Bone overgrowth in the adult traumatic amputee

Bone overgrowth of the residual limb after an amputation is a well documented complication in the pediatric amputee population. Bone overgrowth can cause pain, problems with skin breakdown, and poor prosthetic fit. There have been few reports of bone overgrowth in the adult amputee. Two cases of traumatic transfemoral amputations after extensive tissue damage are presented. Both patients successfully completed an in-patient amputee rehabilitation program and achieved functional ambulation with their prostheses. However, each developed distal residual limb pain within a year after their amputations that significantly limited the amount of time they could wear their prostheses and the distance they could walk. Radiographs demonstrated additional bone growth from the residual femur into adjacent soft tissues in both patients. These case examples demonstrate that bone overgrowth should be considered in the differential diagnosis of residual limb pain in the adult amputee.     

Pain and its absence in an unfortunate family of amputees

A family is described in which 5 male members sustained major traumatic injuries of their limbs. Two of these men had amputations of two of their limbs. The one surviving amputee is left handed. The development of phantom sensations, phantom pain and stump pain was unpredictable, despite their being first-degree relatives, and was independent of handedness.     

Understanding and meeting the needs of farmers with amputations

BACKGROUND: Despite the hazardous nature of the occupation, farmers who sustain serious permanently disabling injuries return to the physical labor of production agriculture. It is estimated that amputations account for 11% of all major farm-related injuries. PURPOSE: This report describes the process of reentry to farm work of farmers across the United States who experienced above-the-wrist traumatic amputations. SAMPLE: Interviews with 16 farmers revealed the unique features of the work and world view of these workers who labor in the fields. FINDINGS: The occupational recovery process included questioning, analyzing, and "getting along." Prostheses and formal rehabilitation programs were viewed as minimally helpful. Suggestions and resources that may be helpful for the orthopaedic nurse to assist this high-risk work group are included.     

Rehabilitation of patients with end-stage renal failure after lower extremity amputation

Four patients with end-stage renal failure on maintenance hemodialysis and one patient with near end-stage renal failure received inpatient rehabilitation following lower extremity amputation. All were prosthetically restored. Three of the patients had bilateral below-knee amputations and were ambulatory at the time of discharge, including the patient with near end-stage renal failure who was on maintenance hemodialysis at follow-up. One unilateral below-knee amputee was also ambulatory at discharge. The other unilateral below-knee amputee had an ulcer on the other foot and used a pylon for transfers only. To assess the prevalence of patients on maintenance hemodialysis with lower extremity amputations, a survey of 310 patients at four dialysis units was performed. Of the 310 patients 2.9 percent had at least one amputated lower extremity and 1.0 percent had bilateral lower extremity amputations. Preliminary data and the potential for functional results following prosthetic restoration suggest the need for further research concerning prosthetic restoration in the lower extremity amputee with end-stage renal failure.     

Inpatient rehabilitation challenges in a quadrimembral amputee after bilateral hand transplantation

Bilateral forearm and hand transplantation poses unique challenges especially in the setting of bilateral lower limb amputations. A 57-yr-old man with bilateral transradial amputations and bilateral transtibial amputations after remote streptococcal sepsis was admitted for inpatient rehabilitation because of severe debilitation after forearm/hand transplantations. He required 6 wks of bed rest to allow the healing of the allografts but developed profound deconditioning. Because of weight-bearing precautions and other complications such as femoral neurapraxia, he required the use of body weight-support apparatus to ambulate with lower limb prostheses, keeping weight off the allografts. He progressed to walking 600 ft using a platform-wheeled walker at a modified independent level, to climbing four stairs with minimal assistance, and to being able to toss a small football using his right hand, indicating improved flexor function in this hand. Tacrolimus levels were maintained without clinical evidence of acute rejection. Through an individualized therapy regimen, careful monitoring of the allografts and dedicated support staff, rehabilitation training of a previous quadrimembral amputee after bilateral hand transplantations can be successful.     

