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, Finger or Thumb


Related Terms

  • Digital Amputation
  • Finger Amputation
  • Thumb Amputation

Specialists

  • Ergonomist
  • Hand Surgeon
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physical Therapist
  • Plastic Surgeon
  • Prosthetist
  • Vascular Surgeon

Comorbid Conditions

Factors Influencing Duration

The underlying disease process or reason for the amputation, the particular digit affected, whether the dominant or nondominant hand is affected, the individual's job requirements, and complications may all influence the length of disability. Loss of the thumb may severely affect hand function and increase duration. Because most manual skills are hampered by partial or total loss of the thumb, preservation, reattachment, reconstruction, or replacement of a thumb has great functional merit.

Medical Codes

ICD-9-CM:
84.01 - Amputation and Disarticulation of Finger
84.02 - Amputation and Disarticulation of Thumb
885.0 - Amputation of Thumb, Traumatic, Complete, Partial, without Mention of Complication
885.1 - Amputation of Thumb, Traumatic, Complete, Partial, Complicated
886.0 - Traumatic Amputation of Other Finger(s) (Complete) (Partial), without Mention of Complication
886.1 - Traumatic Amputation of Other Finger(s) (Complete) (Partial), Complicated

Overview

Amputation is the removal of a body part by trauma or surgery. Amputation of a finger or thumb (digit) by a surgical procedure is performed to remove (excise) all or part of a digit that has been irreparably damaged by injury or illness or that has been accidentally severed (traumatic amputation) from the hand and is not likely to survive if surgically repaired (not viable). Surgical intervention may be necessary to complete a partial traumatic amputation that has occurred in an accident such as during use of power tools. Injury and disease may also functionally amputate a digit by crushing, mangling, stiffening, necrosing, or otherwise destroying all or part of it beyond hope of useful recovery. In such cases, salvage may be impossible, and surgical amputation of the affected digit is justified as a resource to improve overall hand function. Deciding at what anatomic level to amputate a digit is crucial to preserving as much digital length and function as possible. Every effort is made to preserve or salvage the thumb, the most important digit from a functional standpoint for the hand. Severe damage to fingers and thumb that may necessitate amputation includes that resulting from loss of blood supply, peripheral vascular disease, injury, infection, tumors, nerve injuries, and congenital abnormalities.

Source: Medical Disability Advisor



Reason for Procedure

Irreversible loss of the blood supply (ischemia) to a finger or thumb is the only absolute indication for amputation. Other major indications may include infection, loss of soft tissue coverage, or when the remaining irreparably damaged digit impairs overall hand function. Further damage to any part of the affected hand from additional injury resulting from a lack of sensation, motion, or function of an already injured digit also may necessitate amputation. Although advances in surgical technique permit successful re-implantation of a severed digit, the degree of damage to the digit or the hand will help determine whether amputation will produce a better functional outcome for the individual.

The goals of amputation are to (1) preserve the functional length of the digit, (2) provide durable coverage, (3) preserve useful sensibility, (4) prevent symptomatic neuroma development, (5) prevent adjacent joint contracture, (6) allow early return to work, and (7) allow early fitting of a prosthetic, if applicable (Wilhelmi). Different anatomical levels of amputation require adjustments in goals.

Source: Medical Disability Advisor



How Procedure is Performed

Various procedures have been described for amputations of fingers and the thumb at different anatomic levels. Many of these involve advancement of flaps of skin and soft tissue to achieve greater wound coverage and to maintain length, which often results in better function. Such hand surgery is complex and should be performed by an experienced hand surgeon. The surgical procedure will involve providing a stable, painless stump with greatest possible mobility and least interference from the remaining tendon, with preservation of joint function in remaining joints, if any. Soft-tissue coverage of the stump my include use of a flap of local skin from the amputated finger, if possible, although skin from other parts of the body may be used instead. Skin grafts may be used for larger wounds.

