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Amputations

Mangled Extremity Severity Score (MESS) can be used as predictor of eventual amputation versus limb salvage. Higher the score lower the chances of salvage i.e. higher score has higher chances of amputation. However recent studies have shown it to be inaccurate in predicting the functional outcome for mangled limb patient
 

Shock

Ischemia of limb*

Velocity (Skeletal & soft tissue injury)

Age

0 Normotensive

1 Transient hypotension

2 Persistent hypotension

1 Pulse reduced or absent but perfusion normal

 

2 Pulseless (by Doppler) paresthesia, diminished capillary refilling, diminished motor activity

 

3 Pulseless cool, paralysed, insensate, numb, without capillary refill

 

1 Low energy

2 Medium energy

3 High energy

4 Very high energy (massive crush)

 

0 - <30 yrs

1 - 30-50 yrs

2 - >50 yrs

 

Mnemonic = Remember SIVA (Shock, Ischemia, Velocity of truma and Age)

Total Score 11, Six or less = salvageable limb. Seven or greater amputation is recommended.


Ganga hospital open injury severity score

 

 

Description: Table 1. Open injury Severity Score

 

Score less than 15 limbs salvageable

 

Score more than 15 amputation.
 

Indication of amputation

  1. Absolute
    1. Irreparable loss of blood supply of a diseased or injured limb
    2. Fulminant infection (gas gangrene)
    3. Micro vascular ischemia (Burgers gangrene)
    4. Diabetic gangrene
  2. Relative
    1. Infections
    2. Burn
    3. Frostbite
    4. Trauma
    5. Tumors
    6. Nerve injuries – rare
    7. Congenital anomalies - rare
    8. Chronic osteomyelitis – rare
  3. Level of amputation

Description: leg-amputation-types      Description: arm-amputation-types

Mid foot Amputations

 

Type

Level of amputation

Lisfranc

Tarsometatarsal joint

Chopart

Mid- tarsal joint

Pirogoff

Calcaneus is rotated forward to be fused to tibia after vertical section through its middle


Hind foot amputations

 

Type

Level of amputation

Syme

Distal tibia fibula proximal to the periphery of ankle joint passing through the dome of ankle

Sarmiento

Distal tibia & fibula — 1.3cm proximal to the ankle joint and excision of medial & lateral malleoli

Boyd

Talectomy, forward shift of the calcaneus and calcaneotibial arthrodesis

 

Type of Amputation

Traditional Length of Stump

Above knee

12 cm

Below knee

14cm

Below Elbow

18 cm

Above Elbow

20cm

  1. Techniques in Amputation
    1. Myodesis
      1. Attachment of muscles directly to the bone through drill holes
      2. Myodesis should not be performed when vascularity is compromised (Ischemia)
      3. In Myodesis the residual musculature is stitched to the bone such that it retains the ability to develop tension. This helps in achieving structurally stable residual limbs and to reduced atrophy. Myodesis is not preferred in ischemic limbs for fear of damaging the already precarious blood supply.
      4. Myoplasty
         
        Attachment of opposing muscle groups (agonist /antagonist muscle) with each other across the end of the
      5. Myofascial flaps
         
        Attachment of muscle to fascia bone
  2. Bone is kept shorter than soft tissue in flap method of amputation to facilitate closure of amputation stump.
     
    In guillotine amputation, limb is transected at one level through skin, muscle & bone.

Foot Prosthesis for Amputated Limb

 

 Prosthesis

 SACH (Solid ankle cushion heel)

 Jaipur foot

 Appearance

 Does not look normal

 Looks normal

 

 Requires shoe

 Can walk bare foot

 Keel

 Long keel restricting movements

 Small keel allowing all movements

 Ankle movements

 Squatting not possible

 Possible

 Inversion/eversion

 Not present so difficult to walk on uneven grounds

 Present so can walk on uneven grounds

 

Description: sach_foot_16_9_teaser_onecolumn

Description: Jaipurfoot

SACH foot (Solid ankle cushion heel)

Jaipur foot

Description: Lower%20Limb%20Prosthetics%20(Artificial%20Legs)

Description: felso-vegtag-protezis-01

Lower limb

Upper limb

Parts of prosthesis

 

Complications of amputation

  • Hematoma
  • Wound infection
  • Sequestrum formation

Extra edge:

 

Type of Sequestrum

Found In

Ring sequestrum

- Amputation stumps
- Around pin tracks (external fixator)

Tubular sequestrum

- Hematogenous osteomyelitis
- Segmental fractures (middle segment)

Rice grain sequestrum

- Tuberculosis

 

Phantom limb’ is a late complication of amputation and is used to describe the feeling that the amputated limb is still present





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