Rehabilitation and the long-term outcomes of persons with trauma-related amputations

OBJECTIVE: To examine the long-term outcomes of persons undergoing trauma-related amputations, and to explore factors affecting their physical, social, and mental health and the role of inpatient rehabilitation in improving such outcomes. DESIGN: Abstracted medical records and interview data sought for a retrospective cohort of persons who had undergone a lower-limb trauma-related amputation. PARTICIPANTS: Patients identified with a principal or secondary diagnosis of a trauma-related amputation to the lower extremity at the University of Maryland Shock Trauma Center between 1984 and 1994. Patients with spinal cord injury or traumatic brain injury were excluded. RESULTS: Of 146 patients who had trauma-related amputations to the lower limb at the University of Maryland Shock Trauma Center during the study period, nearly 9% died during the acute admission and 3.5% died after discharge. About 87% of all trauma-related amputations involved males, and roughly three quarters involved white persons. About 80% of all amputations occurred before age 40. The health profile of traumatic amputee subjects interviewed in the study (n = 78, 68% response rate) was systematically lower than that of the general US population for all SF-36 scores. The differences in profiles were largest among SF-36 scales sensitive to differences in physical health status, particularly physical functioning, role limitations due to physical health, and bodily pain. About one fourth of persons with a trauma-related amputation reported ongoing severe problems with the residual limb, including phantom pain, wounds, and sores. The number of inpatient rehabilitation nights significantly improved the ability of patients with amputation to function in their physical roles, increased vitality, and reduced bodily pain. Inpatient rehabilitation was also significantly correlated with improved vocational outcomes. CONCLUSIONS: These findings suggest a substantial effect of inpatient rehabilitation in improving long-term outcomes of persons with trauma-related amputations.     

Bilateral lower extremity dressing frame.

Completely independent application of lower extremity prostheses and clothing is essential but often difficult to accomplish in optimal rehabilitation of the bilateral above-knee amputee. This paper suggests an occupational therapy treatment plan for above-knee amputations, discusses reasons for dependency and decreased use of lower extremity prostheses and clothing, and describes a bilateral lower extremity dressing frame designed for independent application of prostheses and lower extremity clothing. The cost of rehabilitation can be justified once independence in application of prostheses and clothing is accomplished and functional ambulation is achieved.     

New perspectives on nursing lower limb amputees

New perspectives on nursing lower limb amputees arise from the author's researches into amputee rehabilitation and a summary of other recent research findings. These are dealt with in the context of basic amputee treatment and the nursing process. There is new material on the psychological and neurological sequelae of amputation, the practical problems of loss of a limb and the prosthetic dimension of treatment. The patients' reactions to lower limb amputation were found to vary from intense grief to intense relief, many noting it to be of minor or moderate consequence. The model of sudden and shocking loss is largely incorrect. Attention is drawn to an unrecognized ordinariness which should become part of amputee nursing. Patients have many practical problems. These are social and economic, personal and domestic. The ward environment is unsuited to these needs but, working closely with therapists, nurses can do much to facilitate amputee rehabilitation. The modern purpose of amputation surgery is prosthetic replacement. Nurses should be working with some urgency towards uniting patient and prosthesis. Pain and discomfort are underestimated and research shows them to be a major characteristic of amputation continually and for many years after surgery. A variety of pain syndromes are involved.     

Psychological response to trauma.

Severe traumatic injuries to the hands, extremities, and face can produce significant psychological reactions. Adjustment problems are more pronounced when the injuries result in disfigurement and significant loss of function. Long after the traumatic event, persistent fear, depression, avoidance, and body image changes result in substantial impairment in personal, social, and occupational functioning.     

Acquired limb loss in patients with traumatic brain injury

The outcome associated with long-term prosthetic use was evaluated in 12 patients who had a dual disability of severe traumatic brain injury and an extremity amputation. The incidence and nature of complications after limb loss was also reviewed. The 12 patients sustained 15 extremity amputations. Lower extremity amputations were the most common disability. Fifty percent of the patients had at least one postoperative complication after amputation. All patients (100%) had at least one complication documented on rehabilitation admission. No patient was using a prosthesis at the time of rehabilitation admission. At discharge six patients were able to use a prosthesis. Only one patient was considered independent. Patient follow-up averaged 28.6 months. At long-term follow-up six patients were using a prosthesis. Four were considered independent. One-third of the total group was considered able to use the prosthesis independently in the community. Of the lower extremity amputated population, only 40% became ambulatory. This is considerably less than can be expected to become ambulatory if there was no amputation. All three upper extremity amputees did not use a prosthesis. All efforts should be directed at salvaging a limb threatened by amputation after survival of traumatic brain injury. Early transfer to a facility specializing in traumatic brain injury rehabilitation may decrease complications, reduce total hospitalization and improve overall functional ability.     

