Lecture # 501:
Amputation of a Lower Extremity

copyright 2008 Cheryl K. Hosken, BSN, MS Psych.

 
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We begin our course on “Vocational Rehabilitation” with two lectures on the most frequent conditions that call for vocational rehabilitation: amputations and lower back injuries. The causes for most lower extremity amputations are diabetes and trauma (usually in automobile accidents).

The systemic effects of diabetes cause poor circulation. Any trauma to the lower extremities may be a cause for ulceration and infection. Trauma can cause irreparable damage to the veins and arteries in the leg so that blood cannot circulate. The soft tissue or muscles may also be damaged so that the extremity cannot be saved.

Meditate Word By Word On These Verses:
Job 3:20-26.

We will discuss diabetic foot problems because preventive care may decrease the incidence of infection and further complications of the foot and leg. When blood glucose levels are high, the ability to fight infection is weakened. High blood sugars also cause damage to the nerves in the legs and feet. With damaged nerves, the sensations of pain, heat, and cold may not be felt. A sore on the foot becomes increasingly worse because it cannot be felt. This lack of feeling is called diabetic neuropathy. Diabetes also affects the blood vessels, reducing the amount of blood flow to the legs and feet. This makes healing of the sore more difficult.

For example, a blister comes from shoes that don't fit right. If a person is diabetic with poor control of blood sugar, he doesn't feel the pain from the blister because he has nerve damage in his foot. Next, the blister gets infected. If blood sugar is high, the infection gets worse. He still doesn't feel any pain. Poor blood flow to his legs and feet can slow down healing by failing to bring needed oxygen and nutrients to the area. Sometimes this kind of infection never heals. It can cause gangrene, in which the skin and tissue around the sore die. When that happens, amputation is needed to keep the gangrene from spreading.

1. High blood sugar in diabetic persons causes:
(Only one of the following answers is correct.)
a) a feeling of happiness,
b) damage to the nerves,
c) blisters.

About 15% of people with diabetes will develop foot ulceration at some point, and 14% to 24% of these will need an amputation. The majority of these - almost 60% - occur in people who are 65 and older. The risk for foot ulceration leading to amputation increases in people over 40 who have had diabetes for 10 years or longer.

People are at high risk for foot problems if they have loss of protective sensation - such that you can't feel an injury, or vascular disease causing poor blood flow in their feet and legs. Other risk factors are skin disorders such as calluses, especially with redness or bleeding under a callus, and nail abnormalities such as very thick nails. Structural/bony deformities such as hammertoes or bunions and limited joint mobility (arthritis) are also risk factors.

There are some specific conditions that warn of impending foot problems:

• Changes in skin color
• Elevation in skin temperature
• Swelling of the foot or ankle
• Pain in the legs
• Open sores on the feet that are slow to heal
• Ingrown and fungal toenails
• Bleeding corns or calluses
• Dry cracks in the skin, especially around the heel

Fortunately, up to 86% of foot ulcers will heal when treated properly. A foot ulcer is defined as a break in the skin or deep sore; they are most often located on the ball of the foot, an area of repeated stress.

If your client develops any kind of sore or wound on his feet that doesn't heal in a day or two, it's very important that he sees a doctor right away. Untreated lesions or ulcers can become infected quickly; even when treated, foot ulcers may not heal well in people with diabetes.

2. Loss of sensation due to high blood sugar results in:
(Only one of the following answers is correct.)
a) loss of the feeling of pain of injury,
b) dry, cracked skin,
c) red, swollen feet.

How are Diabetic Foot Ulcers Treated?
The doctor may x-ray a person's feet to make sure the bone is not infected. If the results are not clear, he may order an MRI (Magnetic Resonance Imaging) scan to help him doctor determine the depth of the lesion.

Treatment must address all of the factors involved in wound healing:

• Infection - which stops or delays the normal wound repair process.
• Repeated trauma during the wound healing process - which continually destroys new tissue.
• Decreased blood flow - which reduces the amount of oxygen and nutrients getting to the tissues.

Treat the Infection
The doctor will thoroughly clean the wound to remove all infected tissue; in severe cases, this may be done in the operating room. Early, aggressive wound cleaning (called "debridement") has been shown to heal these wounds more rapidly. If there is an infection, the doctor will prescribe antibiotics. If the infection is serious, the client may be hospitalized to receive intravenous antibiotics.