All procedures described for finger amputations are performed in a similar manner. First, a skin incision is made, often in a flap fashion. All blood vessels, including the digital arteries, are then identified, clamped, and / or tied off (ligated). The tendons are then identified and severed. In some cases, they are allowed to retract, but in others, they are sewn (sutured) to other tendons to maintain stability of the stump. A cut is then made through the bone (osteotomy) or through the joint (disarticulation), and the amputated segment is then detached and sent to the pathology department for examination. Bone under the stump must be smooth, requiring that bone chips be removed and the stump bone be filed until smooth. The nerve end is positioned away from the stump end to try to avoid abnormal tissue growth at the stump of the nerve (neuroma formation). A flap of skin and soft tissue is then advanced into position to cover the cut bone or joint surface and sutured to the adjacent skin. If infection develops within the wound, a drain may be inserted for 24 to 48 hours, or the wound is left open prior to a secondary wound closure. Sometimes, in severely infected wounds, the wound is left open to fill in (granulate) by the healing process known as secondary intention.

Thumb amputations can severely affect hand function. The anatomical level of amputation determines the extent of the functional deficit, so preserving thumb length is a more critical factor than mobility. Re-implantation usually provides the best return to function, but is not always possible due to extent of injury to the severed digit or the hand. In some cases of complete thumb amputation, the index finger is repositioned or the big toe is attached to the thumb stump to allow grasp and pinch to be restored.

Digital amputations may require a ray amputation. Ray amputations remove the injured finger at the metacarpal base and close the gap between fingers. Ray amputations use dorsal and circumferential incisions that allow a longer skin flap for better soft-tissue coverage, helping to prevent contracture at the finger web space. Because the index finger is second most important to the thumb, especially in the pinch function, individuals who lose this finger often will transfer function to the middle finger. Index ray amputation is appropriate if an index stump could potentially impede middle finger functioning in the pinch function. Ray amputations may also be used for middle and ring finger amputations, but the wider gap created may result in loss of grip strength.

Injury of the small finger is considered to be the most difficult to rehabilitate because it becomes stiff and immobile, interfering with hand function. For this reason, ray amputation is often used for the small finger, achieving both a better aesthetic result and functional outcome.

Source: Medical Disability Advisor



Prognosis

Even after amputation, the outcome can be positive if the thumb is spared. However, results tend to be poor with loss of the thumb or amputation of multiple digits. Results are better if enough finger length is preserved to allow some grasping function.

Source: Medical Disability Advisor



Rehabilitation

Individuals who sustain amputation of a finger or thumb often begin rehabilitation immediately following surgery. Although there are various ways to medically and surgically manage digital amputations, the goals of rehabilitation remain the same: preserve the functional length, preserve useful sensitivity, prevent symptomatic neuromas, prevent adjacent joint contractures, achieve short-duration morbidity, and enable the patient to perform tasks of daily life as quickly as possible (Dillingham). Depending on the severity of the injury (e.g., multiple digit amputation or thumb amputation), psychologists and social workers may also be part of the treatment team (Calandruccio).

A hand, occupational, or physical therapist sees the individual approximately 2 to 3 times a week for the first 6 to 8 weeks. While the wound is open, the therapist monitors the wound, provides protective splinting, controls edema, and maintains range of motion for the uninvolved anatomical regions. The range of motion program for the involved digit at the amputation site adheres to and corresponds with the directives of the surgical plan and the stages of wound healing. The therapist and individual may passively stretch the involved thumb or finger joints to decrease the risk of a contracture. Individuals also perform active range of motion exercises to the uninvolved joints (Wilson).

Once the wound is closed, the therapist addresses desensitization/sensory re-education and scar management. Modalities such as heat and cold may be used to relieve pain and to relax the hand musculature at the outset of each treatment (Braddom). Strengthening exercises, crucial to restore hand function, are introduced once the amputation site is healed and follow the directives of the postoperative protocol and the stages of wound healing. For most surgical protocols addressing digital amputations, strengthening can begin at 6 to 8 weeks after surgery. Once the wound is healed, fine motor, functional, and work hardening activities are added to the therapy program.

A cosmetic prosthesis can be fitted once the amputation has healed and the residual stump is shaped. It is advisable for the prosthetist to be called in early during the stump-reshaping phase so that the therapy program may focus on the prosthetic goal. The prosthetic considerations directly relate to the level of the amputation. The digital prosthesis may be of considerable value aesthetically and can restore lost functional pinch (Bucchieri; Pillet).

