| Traumatic amputation of the foot refers to severing of the foot, or a portion of the foot, from the leg as a result of trauma. Such an amputation may be complete or partial (the foot remains partially attached to the leg by a muscle or tendon) and can result in severe blood loss and shock. The three most common forms of traumatic amputation are guillotine, crush, and avulsion injuries. Guillotine injuries cause less tissue disruption and thus have the best outcomes for reattachment.
Traumatic incidents that may cause foot amputation include car or motorcycle accidents, heavy machinery accidents involving manufacturing or farming equipment, or explosions such as combat injury.Risk: Individuals at greatest risk of traumatic foot amputation include those who operate heavy equipment and machinery, motorcycle drivers, and users of power equipment (e.g., electric saws, lawn mowers and snow blowers). Incidence and Prevalence: Major amputations of the lower extremities, including foot amputations, account for approximately 85% of all amputation cases, 25% of which are traumatic amputations; lower extremity amputations occur on the left and right side of the body in equal proportions (Ellis). |
Source: Medical Disability Advisor
| History: If conscious, the individual will report a history of a recent traumatic event resulting in severe injury to the foot. Individual may complain of pain, dizziness, and nausea. Physical exam: An immediate physical examination is conducted at the accident site to determine the individual’s overall physical status. Vital signs, level of consciousness, airway compromise, and degree of blood loss are evaluated. A quick assessment of the entire body is done to detect any other injuries that may be life-threatening or require immediate attention. Once the individual is stable, he or she should be transported as quickly as possible to the nearest medical center for further evaluation. There, the injury is thoroughly evaluated to determine the extent of damage to adjacent bones, tissues, skin, muscles, nerves, and blood vessels. The decision to attempt reattachment of the foot hinges on the condition of the severed foot and the reattachment site. Tests: Arteriography (x-ray of arteries after injection of dye) or ultrasound scanning (duplex Doppler imaging) can assess the degree of blood vessel (vascular) injury at the amputation site. Imaging studies (x-rays, MRI, CT) of the amputated part and stump are done to look for fractures and assess the status of adjacent joints. Laboratory studies such as complete blood count (CBC) and coagulation studies help monitor blood loss and detect evidence of other injuries. Later laboratory studies help determine whether infection may be present and spreading into the blood stream or adjacent tissue from the site of trauma. |
Source: Medical Disability Advisor
| Initial field and emergency treatment of traumatic amputations of limbs focuses on controlling bleeding and treating shock. Bleeding can usually be controlled by applying pressure to the site. In rare cases where direct pressure does not adequately control bleeding, tourniquets should be used judiciously to avoid impairing circulation to viable tissues. The stump should be elevated, immobilized and covered with a moist sterile dressing. In the emergency department, surgical clamps, cauterization or sutures may be used to stop bleeding from severed vessels.
Signs of shock (low blood pressure and rapid pulse) indicate the need for administration of intravenous fluids to replace lost blood; blood transfusions may also be necessary.
Immediate care of the amputated foot begins at the accident site. If at all possible, the severed body part is retrieved, wrapped in a moist sterile dressing, placed in a sterile plastic bag, and kept cool. It's important to avoid freezing the body part. Prompt and careful management of the amputated part reduces the damage to tissue from lack of circulation and increases the chances of successful reattachment (replantation).
Surgical treatment is always necessary following a traumatic amputation. Based on the condition of the amputated part and the stump, either surgical removal (amputation) or replantation is performed.
Factors that may influence treatment include the age of the individual, overall health including any underlying medical conditions, smoking status, circulatory disorders, pre-existing psychosocial problems, work and recreational activities of the individual, and the desires and realistic expectations of the individual and family.
Reattachment of a foot that has suffered significant and extensive damage to the arteries, veins, nerves, muscles, joints and bones is usually unsuccessful. In such situations, primary amputation is the better alternative. In traumatic amputations, the wound is usually left open to drain and closed later. At the time of wound closure, the bone end is cut clean and a generous length of skin and muscle tissue is left beyond the point of the bone amputation. Blood vessels are tied, nerves severed, and the skin flaps and muscles are stitched over the bone end to form a smooth, rounded stump.
