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 (Traumatic), Lower Extremity


Related Terms

  • AKA
  • Below-knee Amputation
  • BKA
  • Syme's Amputation
  • Traumatic Leg Amputation

Specialists

  • Clinical Psychologist
  • General Surgeon
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Prosthetist
  • Psychiatrist
  • Vascular Surgeon

Comorbid Conditions

Factors Influencing Duration

Any other unrelated injuries, such as head and internal injuries sustained in a motor vehicle accident, can contribute to length of disability. Concomitant underlying illness such as coronary artery disease may affect circulation in a reattached limb, slowing recovery. Psychological implications may include the individual’s perception of being "incomplete" compared to other people, and this perception may retard progress.

Medical Codes

ICD-9-CM:
897.0 - Traumatic Amputation of Leg(s), Complete, Partial, Unilateral, Below Knee, without Mention of Complication
897.1 - Traumatic Amputation of Leg(s), Complete, Partial, Unilateral, Below Knee, Complicated
897.2 - Traumatic Amputation of Leg(s), Complete, Partial, Unilateral, at or Above Knee, without Mention of Complication
897.3 - Traumatic Amputation of Leg(s), Complete, Partial, Unilateral, at or Above Knee, Complicated
897.4 - Traumatic Amputation of Leg(s), Complete, Partial, Unilateral, Level Not Specified, without Mention of Complication
897.5 - Traumatic Amputation of Leg(s), Complete, Partial, Unilateral, Level Not Specified, Complicated
897.6 - Traumatic Amputation of Leg(s), Complete, Partial, Bilateral [Any Level], without Mention of Complication
897.7 - Traumatic Amputation of Leg(s), Complete, Partial, Bilateral Any Level, Complicated

Overview

Traumatic amputation of a lower extremity is most often the non-surgical separation of a leg, or part of a leg, from the body. An amputation can be complete or incomplete (partial). In complete amputation, no connection remains between tissues, muscle, ligaments or tendons and the severed part; in partial traumatic amputation, one or more of these connections remain.

Unlike surgical amputation, which is a planned procedure to remove a limb for arterial insufficiency, malignant tumor, burns, infection, or injury, traumatic amputation is the accidental severing of a limb. It is often the result of accidents involving the following: cars, motorcycles, heavy machinery (farming or industrial equipment), workplace equipment (including mechanical cutting instruments such as chain saws or lawn mowers), or the impact of explosions (including building collapses, ignited gasses, or combat).

The immediate concerns following traumatic amputation are lifesaving measures, such as treating or preventing hemorrhage and infection, and evaluating for multi-system injuries. An immediate decision must also be made by a surgeon about salvaging the body part. If the surgeon determines that the separated body part can be salvaged, immediate surgery is necessary to reattach the severed limb to the body. Microsurgery allows the reconnection of very small severed blood vessels and nerves, making it possible to reattach severed limbs (replantation). The determination to preserve the part depends upon the individual’s overall health, the presence of other injuries, blood flow and vascular status, and the condition of the severed limb. If reattachment is not a viable option, the surgeon will also evaluate the extent of damage at the amputation site and suitability for eventual prosthesis use. Such surgical treatment and rehabilitation will be similar to surgical amputation procedures performed to treat irreversible vascular damage resulting from other traumatic injuries (e.g., crush injuries), disease (e.g., diabetes, peripheral vascular disease, bone and skin cancer), burns, and uncontrollable infection.

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

Source: Medical Disability Advisor



Causation and Known Risk Factors

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).

Source: Medical Disability Advisor



Diagnosis

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.

Source: Medical Disability Advisor



Treatment

At one time, the only treatment for a lost limb was to create skin flaps and suture them over the severed end of bone with remaining muscle to form a smooth and rounded stump. More recently, advances in surgical techniques, rehabilitation, and prosthesis design have made it easier to prepare a stump and fit a prosthesis. Today, for example, prostheses can be attached by suction rather than by straps, making them easier to put on and take off, and less likely to come off accidentally. Emergency care professionals trained in traumatic amputation management can take significant measures, either at the accident site or hospital emergency room, to avoid tissue damage or contamination, supporting successful reattachment of a limb, while also helping to reduce amputation-related morbidity and mortality. These measures may involve timely rescue of an entrapped extremity at the accident site, sealing it in clean or sterile wrapping, and placing it on ice for transport. Bleeding at the amputation site must be controlled and other injuries may also need immediate treatment.