74例地震伤员的心理反应与护理支持

目的 探讨地震伤员的心理反应,为做好护理支持提供依据.方法 采用自制的地震伤员心理反应调查表,对74例年龄≥17岁的因地震灾难所致创伤性骨折的伤员进行问卷调查,内容包括心理反应、躯体症状和心理需求.结果 本组伤员均存在不同程度的心身反应,以害怕、焦虑、没有安全感、失眠和噩梦为多;100%的伤员希望早日康复,89.19%的伤员希望不丧失劳动力.结论 地震伤员的心理反应不容忽视,应及早给予护理支持.     

Adult acquired major upper limb amputation in Norway: prevalence,demographic features and amputation specific features. A population-based survey

Purpose.?To estimate the prevalence of adult acquired major upper limb amputation in Norway. To describe this amputee population regarding demographic features and amputation specific features. To compare our data to data collected internationally.

Method.?Population-based cross-sectional study on adult upper limb amputees with acquired limb loss through or proximal to the radio-carpal joint. Patients were found in the databases of the two companies in Norway that make upper limb prostheses and in the medical records of three of the largest Norwegian hospitals. Data were collected by postal questionnaires.

Results.?We estimated a population prevalence of 11.6 per 100,000 adults (n == 416). Our survey was not 100%% comprehensive and the estimate is conservative. The amputees were predominantly men with traumatic, unilateral, distal amputations at a young age. There were significant gender- and amputation level differences in cause. Most amputees had used prostheses. About four in ten were in paid employment.

Conclusions.?Our findings are mainly consistent with earlier studies from other countries. Implications of our findings related to the planning of future health care for these patients are outlined, including suggestion of regional multidisciplinary rehabilitation emphasising occupational rehabilitation and focus on preventive measures. Potential areas of follow-up are suggested.     

De la blessure à la réparation : parcours croisé du blessé de guerre américain et français

Both France and the United States of America are currently engaged in asymmetric conflicts, with new modes of fight and use of armaments, which have generated an unexpected influx of a new generation of wounded soldiers. These wounded soldiers present severe and complex pathologies: polytrauma, amputations, blast, traumatic brain injuries, with many sequelae and comorbidities, in particular post-traumatic stress disorders, requiring long and multidisciplinary care to meet their needs. Even though the number of soldiers engaged and wounded are not comparable, both countries had to face the same problem, and to adapt their military health system to this new cohort of combat injured. Because of the double engagement of the USA in Iraq and Afghanistan, and of the large number of wounded soldiers seeking rehabilitation care, the American experience regarding rehabilitation and reintegration of these soldiers is considerable. The objective of this work is to present the American and the French medical care of the wounded soldiers in operations, from the initial care on the battlefield, to their process of rehabilitation on the national territory. This comprehensive report makes it possible to introduce the possible actions to be taken by the French military health system, to improve the rehabilitation and return to active duty of the wounded soldiers and to assume the moral duty represented by the medical support of our army.     