If the entire foot has been amputated at the ankle (Syme's amputation), the tough heel skin is retained to cover the stump. The individual can then bear weight on the stump without having to use prosthesis. In partial foot amputations (where a portion of the foot is salvaged), the stump can be fashioned to interface with "shoe filler" in a manner that provides the most comfort and function. In replantation, reconnecting the blood vessels, nerves, muscles, and bones usually restores some level of function to the severed limb. Multiple operations for reconstruction and skin grafts are usually necessary.
Ideally, reattachment of the amputated part is performed within 4 to 6 hours after injury, but success has been reported up to 24 hours after the injury if the amputated body part has been kept cool.
In replantation surgery, the bone ends are shortened to eliminate tension on the repaired vessels. The bone is stabilized with wires followed by repair of the tendon. Digital nerves and vessels are repaired with microsurgical instruments. Skin grafts or flaps may be required followed by closure of the skin. |
Source: Medical Disability Advisor
| Long-term outcome for amputees has improved as a result of advances in early emergency treatment and critical care management, new surgical techniques, early rehabilitation, prosthesis fitting, and new prosthesis design. Most current limb replantation techniques have been moderately successful, but incomplete nerve regeneration remains a major limiting factor. Reattachment does not guarantee a functional foot. In spite of repeated, lengthy, and elaborate reconstructive surgeries, functional limitations may be severe.
After losing a foot, an individual's mobility depends on several factors including the individual’s age, attitude, general health, amputation location, and a properly fitted prosthesis. Most individuals adapt to the loss of a foot and remain physically active. |
Source: Medical Disability Advisor
| Note on research and authorship The goal of rehabilitation following a traumatic foot amputation is the return of the individual to as functional a lifestyle as possible and to use pre-injury status as the ultimate goal.
After surgical management of a traumatic foot amputation, rehabilitation may begin as soon as the individual is medically stable. Throughout the early phase, in addition to exercise, careful attention must focus on controlling stump edema, wound care and stump desensitization. There is evidence supported by randomized controlled trials for the use of semi-rigid and plaster cast sockets to promote wound healing in patients where the blood supply of the stump is uncompromised (Wong; Vigier). This also may lead to earlier prosthetic fitting (Wong).
Rehabilitation should emphasize strengthening exercises of the upper extremities, primarily the shoulder depressors to facilitate use of assistive devices for gait, the uninvolved lower extremity and the proximal joints of the involved lower extremity (Panadian). When indicated, rehabilitation should begin to focus on stretching and strengthening of the residual limb. Full range of motion of all joints on the involved limb is critical for early prosthetic fitting (Panadian). Once full range is achieved, strengthening of all muscle groups of the involved lower extremity is indicated.
Although up to 70% of individuals who suffer a traumatic amputation experience phantom limb pain, there is little evidence from randomized control trials to guide clinicians in effective treatment (Halbert). Common clinical treatment includes desensitization of the stump through the application of sensations such as pressure, massage, and vibration.
An important component of rehabilitation is assessing not only the physical status of the individual but also the mental and social health outcomes. In-patient rehabilitation may be beneficial to those requiring more support including future vocational options (Pezzin). |
| FREQUENCY OF REHABILITATION VISITS | | Surgical | |
| Physical Therapist | | At least 24 visits within 8 weeks | |
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| 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
| Bleeding, swelling, and infection are the most frequent complications of amputation. Others include wound breakdown, pain, loss of sensation in the sole of the foot, persistent bone infections (chronic osteomyelitis), joint contracture, deformity, and cold intolerance of the replanted foot or portion of the limb remaining intact. The body may also reject the replanted foot resulting in a potentially serious systemic infection.
A less common complication of reattachment occurs if the tissue suffers damage and death (necrosis). This dead tissue can produce large amounts of tissue byproducts that tax the kidneys and ultimately lead to kidney dysfunction.
Individuals with a complete amputation may experience phantom limb sensations (pain, numbness, tingling, itching) where the foot used to be. These sensations can vary in frequency, duration and intensity but may be very debilitating. In those with surgical amputations rather than replantation, a painful, noncancerous tumor of nerve tissue (neuroma) sometimes develops in the stump. |
Source: Medical Disability Advisor
| Following either replantation or amputation, sensory and physical impairments of the stump or reimplanted foot limit the individual's ability to perform tasks that require prolonged standing or walking. Likewise, the limb may be more sensitive and susceptible to cold and cold injuries. Reassignment to jobs that can be performed while sitting should be considered. Mobility of the individual will likely be reduced and should be considered in the return to the work environment. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Did the diagnostic workup determine important factors such as the length of time between injury and treatment and condition of the amputated foot?
