Amputation (Traumatic), Lower Extremity

Risk: Four out of every five traumatic amputations occur in individuals between the ages of 15 and 40; the majority of these individuals (80%) are male (Murphy).

Incidence and Prevalence: Approximately 30,000 traumatic amputations occur each year in the US ("Traumatic Amputations").

History: It is important for physicians and surgeons to know both the circumstances that resulted in injury and the time interval between the accident and beginning of medical care. If 6 to 8 hours have elapsed since the leg was severed, tissue damage from lack of blood flow would prohibit reattachment of the severed part. Other important factors include the individual’s age, overall health, presence of underlying disease, previous illnesses, smoking status, pre-existing psychosocial problems, work and recreational activities, and desires and realistic expectations of the individual and family members.

Physical exam: The individual will be examined for blood pressure, heart rate, and multi-system, life-threatening injuries, including internal injuries, hemorrhage, shock, and adult respiratory distress syndrome (ARDS). Complete or partial amputation will be determined. Because reattachment of the leg is based on the condition of the severed leg and possible reattachment site, the degree of damage to bone, skin, muscles, nerves, and blood vessels will be evaluated. The mechanism of injury and location of traumatic amputation affect the viability of reattachment. If reattachment is not an option, location and degree of damage will influence suitability for prosthesis. As in therapeutic amputations, optimum function may be gained by preparing a site for prosthesis that is closer to the damaged part of the limb (distal amputation), while the risk of complications may be reduced if a greater portion of the damaged limb is removed (proximal amputation).

Tests: Vascular status, evaluated by laboratory testing and diagnostic imaging, is the primary criterion in determining whether to replant the amputated limb or prepare for eventual prosthesis use by completing the amputation. Laboratory tests will be performed to estimate the loss of blood and to rule out coagulation disorders, such as an inherited clotting deficiency or the complication of disseminated intravascular coagulation (DIC). Arteries may be x-rayed following an injection of a dye (arteriography) or examined by ultrasound imaging (duplex Doppler imaging) to assess the degree of blood vessel (vascular) injury at the amputation site and within the severed part. If the arteriogram shows that adequate blood flow could be re-established with replantation, the limb will be reattached. If adequate blood flow cannot be re-established, if the severed part is grossly contaminated or beyond reconstruction, or if tissue death (necrosis) has already occurred, completion of the amputation will be performed and a stump created for prosthesis.

The goal of rehabilitation following a traumatic amputation of the lower extremity is the return of the individual to as functional a lifestyle as possible and, ultimately, to use pre-injury status. The early emphasis of rehabilitation focuses on preparing the individual for a prosthesis. The time for prosthetic fitting will be guided by the treating physician.

After surgical management of a traumatic amputation, rehabilitation may begin as soon as the individual is medically stable. Throughout this early phase, in addition to exercise, careful attention must focus on shaping the stump, controlling stump edema, wound care and stump desensitization. Where the blood supply of the stump is uncompromised, evidence supported by randomized controlled trials has demonstrated the use of semi-rigid and plaster cast sockets to promote wound healing (Wong; Vigier). This also leads 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 (when possible) and the proximal joints of the involved lower extremity (when possible) (Pandian). 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 (Pandian). Once full range is achieved, strengthening of all muscle groups of the involved lower extremity is indicated.

Individuals experiencing a traumatic amputation may require equipment and home modifications to support an independent lifestyle. An occupational therapist can train the individual in activities of daily living and recommend useful equipment to promote independence.

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 for this problem (Halbert). Desensitization of the stump through the application of pressure, massage, and vibration may help mitigate pain.

An important component of rehabilitation is assessing the mental and social health outcomes of the individual, not only the physical status. In-patient rehabilitation may be beneficial to those requiring more support including future vocational options (Pezzin).