Dressings are used to prevent further trauma, to minimize the risk of infection, to relieve local pain, and to optimize the environment for healing. A moist wound environment is important for wound healing to occur.

Keep the area clean and moist at all times and use the medications the doctor has prescribed. It's important to only use the medications your doctor has suggested. People previously used cleansers or antiseptics such as hydrogen peroxide on these types of wounds, but it is now known that they actually delay wound healing. They also dry out the tissue, and it is now believed that a moist environment stimulates more rapid wound healing.

Off-Load Pressure
Depending on the location of the foot ulcer, the client may need to keep pressure off the area. This is called "off-loading" and means avoiding all mechanical stress on the wound so that it can heal. If there is no infection, a total contact cast may be used to relieve pressure. The doctor may recommend using "non-weight-bearing" devices such as orthopedic shoes, a walker, crutches, or even a wheelchair or bed rest - these can help healing by relieving pressure on the injured part of the foot. If the doctor has suggested keeping weight off of the foot, it's important to do so. Keep the foot elevated as much as possible.

3. Infected foot sores are healed by:
(Only one of the following answers is correct.)
a) the use of elastic bandages,
b) antibiotics,
c) treating the infection and not walking on the foot.

Improve Blood Flow
If there is evidence of impaired blood flow to the feet, then the doctor may consider a surgical procedure called "revascularization." This surgical procedure bypassing or implanting a graft around the arteries that are obstructing blood flow. These procedures have been as successful in restoring blood flow for people with diabetes as in others and have been shown to help achieve rapid and durable healing of diabetic foot ulcers. They have also been shown to decrease the need for amputation.

Promote Healing
New treatments such as bio-engineered skin patches are now available to help improve healing of foot ulcers. Growth factor gels contain a protein that helps the ulcer fill in with healthy tissue, so it heals faster and better than it would otherwise. Human skin cells are processed and grown in the laboratory to produce bio-engineered skin, or skin equivalents, which are applied to the foot ulcer to enhance the process of wound healing. Foot care experts are encouraged by the early results of these treatments, which, they say, "are healing diabetic foot wounds faster and preventing amputations." Used with traditional approaches such as removing pressure, the new high-tech treatments reduce healing time, infection, hospitalization, and amputation while improving the quality of life.

Other treatments are sometimes used but they have not been adequately tested in clinical trials to prove their worth. These include hyperbaric oxygen, electrical stimulation, cold laser, and heat treatments.

Oftentimes, much effort is spent to try and heal the damaged area of the foot. If all efforts fail, amputation is the only alternative. The loss of a part of the body is a psychological trauma for a person. He also recognizes that the diabetic disease has caused this trauma. Depression and anger are the most common responses to amputation. Therefore, do not be surprised if your client shouts or withdraws from you. A soft answer turns away anger and our approach to these people needs to be kind, but firm. We are kind because we try to understand what they have experienced. We are firm in rehabilitation goals because we do not want further complications of diabetes to affect our clients. They must begin activities to return to optimal living.

4. Anger and depression follow amputation because:
(One or more of the following answers may be correct.)
a) there is a change in the way the body looks,
b) the preventative measures failed,
c) there are major changes in his lifestyle.

Rehabilitation Considerations Following Amputation:
A. Skin Care
Folllowing amputation, a person must learn to care for his limb or stump once the sutures are removed. A daily hygiene routine with mild soap and tap water is usual. The stump needs to be dried completely before any shrinkage devices are applied to prevent skin problems.

Gentle massage to the residual limb helps to decrease sensitivity and increases tolerance to pressures. Any open area should be aired for short periods daily (e.g., one hour four times per day), or as ordered by physician. To protect open areas or sutures, non-sticking pads are used under the shrinkage device.

B. Positioning
Positioning is an essential part of patient's program because it prevents shortening of soft tissue as well as prevention of joint contracture. It must be consistently stressed to the person that he does active range of motion exercises to keep the residual limb fully mobile. Use of a pillow under the hip or knee of the residual limb is not recommended because it develops flexion contractures.

C. Residual Limb Shrinkage:
When the residual limb has started to heal, bandaging is important to prevent swelling and ensure that the residual limb is properly shaped. A cylindrical shaped residual limb is easier to fit with a prosthesis and therefore is desirable. The limb is usually rewrapped with an ace bandage every three to four hours in order to allow the residual limb to be exposed to fresh air and to adjust the bandage's tension.

