|Year : 2020 | Volume
| Issue : 1 | Page : 78-83
A study to evaluate the pattern, cause and type of traumatic major limb amputation in Eastern Nepal
Anand Shankar1, Santosh Kumar2, Raju Rijal3, Shiv Raj Paneru4, Reetesh Roshan5
1 Assistant Professor, Dept. of Orthopaedics, NMCH, Jamuhar, Sasaram, India
2 Professor & Head, Dept. of Orthopaedics, IGIMS, India
3 Professor, B.P. Koirala Institute of Health Sciences, Dharan, Nepal, India
4 Assistant Professor, Dept. of Orthopaedics, B.P. Koirala Institute of Health Sciences, Dharan, Nepal, India
5 PG Student, Dept. of Orthopaedics, IGIMS, India
|Date of Submission||15-Feb-2020|
|Date of Acceptance||22-Feb-2020|
|Date of Web Publication||16-Nov-2020|
Prof. & Head Dept. of Orthopedics, IGIMS, Patna
Source of Support: None, Conflict of Interest: None
Background & objectives: The amputation of injured extremities has been performed for over 2,500 years. Despite the advances in limb prosthetic technology, traumatic amputations continue to have a major impact on daily activities and subsequent quality of life. The loss of a limb often has profound economic, social and psychological effects on the patient and their family. However in many cases, amputation of the limb is the only viable option to save the patient’s life. We also did a study to evaluate the pattern of amputation after major trauma and its outccome.
Methods: Total sixteen patients were included in the study. All patientswith traumatic injury to the limb leading to non-viability of the major part of the limb (above wrist and above ankle) coming to emergency of BPKIHS giving written consent for the trial were included in the study.All patients underwent emergency amputation. The clinico-radiological outcomes were evaluated for involved limb, level of involvement, cause, active bleeding, Blood pressure, Pallor, infection, type of amputation, infection, phantom pain, phantom limb, Mangled Extremity Severity Score. Collected data were evaluated and various statistical tests applied.
Results : Upper limb involvement is more than lower limb, crush injury is more common than road traffic accident, only one case has Ischemic heart disease, only two patients had intact neurology, two case had compartment syndrome, none of the patients had viable distal limb, only three closed amputation was performed primarily, post operatively three had infection, five had phantom limb and pain none of the cases had change of job.
Conclusion : Traumatic major limb amputation can occur both in upper and lower limb. Better prosthetic fitting and rehabilitation is needed to make the patient conduct his near normal life style.
|How to cite this article:|
Shankar A, Kumar S, Rijal R, Paneru SR, Roshan R. A study to evaluate the pattern, cause and type of traumatic major limb amputation in Eastern Nepal. J Indira Gandhi Inst Med Sci 2020;6:78-83
|How to cite this URL:|
Shankar A, Kumar S, Rijal R, Paneru SR, Roshan R. A study to evaluate the pattern, cause and type of traumatic major limb amputation in Eastern Nepal. J Indira Gandhi Inst Med Sci [serial online] 2020 [cited 2020 Nov 26];6:78-83. Available from: http://www.jigims.co.in/text.asp?2020/6/1/78/300747
| Background and Introduction|| |
The amputation of traumatized extremities is beeing performed for over 2,500 years. Despite the advances in limb prosthetic technology, traumatic amputations continue to have a major influence on daily activities and subsequent quality of life. The first surgical description of a limb amputation was by Hippocrates (460-377 BC). Although prostheses are not mentioned in medical literature from ancient times, they were indeed made and used as learnt from the non-medical books and pictures.,
The lost limb usually has profound economic, social and psychological effects on the patient and their family. However in many cases, amputation of the limb is the only viable option to save the patient’s life. The indications for limb amputations are generally considered as the three Ds: dead, deadly and dead loss.
Amputation is the removal of one or more parts of the body. It can be as a result of unprecedented havoc or natural disasters; like accidents, earthquakes of major intensity, terrorism and war, or carried out due to medical reasons with the motive to improve health outcomes and quality of life of patients. In cancer patients, it is performed as a lifesaving procedure. In debilitating vascular conditions of the extremities, limb gangrene, leprosy, etc., it is performed to prohibit further progression or to restore functions of that body part by making it amenable for prosthesis, and thereby making the person mobile.
Irrespective of the cause of amputation, it brings a drastic change in a person’s life. One goes from a stage of shock, to acknowledgement, and finally adjustment. Horne et al. referred to amputation as triple insult, as it brings loss of function, loss of sensation, and loss or change of body image. This dramatic change has an effect on the QoL of the individual due to the physical activities limitations after amputation as well as has longer-term implications in varied facets of life. It also affects the individuals at psychosocial level, and can have long term economic implications on the life and opportunities for employment.