Rééducation de l’amputé fémoral en fonction du type de genou prothétique

Physiological walking, like the gait of the femoral amputee, must be safe, functional and comfortable. It requires security and stability, efficiency, symmetry of the step, dynamism and mobility. In the transfemoral amputee, prosthetic knees must ensure those objectives of the gait cycle. Four categories of prosthetic knees exist: single axis and lock knee, another one with static control of the stance phase, next one with 5–7 axes and the last one with dynamic control of the stance phase. The choice is based on the activity level of the patient, using on flat ground, slopes and stairways. Knee and foot prosthesis form an inseparable pair during gait. Rehabilitation objectives are improving the balance on the prosthesis to support phase and the correct use of the prosthesis in tilting stage. Principles of rehabilitation vary depending on the type of knee: 1) learn how to use lock-knee should ensure mastery and maximum security; 2) for free knees, common principles of rehabilitation apply to each gait phase - a) during the stance phase, the work of weight bearing is fundamental, completed by the increase of proprioception with the stump-socket couple, the muscle strengthening and rehabilitation of the body’s equilibrium; b) during the swing phase, the regulation of the knee unlock, the control of length of the step and the heel attack moment should be taught. Specific exercises are according to each type of knee prosthesis on flat ground, strong slopes and stairs, incorporating depreciation notions and eccentric or concentric contraction of the gluteus maximus muscle. The global dynamic rehabilitation provides fluidity and optimal speed allowing the patient to gain confidence in prosthesis.     

Prosthetic rehabilitation of geriatric amputee patients: a follow-up study

During a four-year period, 116 lower extremity amputee patients older than 65 years were evaluated and treated by our department. Fifty-nine patients with below-knee (BK) amputations, 22 with above-knee (AK) amputations, and 15 with bilateral amputations were fitted with prostheses and trained in their use. A follow-up study on all patients was done at an average of 22 months after they had completed their training program but not earlier than after 6 months. Of all BK amputees who had been fitted with a prosthesis, 73% were using it fulltime and as their main mode of locomotion; 25% were using it part of the time. The results were less favorable for AK and for bilateral amputee patients: 50% of AK amputees and 33% of the bilateral amputees had become fulltime users of their prostheses. Age alone was not a major determining factor in success or failure of prosthetic rehabilitation. Failures usually were due to concurrent medical disease or mental deterioration. The study indicates that the effort and expense of fitting and training geriatric patients with prostheses may be well worthwhile.     

The CQI pathway

The use of CQI to identify issues, processes, and methods of quality management was a favorable learning experience for the Botsford General rehabilitation staff. They experienced improved interdepartmental communication and enhanced understanding of the roles and responsibilities of other disciplines, as well as the overall CQI process. The use of the CQI process accomplished the objective of decreasing the length of stay of patients with amputations by 6 to 8 days, thereby reducing costs. Use of flowcharting to outline a typical patient stay from admission to discharge helped to clarify potential problems, eliminate unnecessary steps, and reduce documentation time. Although rehabilitation services are currently exempt from diagnosis-related group application, in order to maintain cost efficiency and service effectiveness, it behooves us to continually track and stay in line with the competition. In light of anticipated health care reforms, the rehabilitation industry must be proactive in its management of service delivery with an emphasis on functional outcomes. Botsford General's success with using a critical pathway for the amputee program as part of a program evaluation system will lead to the development of critical pathways for additional diagnoses.     

Bilateral below-knee amputations: experience with 80 patients

This review expands information concerning the bilateral below-knee (BK) amputee, describing the findings of a retrospective assessment of 80 such patients. Factors evaluated included etiology, associated conditions, time between amputations, late revisions, use of prostheses, and survival. In 63 patients both amputations were because of atherosclerosis. Of these patients, 86% were diabetic and 84% hypertensive. Peak incidence of the second amputation was during the 7th decade. Average time between amputations was 23 months. Forty-five (71%) of the atherosclerotic patients achieved some functional use of bilateral prostheses. The five patients employed at the time of the second amputation returned to work using prostheses. Average survival after the second amputation was 44 months for those deceased, and 64 months for those alive at the end of the study period. Nine patients had amputations because of various forms of injury, including one for sequential developments due to alcohol-related sensory loss. Eight of this group had a diagnosis of alcohol abuse of psychosis. Reasons for amputations included frostbite, burns, suicide attempt and sensory loss. Five achieved long-term but generally suboptimal prostheses use. The findings support the impression that most atherosclerotic bilateral BK amputees can use prostheses and that their survival and low rate of late stump revisions justify restorative efforts. Mental status was the major determinant of amputation and prostheses use among the non-atherosclerotic patients; discharge from psychiatric hospitals without adequate community support systems was probably contributory. Management and prevention require close collaboration between the rehabilitation, surgical, psychosocial, and public health disciplines.