Post-surgical Dressings:
Just after surgery any or all of three basic types of dressings may be used.

Rigid Dressing
As the physician orders many patients are fitted with a rigid dressing (cast) to ensure control of swelling and to provide comfort. The end of the cast is made to take a simple training prosthesis (usually called a "pylon") so training in standing and walking can be started immediately.

Ace Wrap
Wrapping with an elastic bandage is still the most frequently used shrinkage method. Careful patient and family instruction is necessary because poor wrapping leads to skin problems and a poorly shaped residual limb. With any patient who fails to learn the technique, who has visual or sensory deficits, or who lacks the use of one upper extremity, and alternative shrinkage method needs to be provided.

Compression Pump
These air-filled sleeves place constant, equal pressure on all sides of the residual limb to shrink it rapidly and to shape it appropriately.

Residual Limb Shrinkers
a. Shrinker socks made of elastic are most often used after the final prosthesis is made and adjusted. Residual limb shrinkers are frequently worn at night as well as during the day when the patient is not wearing the prosthesis.
b. A series of gradually smaller sizes will be employed to encourage consistent, even shrinkage. Shrinkage and shaping of the residual limb take about six weeks to three months, depending on the patient's response and condition.

5. Why does the remaining part of the extremity (leg or arm) need to be decreased in size after surgery?
(Only one of the following answers is correct.)
a) to increase circulation,
b) to fit a prosthesis,
c) to shape it properly.

D. Prosthetic Fitting:
When the residual limb has healed and is relatively stable in size and shape, the patient will be measured for a prosthesis, as ordered by the surgeon. The first fitting is for "a temporary prosthesis", about six weeks after the amputation, barring no complications. This prosthesis will be used through the interim shaping period (3 to 6 months post surgery).

The following instructions are part of a goal-directed rehabilitation program for a person with an amputation.

PHASE I: IMMEDIATE CARE AFTER SURGERY
PHASE II: INPATIENT REHABILITATION

Pre-Prosthetic Program Goals for the Patient

1. To gain the ability, safety and independence to do social adaptation - bathe, dress, walk.
2. To achieve maximum independence with bed mobility activities to prevent bed-rest hazards (such as thrombophlebitis, pulmonary embolism, decubiti and pneumonia).
3. To independently care for the residual limb.
4. To gain full range of motion in all joints to prevent contractures.
5. To gain flexibility of major muscle groups.
6. To have functional strength of all muscle groups on both lower extremities to prevent significant muscle weakness. The muscles must be strong so that the prosthesis fits correctly and training is consistent.
7. To increase upper extremities/upper body (trunk) strengthening to facilitate mobility, transfers and walking.
8. To educate the person about residual limb sensory expectations, i.e., phantom sensation and phantom pain.
9. To teach independent and safe transfers to all surfaces.
10. To train patient for functional walking with an assistive device (crutches, walker, wheelchair) as appropriate.
11. To maximize endurance and cardiopulmonary fitness through exercise.
12. To teach the person about using a wheelchair and repair of the wheelchair parts.
13. To ensure "optimal residual limb shrinkage and shaping" in preparation for prosthetic fitting.
14. To educate patient and family as needed to ensure independence and safety. Providing written instructions for positioning, stump wrapping and specific home exercise programs.
15. To assess equipment needs prior to discharge.
16. To ensure patient's safety after discharge from the hospital by visiting his home or by having him draw a plan of his home.
17. To make arrangements for outpatient physical or occupational therapy as needed or assist with other arrangements as per patient's needs.
18. To help amputees regain their normal functional independence so they can return to their home, to their work, and to their place in the community participating in the activities that are important to them.
19. To encourage the patient and family to express and examine feelings about body changes.
20. To instruct and assist the patient in ways of enhancing his or her appearance.
21. To support the patient during the grieving process related to changes in the body.

6. What major goals are set for the amputee to learn?
(Only one of the following answers is correct.)
a) healthy appetite, weight loss, return to work,
b) training in care of the amputated limb, increased strength, return to his community,
c) care of the amputated limb, emotional support, wheelchair.