When reattachment will not provide a functional extremity, a more effective alternative may be planned surgical amputation (primary amputation) at a level above the injury. In traumatic amputations, the wound is usually scraped clean (debridement), 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 bone amputation. Blood vessels are tied, nerves severed, and the skin flaps and muscles are stitched (sutured) over the bone end to form a smooth, rounded stump, one that is usually suitable for prosthesis.

When reattachment is a viable option, the procedure involves reconnecting blood vessels, nerves, muscles, and bones to restore the severed limb. Multiple operations are typically performed for reconstruction, and skin grafts are usually necessary as well.

After either reattachment and reconstruction, or primary amputation, a post-operative fitness program is helpful because of the added energy expenditure required to walk with a replanted leg or with a prosthesis following an amputation.

Source: Medical Disability Advisor



Prognosis

After losing a leg, an individual's mobility depends on several factors including age, attitude, general health, the location of the amputation, and a properly fitted prosthesis. The individual's mental attitude is important. Some individuals remain physically active; others choose a life of confinement to wheelchairs. Young, healthy individuals usually adapt well to their prostheses and lead active lives, even returning to work and sports, while the outcome for older or debilitated individuals may be of a more sedentary nature. Physical therapy is important in the long-term outcome of amputees, as is a close relationship with the prosthetist. Many individuals have some degree of phantom pain that may require treatment. Individuals may experience depression and other psychological problems following the amputation, particularly initially. Appropriate counseling and support groups may be helpful in coping with these issues.

Source: Medical Disability Advisor



Rehabilitation

The goal of rehabilitation following a traumatic lower extremity amputation is the return of the individual to as functional a lifestyle as possible, using pre-injury status as the ultimate goal.

After surgical management of a traumatic lower extremity amputation, rehabilitation may begin as soon as the individual is medically stable. Initial treatment includes edema control, shaping of the residual limb, wound healing, contracture prevention, and pain management (Frontera). Semi-rigid or conventional plaster cast sockets may be used to promote wound healing in individuals where the blood supply of the stump is uncompromised (Johannesson). The early phase of rehabilitation also focuses on strengthening exercises and stump desensitization.

Rehabilitation should emphasize strengthening exercises of the upper extremities, primarily the shoulder stabilizers and depressors, to facilitate the use of assistive devices for gait. Strengthening should also focus on the uninvolved lower extremity and the proximal joints of the involved lower extremity (Frontera). When indicated, rehabilitation should include stretching and strengthening of the residual limb. Full range of motion of all joints in the involved limb is critical for early prosthetic fitting (Frontera). 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 of phantom limb pain includes desensitization of the stump through the application of sensations such as pressure, massage, and vibration. Mirror therapy may also be useful for some patients (Moseley; Hegmann).

An important component of rehabilitation is assessing not only the physical status of the individual but also the mental and social health outcomes. Inpatient rehabilitation may be beneficial to those requiring more support and should include the exploration of future vocational options (Frontera).

FREQUENCY OF REHABILITATION VISITS
Surgical
SpecialistAmputation (Traumatic), Lower Extremity
Physical TherapistAt least 24 visits within 8 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

Reattachment does not guarantee a useful limb. In spite of repeated, lengthy, and elaborate reconstructive surgery, functional limitations may be severe. Wound breakdown can occur as well as skin irritations, infection, swelling, and limited range of motion as the result of joint contraction. There may also be pain, loss of sensation in the retained limb, persistent bone infections (chronic osteomyelitis), stiff joints, and deformity. In rare cases, the body may reject a reattached limb. Non-cancerous scarring of nerve tissue (neuroma) sometimes develops in the stump. Phantom limb pain and other psychological difficulties are common.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

The individual may no longer be able to perform duties that require sustained standing or walking. Work responsibilities may have to be modified to fit specific capabilities. A properly fitted prosthetic device may permit the individual to do some standing or walking.