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Were appropriate diagnostic tests done (i.e., x-rays, nerve and muscle studies, vascular studies) to determine the degree of damage to bone, skin, muscles, nerves, and blood vessels?
Regarding treatment:
- Did individual receive emergency care that involved controlling bleeding, administering intravenous fluids, and supporting blood pressure, as needed?
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Was the amputated foot cared for properly by placing it in a plastic bag and keeping it cool?
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Was individual promptly evaluated by appropriate specialists (i.e., plastic surgeon experienced in replantation or orthopedic surgeon)?
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Was the treatment appropriate for the type of injury present?
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Were multiple surgeries necessary to repair structural damage?
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Was a prosthesis or artificial foot required?
Regarding prognosis:
- Considering the general health of individual and the type of surgery required, what was the expected outcome?
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Has adequate time elapsed for recovery?
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Did individual receive early rehabilitation? Has individual participated in appropriate physical and occupational rehabilitation programs? If not, what can be done to facilitate participation (transportation, psychological counseling)?
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Are there signs of a poorly fitting prosthesis such as blisters, redness, or swelling of the limb? Has the fit been re-evaluated?
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Did individual experience any surgical complications such as bleeding, bone or tissue infection, sensory loss, or development of neuroma that may influence length of disability and outcome?
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Does individual smoke or have a pre-existing vascular insufficiency? Does individual have any other conditions (i.e., advanced age, diabetes mellitus, obesity, cardiovascular disease, pulmonary disease, bleeding disorders) that may slow recovery?
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Does individual have feelings of hopelessness, a poor appetite, or other signs of depression? If so, has individual received behavioral or psychological interventions to address the depression?
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Does individual participate in a support group for amputees? Does individual have other support systems (family or friends)?
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Source: Medical Disability Advisor
| Ellis, Walter, Stephen Kishner, and James Monroe Laborde. "Gait Analysis after Amputation." eMedicine. Eds. John S. Early, et al. 2 Jan. 2007. Medscape. 19 Nov. 2008 <http://emedicine.com/orthoped/topic633.htm>.Halbert, J., M. Crotty, and I. D. Cameron. "Evidence for the Optimal Management of Acute and Chronic Phantom Pain: A Systematic Review." Clinical Journal of Pain 18 2 (2002): 85-92. National Center for Biotechnology Information. National Library of Medicine. 17 Jul. 2008 <PMID: 11882771>. Pandian, G., and K. Kowalske. "Daily Functioning of Patients with an Amputated Lower Extremity." Clinical Orthopaedics and Related Research 361 (1999): 91-97. National Center for Biotechnology Information. National Library of Medicine. 17 Jul. 2008 <PMID: 10212601>. Pezzin, L. E., T. R. Dillingham, and E. J. MacKenzie. "Rehabilitation and the Long-Term Outcomes of Persons with Trauma-Related Amputation." Archives of Physical and Medical Rehabilitation 81 3 (2000): 292-300. National Center for Biotechnology Information. National Library of Medicine. 17 Jul. 2008 <PMID: 10724073>. Vigier, S., et al. "Healing of Open Stump Wounds after Vascular Below-knee Amputations: Plaster Cast Socket with Silicone Sleeve Versus Elastic Compression." Archives of Physical and Medical Rehabilitation 80 10 (1999): 1327-1330. National Center for Biotechnology Information. National Library of Medicine. 17 Jul. 2008 <PMID: 10527096>. Wong, C. K., and Joan E. Edelstein. "Unna and Elastic Postoperative Dressings: Comparison of their Effects on Function of Adults with Amputation and Vascular Disease." Archives of Physical and Medical Rehabilitation 81 9 (2000): 1191-1198. National Center for Biotechnology Information. National Library of Medicine. 19 Nov. 2008 <PMID: 10987161>. |
Source: Medical Disability Advisor
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