AMPUTEES TREATMENT PLAN
Below is a standard treatment plan for care of a person with an amputation. It is divided into sections so that the person with the amputation can learn various levels of self-care after surgery.

I. PHASE ONE (ACUTE CARE HOSPITAL)
  A. Post-Operative Day 1 - 10
  Activities: (as the doctor orders)

• Begin bed mobility skills - turning, getting up, lying down, moving amputated leg
• Begin training on Social Adaptation - bathing, dressing
• Begin training on how to transfer from the bed to the wheelchair, wheelchair to toilet, etc.
• Start education on proper positioning of amputated part to prevent contractures.
• Begin education on Active Range of Motion Exercises to upper and lower extremities.

Question:
7. Why do you think it might be advisable to have such a treatment plan for patients with amputations?

II. PHASE TWO (INPATIENT REHABILITATION PRE-PROSTHETIC TRAINING)
  A. Nursing Focus
  B. Post-Operative Day 11-28
  Activities: (as the doctor orders)

* Teach skin care for the other limbs and areas at risk for breakdown - checking daily for sores or redness, wearing shoes that are comfortable, cleaning and thorough drying of skin, avoidance of extremely hot water and trauma.
* Nutrition that promotes healing and prevention of further breakdown - adequate protein, fluids.
* Patient Education about causative disease processes such as: mismanagement of blood sugar, inadequate diet.
* Diabetic Daily Self-Management skills including:

• a) administering insulin and other anti-diabetic agents,
• b) self- monitoring of blood glucose level,
• c) diabetic emergencies,
• d) foot/nail care practices - cutting nails, treatment of fungus infections, massage,
• e) chronic complications prevention/management - being aware of the effects of diabetes on the body.

* Peripheral Vascular Disease:

• a) detection and response to emergencies - decreased circulation to other foot or stump,
• b) use of medications,
• c) positioning and prevention of vascular constriction/occlusion.

* Pain Management Modalities - medication, exercise.
* Education on shrinkage device use. (The patient should know purpose of shrinkage, time schedule for wearing shrinkage device and when to discontinue the use of it).
* Psychological Impact of Amputation - change in body, change in acceptance by others, change in work.
* Emotional Support during the grieving process - expressions of anger, regret over behavior, feelings of uselessness.
* Practical suggestions about dressing and improved appearance.

  B. Functional Activities:

• Activities of Social Adaptation - personal hygiene.
• Bed mobility skills - patient must be independent moving in bed in all directions, (rolling, moving from side to side and up and down in bed. Rising from supine to short sitting, scooting forward, backwards and laterally).
• Transfer training to all surfaces: bed, wheelchair, mat, toilet, tub, shower, upholstered sofa or chair, car, floor as indicated.
• Positioning techniques and education to patient and family to prevent contractures on the residual limb as well as on the uninvolved extremities. (Proper positioning in sitting, supine, prone and standing.)
• Education on care of the residual limb including desensitizing techniques, prevention of skin breakdown, and residual limb wrapping.
• Pressure Relief Techniques training - checking the stump for redness, soreness, and massaging after wearing prosthesis.
• Wheelchair mobility/training including propulsion on different surfaces indoors / outdoors, maneuvering wheelchair in narrow / small places and safe management of wheelchair parts and maintenance.
• Sitting and standing balance training.
• Endurance training in sitting and standing.
• Gait training with crutches or walker as applicable. (Include safety issues and safety awareness to prevent falls as possible).

8. What does Phase II prepare the person to do?
(Only one of the following answers is correct.)
a) help his body to accept a prosthesis,
b) increase his strength,
c) accept his appearance.

  C. Range of Motion Therapeutic Exercises:
  Activities: (as the doctor orders)
Upper Extremities (working on all planes and all joints.)
Lower Extremities (working on the residual limb and uninvolved leg on all planes and all joints.

  D. Strengthening Therapeutic Exercises:
Upper Extremities (to achieve maximum strength for transfers and use of a walker or crutches).
Lower Extremities (to achieve maximum strength possible in all muscle groups of the residual limb and the uninvolved lower extremity.
Upper body strengthening to improve trunk stability to facilitate transfers and walking.

  E. Patient and Family Education
Teach family instructions for appropriate care of the residual limb, positioning and patient's Home Exercise Program.
Conduct a home safety evaluation if necessary.