Source: Medical Disability Advisor



Failure to Recover

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 work up determine important factors such as the length of time between injury and treatment and condition of the amputated extremity?
  • 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:

  • Was there significant tissue destruction, vascular injury, or bone injury?
  • Was replantation indicated?
  • Were multiple surgeries necessary to repair structural damage?
  • Was a prosthesis or artificial limb required?
  • Did amputation site fail to heal? Was culture performed on any drainage present in order to document infection? Was infection treated by incision, drainage, and antibiotic therapy?
  • Were other injuries sustained that complicate treatment and return to function?
  • Is there a stump problem like a neuroma or inadequate skin or soft tissue coverage that interferes with prosthesis use?
  • Has physical therapy resulted in maximum rehabilitation, or is additional therapy likely to improve strength, range of motion, or endurance and thus increase function?
  • Are there untreated issues like phantom pain or depression that are delaying recovery?

Regarding prognosis:

  • Considering the general health of individual and the type of surgery required, what was the expected outcome?
  • Has adequate time elapsed for recovery?
  • Is there evidence of physical deformity that impairs ambulation?
  • 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)?
  • Are signs evident of a poorly fitting prosthesis such as blisters, redness, or swelling of the limb? Was the fit re-evaluated?
  • 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?
  • Does individual smoke or have a pre-existing vascular insufficiency? Does individual have any other conditions (advanced age, diabetes mellitus, obesity, cardiovascular disease, immune suppression, pulmonary disease, bleeding disorders) that may slow recovery?
  • Does individual have feelings of hopelessness, a poor appetite, or other signs of mental depression? If so, has individual received behavioral or psychological interventions to address the mental depression?
  • Has infection spread beyond the level of the leg? Were follow-up x-rays and bone scans done to determine if additional bone removal (resection) is necessary?

Source: Medical Disability Advisor



References

Cited

"Traumatic Amputations." CHC Medical Library & Patient Education. Dr. Joseph F. Smith Medical Library. 10 Sep. 2004 <http://www.chclibrary.org/micromed/00068860.html>.

Gittler, Michelle. "Chapter 109 - Lower Limb Amputations." Essentials of Physical Medicine and Rehabilitation. Eds. Walter R. Frontera, Julie K. Silver, and Thomas Rizzo. 2nd ed. Philadelphia: Saunders, Elsevier, 2008.

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.

Hegmann, Kurt T., et al., eds. "Chapter 6: Chronic Pain." Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers. 2008 Revision 2nd ed. ACOEM, 2008. 73-502.

Johannesson, A., et al. "Comparison of Vacuum-Formed Removable Rigid Dressing with Conventional Rigid Dressing after Transatibial Amputation: Similiar Outcome in a Randomized Controlled Trial Involving 27 patients.." Knee Surgery, Sports Traumatology, Arthroscopy July 16 (2009): 361361-369.

Moseley, G. L., A. Gallace, and C. Spence, eds. "Is mirror therapy all it is cracked up to be? Current evidence and future directions." Pain 138 1 (2008): 7-10.

Murphy, Paul, et al. "Tramautic Amputations." EMSResponder.com. 22 Aug. 2006. Cygnus Business Media. 2 Jan. 2008 <http://www.emsresponder.com/features/article.jsp?id=3541&siteSection=16>.

Pandian, G., and K. Kowalske. "Daily Functioning of Patients with an Amputated Lower Extremity." Clinical Orthopaedics and Related Research 361 (1999): 91-97.

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.

General

Bodeau, Valerie S., and Robert C. Mipro. "Lower Limb Prosthetics." eMedicine. Eds. Everett C. Hills, et al. 27 Aug. 2002. Medscape. 10 Sep. 2004 <http://emedicine.com/pmr/topic175.htm>.

Source: Medical Disability Advisor






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