot, leading to interrupted blood flow and tissue death (gas-gangrene), and at times may be remedied only by amputation. Secondary infection is a major concern following amputation procedures performed in the presence of existing uncontrolled infection. Finally, amputation may be necessary if pervasive tissue damage occurs in an extremity after burns, electric injury, or frostbite, or if birth defects (congenital anomalies) render the lower limbs or digits useless, or rarely, a physical liability.

Source: Medical Disability Advisor



How Procedure is Performed

Amputation is major surgery that can either be planned or performed on an emergency basis. It is usually performed under a general or regional block anesthetic, although a local anesthetic is sometimes used for finger or toe amputations. Each type of amputation involves a specific amputation level, such as transmetatarsal, transtibial, transfemoral, and through-knee amputation. Most procedures, however, make use of similar techniques. First, the skin is cut (incised) at the determined level, working blood vessels are pulled aside and either tied off (ligation) or sealed off with an electric needle (cauterized). Muscles and other soft tissue are either cut through or pulled aside (retracted) to allow surgical access. The bone is then severed with a saw, or the joint is severed through all of its soft tissue attachments (disarticulation). Nerves are severed well above the stump to prevent irritation from a prosthesis after healing. Sometimes a severed nerve will be implanted into a muscle area to cover the severed nerve end and pad the possible formation of a small nerve growth (neuroma) that can cause pain if stimulated by pressure. The surgeon cuts (resects) muscles and tendons at the level of the amputation and removes (debulks) additional muscle tissue as needed to allow formation of a stump that will permit fitting of a prosthetic device. The bony stump is then remodeled and smoothed to the extent needed. A generous length of skin and muscle tissue left beyond the point of bone resection is typically used to create a flap; the flap is then placed over the end of the stump and sewn (sutured) to the adjacent skin.

A drain may be inserted and allowed to protrude from between sutures to drain fluid from the surgical site. This drain is removed within 24 to 72 hours. In emergency amputations or in contaminated or infected wounds, the wound may be left open longer to drain completely. The wound will be closed later (delayed closure) when no signs of infection are present. The surgical area must be protected until healing is complete and the individual can be fitted for a prosthetic, if appropriate.

Source: Medical Disability Advisor



Prognosis

Surgical technique, postoperative rehabilitation and prosthetic design have improved greatly since mid-1900s, allowing most individuals who undergo amputation to return to high levels of functioning after reconstruction and rehabilitation. Amputations usually succeed in arresting the spread of infection or cancer. Amputation does not correct underlying conditions such as PVD or diabetes, which will still require medical treatment. Repeat surgery may sometimes be necessary in these individuals to remove more of a limb or, in advanced stages of diabetes or PVD, another limb. Although loss of part or all of an extremity always produces some degree of permanent disability, individuals undergoing amputation of a lower extremity are highly likely to be ambulatory. Younger individuals even have prostheses that encourage a return to recreational activities and competitive sports. Upper extremity prostheses typically provide partial return of normal function. However, amputations of fingers, and especially the thumb, often reduce the ability to perform tasks involving manual dexterity.

Source: Medical Disability Advisor



Rehabilitation

Rehabilitation after amputation varies greatly, depending on which body part is amputated and what amputation level is involved. In the early stages of rehabilitation following amputation, the most important considerations are to control pain and swelling and to avoid infection. Cold treatments, such as cold packs with or without compression, cause blood vessels to become smaller, helping to control excess bleeding and swelling of soft tissues. Physical therapists often combine various cold treatments with electrical stimulation. If extremity pain is severe and persists for extended periods of time, transcutaneous electrical nerve stimulation (TENS) may be helpful. Electrical stimulation methods used in physical therapy decrease pain by producing an electrical response in the muscles around the region that was traumatized.

Once pain and swelling have subsided, rehabilitation then focuses on returning range of motion and strength to the remaining joints of the extremity (or residual limb) following amputation. Maintaining the flexibility of specific muscles will help the individual function as normally as possible. For example, if the amputation is below the knee, keeping the hamstrings flexible is critical. If the amputation is above the knee, therapy focuses on the hip muscles, both in front and in back of the thigh.

Strengthening the residual upper or lower limb begins early in rehabilitation. Regarding lower extremity amputations, walking exercises (gait training) with the use of a temporary prosthesis are often indicated and started when appropriate. A temporary prosthesis allows a predetermined amount of weight to be placed on the involved limb and enables the individual to progress with exercises while the size of the residual limb stabilizes, allowing a permanent prosthesis to be fitted.

The upper or lower extremity amputee depends heavily upon muscles to control the prosthesis. The therapist will instruct the amputee in muscle strengthening exercises. Similarly, exercises related to functional training are important in preparing the individual for physical demands at home and for the return to work. These activities include ascending and descending stairs or repeatedly practicing going from sitting to standing. Upper extremity activities include dressing and other self-care requiring reaching, pulling, and grasping. Such activities more closely match normal requirements of activities of daily living (ADL).

The therapist will instruct the individual in a home exercise program that gradually progresses in difficulty up to the date of discharge. The final step is to incorporate activities that resemble work requirements with patient education regarding placement and removal of the prosthesis, so that the individual may successfully return to home and work.

Source: Medical Disability Advisor



Complications

Complications from an amputation include blood loss, infection, hematoma, necrosis, contractures, neuromas, and phantom limb pain, as well as other psychological difficulties.

Individuals who have undergone amputation may continue to perceive an image of the intact limb, which may result in falls upon arising from sleep. It is not unusual for individuals who have lost a limb through trauma to recall the incident so vividly that insomnia, concentration impairment, trembling, and speech impediments may result. Phantom pain, or pain associated with the amputated limb, can be a persistent problem that may be difficult to correct. Estimates are that 70% of amputees experience phantom pain (May 627).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work restrictions or accommodations vary according to the site of the amputation. The individual may require wheelchair accessibility or retraining for a new job. Lower extremity amputations may have limitations in any of the following: standing, working at unprotected heights, climbing, balancing, or operating foot controls. Upper extremity amputations may have limitations regarding the manipulation of objects, lifting, carrying, and using mechanical devices.

Source: Medical Disability Advisor



References

Cited

Bowker, HK, and JW Michael, eds. "Chapter 2c." Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. 2 ed. Rosemont, IL: Academy of Orthopedic Surgeons, 1992. Orthotics and Prosthetics Library. Digital Resource Foundation for the Orthotics & Prosthetics Community. 7 Jan. 2008 <http://www.oandplibrary.org/alp/chap02-03.asp.>.

May, Bella. "Assessment and Treatment of Individuals Following Lower Extremity Amputation ." Physical Rehabilitation: Assessment and Treatment. Eds. Susan B. O'Sullivan, et al. Philadelphia: F.A. Davis Company, 1994. 619-644.

General

"Hospital Discharge Rates for Nontraumatic Low Amputation by Diabetic Status--United States." Centers for Disease Control and Prevention. U.S. Department of Health and Human Services. 8 Sep. 2004 <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5043a3.htm>.

"Limb Loss in the United States." Amputee Coalition of America. 8 Sep. 2004 <http://www.amputee-coalition.org/fact_sheets/limbloss_us.pdf>.

Source: Medical Disability Advisor






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