  F. Follow-up Recommendations:
If the patient is unable to perform functional activities safely and independently, outpatient rehabilitation is highly recommended.

Question:
9. Why are body strengthening exercises important for persons with an amputation?

III. PHASE THREE (OUTPATIENT REHABILITATION)
  A. Pre-prosthetic Training: (Post-Operative Week 4-6)
  Recommended for patients who have been discharged from Inpatient Rehabilitation, but still need more therapy "to achieve maximum independence and safety" with transfers and functional ambulation activities without the prosthesis. To maximize balance, endurance and strength of upper body and all four extremities.

  Therapy/Treatment:

• Education on shrinkage device use. (The patient should know purpose of shrinkage, time schedule for wearing shrinkage device and when to discontinue the use of it).
• Reinforcement of residual limb (stump) skin care.
• Range of Motion activities and positioning - patient should be able to demonstrate proper positioning in sitting, supine, prone, and standing, as well as being independent for ROM exercises for all joints of all four extremities.
• Education/training on progressive strengthening exercises of all extremities. Goal: is to improve strength of all muscles to their maximum in preparation for prosthetic training. Active exercises progressing to resistive exercises including a variety of concentric, eccentric, and isometric therapeutic exercises.

  Mobility:

• Reinforcement of bed mobility skills - patient must be independent moving in bed in all directions, (rolling, moving from side to side and up and down in bed. Rising from supine to short sitting, scooting forward, backwards and laterally).
• Mobility on floor training - patient must be able to move in all directions on the floor. (Example - could the patient move away from a dangerous situation such as a hot radiator?)
• Wheelchair Mobility Indoors - patient must be able to lock and unlock brakes, manage footrests and armrests, propel in all directions, and manage doors.
• Wheelchair Mobility Outdoors - patient is to be evaluated on grass, concrete, gravel, rough terrain (broken sidewalk), inclines (1:10 ratio), curbs, and crossing the street safely.

  Transfer Training:
Education and reinforcement on transfers at all levels -( standing pivot transfer, lateral or front transfers as applicable. (Transfer to and from bed, transfer to and from toilet, transfer to and from car, transfer to and from upholstered furniture, transfer to and from tub or shower).

  Gait Training:

• Balance and coordination exercises in standing reinforcing good posture.
• Endurance training- a gradual increase in the length of time a person can walk
• Gait Training Indoors - including walking on carpeting, managing doors, stepping over obstacles. Assistive device as applicable.
• Gait Training Outdoors - patient is to be trained walking on ramp and un-level terrain

  B. Prosthetic Training:
Time for prosthetic training varies depending on patient's status, healing of the residual limb and surgeon's orders.

Therapy for Prosthetic Training:

• Fitting of prosthesis.
• Educating patient on appropriate use of prosthetic socks, usually cotton or light wool, to take moisture away from the skin
• Education on skin care (awareness of appropriate pressure points and gradual increased use of prosthesis.)
• Education/training for proper independence in application and removal of prosthesis.
• Person must be able to put on and take off his own prosthesis
• Educate patient on proper care of prosthesis and prosthetic socks. Teach inspection of socket for: cracks, missing rivets, cracked bumpers.
• Transfers training to all surfaces wearing the prosthesis. (Transfers to the toilet, to the bed, to regular furniture, to the car and to the floor).
• Balance training with prosthesis.
• Gait training with prosthesis. (Evaluate for appropriate assistive device.) Indoors/Outdoors.
• Educate on appropriate prosthetic component control.
• Training on all surfaces (smooth to rough and uneven)
• Ambulation and maneuvering in narrow places.
• Training on: Stairs, ramps, curbs, elevators, escalators.
• Training on ability to "fall safely", if indicated.
• Reevaluate ambulation skills periodically and "upgrade" assistive (for example from use of the wheelchair to use of crutches, or from the use of crutches to a cane) device as applicable.
• Family training as necessary - include education on skin (stump) care, prosthesis care and Home Exercise Program.
• Home / workplace evaluation as applicable.
• Driving evaluation and referral for training as appropriate.

10. Why is so much training necessary for the person with a new amputation?
(Only one of the following answers is correct.)
a) to give him optimum chance of accepting his limitation and returning to as normal a lifestyle as possible,
b) most diabetics have problems with thinking and need much attention,
c) an amputation is a difficult problem.