Amputations 1



Phantom limb sensation, the feeling that all or part of an amputated
limb is present, occurs in virtually all adults following an amputation. It
usually diminishes with time. Phantom pain is a burning, painful sensation
in the distribution of the amputated part. It is present in less than 10%
of adults with acquired amputations. Noninvasive treatments, such as
increased prosthetic limb use, physical therapy modalities, intermittent
compression, and transcutaneous electrical nerve stimulation, often will
decrease symptoms.

A more common cause of residual limb pain is a condition that is
similar to reflex sympathetic dystrophy. In this condition, the pain is
within the residual limb. The pain is described as burning, tearing,
throbbing, or piercing. These patients frequently underwent amputation
following a crush injury and, therefore, have symptoms much like those of a
major causalgia. The personality traits of these patients often mirror
those of the reflex sympathetic dystrophy population.

Localized residual limb pain is often related to an incompetent
soft-tissue envelope, prominent underlying bony projection, or scarred deep
structures. An etiology of pain not directly related to the amputation
should be considered. Ischemia of the residual limb is an occasional
etiology of pain in the patient with peripheral vascular disease. Nerve
entrapment, disk herniation, proximal arthritis, or visceral etiologies
occasionally cause pain in the residual limb.


Postoperative residual limb edema is common following amputation. It
is uncomfortable for the patient, and it may impede wound healing by
increasing tissue and venous pressures. Rigid dressings help reduce this
problem. If soft dressings are used, they should be combined with
compression stump wrapping. Compression stump wrappings, if too tight
proximally, can produce bulbous distal swelling and a residual limb that is
difficult to encase within a prosthetic socket. Compression wraps in
transfemoral residual limbs fall off if not suspended about the waist.

Late residual limb swelling can be produced by proximal constriction
of the prosthetic socket, thus causing congestion in the stump. In its most
severe form, verrucous hyperplasia develops in transtibial amputations when
distal total contact is not achieved. This condition is characterized by a
wart-like overgrowth of skin combined with darkened pigmentation,
fissuring, and a serous discharge, which often becomes secondarily
infected. The cellulitis is treated with broad spectrum antibiotics and
avoidance of socket wear. The prosthetic socket needs to be altered on an
ongoing basis to provide total contact, until a volume stable residual limb
with a healthy soft-tissue envelope is achieved.

Joint Contractures

Joint contractures usually occur between amputation surgery and
prosthetic fitting. They are best avoided by early prosthetic fitting and
weightbearing, combined with an aggressive physical therapy program. Hip
flexion contractures in transfemoral amputation can be produced at the time
of surgery by performing myodesis or myoplasty with the retained muscles
tensioned with the hip in a flexed position.

Preoperative, static joint contractures need to be corrected at the
time of surgery, because they rarely can be corrected postoperatively. The
transfemoral amputee should be encouraged to lie prone after surgery to
prevent hip flexion contracture. The transtibial amputee should not sit for
long periods with the residual tibia unsupported in a flexed knee position.

Wound Failure

Wound failure following amputation is not uncommon, especially in
diabetic and ischemic limbs. Open wound care can be used for small wounds.
Even larger wounds can be managed with total contact plaster or plastic
sockets and continued weightbearing, as long as the bone is not exposed.
When localized wound failure is larger, or the bone is exposed, or the
soft-tissue envelope is tight (as long as the vascular inflow remains
adequate), the residual limb can be revised by shortening the bone,
resection of a wedge of soft tissue, and nontensioned wound closure.

Dermatologic Problems

Many skin problems can be prevented by good hygiene, which includes
keeping both the residual limb and socket clean, dry, and free of any
residual soap. Epidermoid cysts can occur at the socket brim. They are best
managed by modification of the socket to relieve localized pressure.
Contact dermatitis can be confused with infection. It is often caused by
retained detergents or soaps. Treatment involves good hygiene practices and
topical steroid creams. Folliculitis or acneform hidradenitis is common.
Meticulous hygiene, sweat-absorbing stump socks made from natural fibers,
and occasional courses of oral tetracycline therapy can usually control
this problem.

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