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, Toe


Related Terms

  • Terminal Syme Amputation
  • Toe Removal or Excision

Specialists

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

Comorbid Conditions

  • Bleeding disorders
  • Cardiovascular disease
  • Diabetes mellitus
  • Obesity
  • Pre-existing vascular insufficiency
  • Pulmonary disease

Factors Influencing Duration

The underlying disease condition, complications, number of toes removed, individual's psychological status, and individual's job requirements may influence length of disability.

Medical Codes

ICD-9-CM:
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)

Overview

Surgical amputation of part or all of a toe usually is necessary because of trauma or diseases associated with poor blood supply or nonhealing ulcers.

Diseases that can cause damage leading to toe amputation include diabetes, peripheral vascular disease, osteomyelitis, injury, infection, impaired immune function, tumors, frostbite, nerve injuries, and congenital deformities. Interruption of blood supply to the toe (gangrene) may also lead to partial foot amputation necessary to remove (débride) infected or dead (necrotic) tissue.

Foot ulcers caused by diabetes are responsible for 85% of nontraumatic amputation in the lower extremity and toes (up to 15% of individuals with diabetes will experience a foot ulcer during their lifetime) (Pinzur). Individuals with peripheral neuropathy or those who develop bunions, hammer toes, claw toes, or mallet toe deformities that result in tissue swelling, ulcer formation, and infection are at increased risk for toe amputation. Also, individuals with impaired autonomic function may develop dry, cracked skin which allows access for bacterial infection that may precede amputation.

Traumatic injury such as crushing, mangling, or partial amputation may block blood supply to such an extent that surgical intervention such as partial traumatic amputation may be necessary. Birth defects (congenital) such as extra toes (polydactyly) may require surgical amputation to remove the extra digit. Recurrent infection and pain from an ingrown toenail of the great toe may lead to amputation of part or all of the great toe (terminal Syme amputation). The great toe may also be amputated in order to harvest the digit for thumb reconstruction, and the second and third toes may be amputated to use for finger reconstruction. However, the fifth toe is the most commonly amputated, usually as a result of its propensity to lift up and create friction against the fourth toe.

Source: Medical Disability Advisor



Reason for Procedure

Severe and irreparable damage to the toe from disease, trauma, loss of blood supply (ischemia), infection, tumor, nerve injury, or congenital abnormality may lead to amputation. Individuals with arterial disease (atherosclerosis) or a blood clot (thrombosis) that blocks or interrupts blood supply to the toe may develop tissue death (gangrene). Amputation may also be necessary to prevent the spread of infection, bone cancer, or skin cancer. The goal for toe amputation is to remove damaged tissue and relieve pain while preserving healthy tissue and foot function.

In some individuals who have had severe hand injury, one or several toes may be amputated for transplantation onto the affected upper extremity.

Source: Medical Disability Advisor



How Procedure is Performed

A general or regional anesthesia may be used. The skin is cleaned and an incision made, in a flap fashion if possible, to enable easier postoperative skin closure. The type of skin incision may vary according to which toe is involved. Tendons are divided and allowed to retract to the level of the intended bony stump. Nerves and blood vessels are identified and then clamped and tied off (ligated), or sealed through heat (cauterized). A cut is 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. The remaining end of the bone is rasped smooth. In the case of great toe amputation at the junction of the toe with the foot (metatarsophalangeal joint), small bones within the tendon (sesamoid bones) may also be removed. ("Ray amputation" refers to removal of a toe and part of the corresponding metatarsal bone.) Following amputation, a flap of skin and soft tissue is then positioned to cover the cut bone or joint surface, and stitched to the adjacent skin with nonabsorbable sutures.

A terminal Syme amputation of part of the last bone of the toe (distal phalanx) is done via an elliptical incision and involves resection of the toenail, nail bed, and approximately half of the distal phalanx, usually of the great toe. After the initial skin incision, the flexor and extensor tendons on the part of the distal phalanx closest to the body (proximal distal phalanx) are left intact if possible. Nerves and vessels are clamped off or tied, and the bone is shortened and contoured smoothly part-way along the distal phalanx. The nail bed including the toenail is removed. The wound is closed by placing the skin flap over the stump and suturing the skin.

If there is an active infection, a drain is inserted into the wound and then removed in 24 to 72 hours. Sometimes, in severely infected wounds, the wound is left open to fill in (granulate) by the healing process known as secondary intention. If the wound is left open, it is packed with moist dressings that are changed daily until healed.

Source: Medical Disability Advisor



Prognosis

Prognosis depends upon which toe has been amputated, how many toes were removed, and whether one or both feet were affected. Amputation of the great toe or even all five toes usually does not impair walking ability, although there may be increased difficulty walking quickly or running due to decreased push-off from the foot. Amputation of the second toe may result in eventual hallux valgus, in which the great toe migrates laterally toward the space left behind by the absent second toe. Amputation of the third, fourth, or fifth toes usually results in little disability.

Source: Medical Disability Advisor



Rehabilitation

Toe amputation typically should not require rehabilitation or impede activities of daily living once healing has occurred. If rehabilitation is necessary, then the goal is to return the individual to full function with a painless foot. Treatment duration is related to any complications or difficulty standing or walking.

Protocols for rehabilitation will be dictated by the treating physician, and must be based on the individual's postoperative status.

Modalities such as cold and compression wrapping may be used when necessary to control pain and edema. The physical therapist may instruct the individual in gait training using appropriate assistive devices during the healing phase. When indicated, the therapist progresses the individual's foot and ankle range of motion, sensory awareness (proprioception), and strengthening exercises until a normal gait and full function are evident.

Source: Medical Disability Advisor



Complications

Complications include risks of surgery such as infection, poor wound healing, and death. Following amputation, there may be phantom limb pain, contractures, necrosis, hematoma, or neuroma.

Individuals with increased risk for surgical complications include those with an infection, poorly controlled diabetes, poor blood circulation or bleeding disorders, hypertension, congestive heart failure, kidney failure, and habit of smoking.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Depending on the toe(s) amputated, individuals may need accommodation for increased periods to rest and elevate the leg during the recovery phase. The individual may need to use a special postoperative shoe and possibly an assistive device such as a walker, crutches, or cane for protected weight bearing. The ability to squat and reach from the tiptoes may be impaired.

Source: Medical Disability Advisor



References

Cited

Canale, S. Terry. "Amputations About Foot." Campbell's Operative Orthopaedics. 10th ed. St. Louis: Mosby, Inc., 2003. 555-558. MD Consult. Elsevier, Inc. 12 Oct. 2004 <http://home.mdconsult.com/das/book/41552076-2/view/1111?sid=294441657>.

Pinzur, Michael S. "Diabetic Foot." eMedicine. Ed. John S. Early. 2 Jun. 2004. Medscape. 12 Oct. 2004 <http://emedicine.com/orthoped/topic387.htm>.

Vinik, A. I., and Anahit Mehrabyan. "Diabetic Neuropathies." Medical Clinics of North America 88 4 (2004): 947-999. MD Consult. Elsevier, Inc. 12 Oct. 2004 <http://home.mdconsult.com/das/journal/view/41552076-2/N/14938888?ja=433163&PAGE=1.html&sid=294436506&source=>.

Source: Medical Disability Advisor






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