Outcomes and long term functioning after amputation can also have an influence on the individual’s contribution to the society. A significant +ve relationship has been observed between higher QoL after amputation and good physical functioning. Also, better social and psychological functioning are always related with better QoL. Social support, effective rehabilitation and appropriate prosthetic treatment can help the amputees in oping and overcoming the triple insult, and improving their QoL.
War trauma-related amputations are unique. They are usually the result of a blast mechanism and are complicated by wider zones of injury with very high or severe contamination and ongoing overt or latent infection. Other limb injuries/trauma, systemic illness, and a delay to definitive care for intercontinental flight complicate the care of these amputees. These patients differ significantly from the more common elderly, dysvascular amputee population ; they are generally younger and previously healthy and have the promising potential to rehabilitate to very high levels of activity.
Every effort should be made to perform sound initial and definitive trauma related amputations so that these casualties may return to their highest possible level of function. Adherence to established amputation principles at each anatomic level can dramatically affect the outcome and ultimate function of the amputee. Long-term followup of these patients should be sought to ensure that the residual limb continues to be capable of tolerating prolonged prosthetic wear at a high demand level.
| Early Surgical Goals|| |
The primary surgical goal in the treatment of a patient with a severe lower extremity combat injury is - thorough debridement of all contaminated wounds. All the devitalized muscle, skin, and bone must be excised/ removed during the early surgical treatments in theater. Conversely, any and all viable muscle and fasciocutaneous tissue should be saved / conserved for possible use in the definitive soft tissue reconstruction.
| Soft Tissue Management|| |
Proper management of the soft tissue envelope is essential and critical. The best predictor of the timing of definitive closure, final limb length, and prolonged prosthetic use is the presence of adequately robust soft tissue coverage. Myofascial and/or myoplasty closures are very frequently used in the dysvascular and civilian trauma populations.,,, Alternatively, myodesis can/is the preferred technique of soft tissue stabilization following trauma-related amputation.,
| Management of Nerves|| |
Symptomatic neuromata accompany 0%-25% of major limb amputations and remain a frequent indication for reoperation.,, A traction neurectomy places the neuroma away from the region of the definitive closure and scarring as well as the ligated vessels. It is recommended for all named and other grossly visible nerves of the upper and lower extremity at the various amputation levels. A relation between acute postoperative pain with chronic amputation-related pain has been studied and identified. Patients who report the highest acute phantom limb pain are more likely to have phantom limb pain at 6 and 12 months following surgery. Current anesthesia guidelines continue to focus on methods to prevent central neuroplastic changes from occurring through the use of preventive multimodal analgesic techniques to include nonsteroidal anti-inflammatory drugs, local anesthetic nerve sheath injections, alpha-2 agonists, ketamine, opiods, preemptive epidurals, and regional nerve blocks.
| Level of Amputation|| |
There is an increasing oxygen cost of ambulation as the site of amputation moves to more proximal levels. In an attempt to conserve energy, the average walking speed of an amputee self-adjusts to maintain a similar overall oxygen consumption to control patients without limb loss. For this reason, better outcomes are usually associated with longer residual limbs. However, this dictum often does not hold true in cases of very severe foot and ankle injuries when a transtibial amputation is often indicated over a more distal foot or ankle amputation because of better prosthetic fit and component options.
When determining the final level of limb length and closure, the following tenets of Pinzur should be observed:- 24A. Optimal residual limb length without osseous prominences should be chosen.B. Reasonable function in the joint proximal to the level of the amputation should be present in order to enhance prosthetic functi’on.C. A durable soft tissue cover/envelope should be achieved and a full thickness myocutaneous flap to cushion areas of high pressure and shear is desired.
| Preservation of Length|| |
Multiple methods of preserving amputation length with creative soft tissue coverage have been developed,,,,,,,,,. Split-thickness skin grafting is the simplest mechanism to preserve length when robust muscle coverage is present. Soft tissue expanders can also be used in conjunction with split thickness skin grafting in order to achieve early, closure and a delayed, durable coverage at a later date., Finally, more complex and/or free tissue transfer can be used to preserve/save the limb length with good success when indicated.,
These length-preserving procedures are, however, related with delayed/late prosthetic fitting and frequent revision surgery., They are most commonly indicated/used around the knee to maintain a transtibial level of amputation.