If indicated, an ergonomist may be helpful in modifying the work environment to optimize employability. In some instances, a vocational counselor may be necessary, if the individual cannot return to the previous job secondary to this condition.

FREQUENCY OF REHABILITATION VISITS
Surgical
SpecialistAmputation, Finger or Thumb
Occupational / Hand / Physical TherapistOutpatient: up to 20 visits within 10 weeks
Surgical
SpecialistAmputation, Finger or Thumb
Occupational / Hand / Physical TherapistInpatient: daily
Surgical (reconstruction or prosthesis)
SpecialistAmputation, Finger or Thumb
Occupational / Hand / Physical TherapistOutpatient: up to 28 visits within 12 weeks
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Complications of amputations of the finger or thumb include infection, hematoma, necrosis, joint contractures, neuromas, and phantom sensations. If amputation does not arrest the progression of an infection, further infection of the hand, wrist, and arm may occur. Gangrene can result if blood supply to the hand is interrupted (ischemia). This would necessitate another amputation farther up the hand or arm (proximal amputation). A similar outcome can be seen when bone cancer that has resulted in amputation of a finger continues to spread into the hand. Hand function can be severely compromised if any of these complications occur.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Depending on the digit(s) amputated, individuals may need to be retrained to a new job. Loss of the thumb produces the most disability, as it is crucially important in grasp and pinch (opposition). Although individuals who have lost thumbs will not be able to effectively grasp tools, they may still be able to perform tasks that primarily involve the fingers (such as typing). Loss of one or two fingers is not as devastating as that of the thumb, as most individuals can still use their hands for most tasks. However, amputation of multiple fingers results in greater functional loss, including weaker grasp.

Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

Risk: Risk for additional amputation or shortening of the already amputated thumb or finger is dependent on the original mechanism of injury, the quality of the remaining tissue, the length of the digit, and the individual's general health.

Capacity: Function is affected by which digit or digits, associated soft tissue injuries, and pain level.

Tolerance: Once healing has occurred, pain is reduced, and tolerance is improved. One’s ability to function with pain is often affected by the concept of "loss body part." This will require sensitivity to the emotional aspect of an amputation.

Accommodations: The ability to accommodate provides for the opportunity for early return to work limited by capacity and tolerance.

Source: Medical Disability Advisor



Maximum Medical Improvement

60 to 90 days.

Source: Medical Disability Advisor



References

Cited

Braddom, Randolph L. Physical Medicine and Rehabilitation. 3rd ed. Philadelphia: W.B. Saunders, 2006.

Bucchieri, J., et al. "Restoration of Thumb Function After Partial or Total Amputation." Rehabilitation of the Hand and Upper Extremity. Eds. E. J. Mackin, et al. 5th ed. Philadelphia: Mosby, Inc., 2002.

Calandruccio, James H. "Chapter 14: General Principles of Amputations." Campbell's Operative Orthopaedics. Eds. S. Terry Canale and James H. Beaty. 11th ed. Philadelphia: Mosby Elsevier, 2008.

Dillingham, Timothy R., and Diana W. Braza. "Chapter 108: Upper Limb Amputation." Essentials of Physical Medicine and Rehabilitation. Eds. Walter R. Frontera, Julie K. Silver, and Thomas Rizzo. 2nd ed. Philadelphia: Saunders, Elsevier, 2008.

Pillet, J., and E. J. Mackin. "Aesthetic Hand Prosthesis: Its Psychologic and Functional Potential." Rehabilitation of the Hand and Upper Extremity. Eds. E. J. Mackin, et al. 5th ed. Philadelphia: Mosby, Inc., 2002.

Wilhelmi, Bradon J. "Digital Amputations." eMedicine. Eds. Joseph Sheppard, et al. 4 Nov. 2013. Medscape. 19 May 2014 <http://emedicine.medscape.com/article/1238395-overview>.

Wilson, R. L., and M. S. Carter-Wilson. "Rehabilitation After Amputations in the Hand." Orthopedic Clinics of North America 14 4 (1983): 851-872. National Center for Biotechnology Information. National Library of Medicine. 19 May 2014 <PMID: 6634096>.

Source: Medical Disability Advisor






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