Complications of Amputations
These can range from minor dermatologic complaints to major complications requiring multiple return trips to the operating room. In the recent review of the complications from the LEAP study group in a civilian trauma population, over 85% of patients who had a trauma-related amputation had a significant complication within the first 6 months after amputation. Trauma/injury related amputation had either a wound infection or wound necrosis. The other more frequent complications included stump complications, symptomatic neuromas, and phantom limb pain. Late/delayed complications include heterotopic ossification, symptomatic neuromas, late infections, myodesis failures, and tibiofibular synostosis related complications.
| Emergency Use of Tourniquet|| |
Hemorrhage from injured limbs continues to be a leading source of battlefield death, tourniquet use remains controversial and not agreed upon by all authors,,, with some authors banning prehospital use of tourniquets altogether. some authors has shown benefits of use of tourniqutet.
| Rehabilitation|| |
The goals of rehabilitation after major limb loss include not only functional restoration but also a return to a high quality of life (QOL). Patients who have undergone amputation, whether upper and/or lower limb amputation, will face difficulties/obstacles due to the amputation. Thus, the loss of a limb (or even just a part of it) usually leads to limitation of activity or ability. In addition to the impairment and the ability limitation created, external factors (personal and environmental factors) will lead to social participation restrictions, generally called “disability”. In order to prevent or reduce the level of disability the patient will face when returning home (and, therefore, improve the surgical outcome), rehabilitation (in its broadest sense) should take place, from an early stage prior to returning home and social inclusion. The rehabilitation process secondary to amputation usually includes:
- Medical/surgical rehabilitation services mainly aiming at preventing secondary and disabling complications, encouraging healing and preparing for prosthetic fitting
- Psychosocial/mental support aiming at facilitating acceptance of and adaptation to the new condition, environment and overcoming traumatic and psychological difficulties
- Functional/physical rehabilitation aiming at recovering functional abilities and autonomy in daily life activities, usually through the provision of assistive device(s) and training for proper use of those device(s)
- Social reintegration tackling broader/wider issues such as livelihood, education, family and social inclusion, accessibility, rights, empowerment, gender and community’s atátude changes
The beginning/starting point for rehabilitation is often considered to be the amputation itself and its cornerstone is the fitáng of a device. Providing/applying a prosthetic device is indeed a key stage of the rehabilitation process as, if successful, it will greatly influence the level of functional recovery and therefore social participation. As for the starting point of rehabilitation, when considering the influence that the surgical act (its quality and the level of amputation,,) has on rehabilitation outcomes, it clearly appears that it should precede the amputation itself. Choosing/selecting the proper site for amputation is primarily guided by pathological, anatomical and surgical factors (e.g. cause of amputation, viable tissues, blood supply).
Nonetheless, other personal and contextual factors that may influence expected outcomes should also be taken into consideration. In order for these to be appropriately considered when identifying/selecting the proper site for amputation, input from a rehabilitation professional might be required before the amputation is done. Comprehensive and multidisciplinary approaches, including rehabilitation services providers in the medical team, have long been advocated. Nowadays, in developed countries and in some developing countries where the situation is stable, early rehabilitation and early involvement of the rehabilitation team is, if not systematic, very common.
There are lots of challenges in managing a traumatic amputation case in developing countries like Nepal. Most of the people live in hilly areas as well as very poor to afford even the travel expenses from their place to a tertiary care center in Nepal like B. P. Koirala Institute of Health Sciences, Dharan. So a study was done to assess the prognosis and rehabilitative measure that can be done in developing countries with least expenditure and also to provide better job for them.
| Methods:|| |
Total sixteen patients were included in the study. All patients with traumatic injury to the limb leading to non- viability of the major part of the limb (above wrist and above ankle) coming to emergency of BPKIHS giving informed and written consent for the trial were included in the study. All patients underwent emergency amputation. Collected data were evaluated and various statistical tests applied.
| Observation and Results:|| |
|Table 3: Showing frequency of status of affected limb at the time of presentation|
Click here to view
| Discussion and Conclusion:|| |
In our study most common mode of injury was crush injury (56.3%), next to this is road traffic accidents (25%). This data well corroborates with other study done in past., This data contradicts other study in which combat related injury was most common., In other studies trauma was the main indication for amputation but they have not specified the mode of injury.2,46 One of the studies has divided injury type in to blunt and penetrating.
None of the studies has shown the injury to hospital delay. In our study most of the patients reached hospital within 24 hours of injury. Those who came late are due to development of compartment syndrome after ill management of closed fracture and due to remote areas.
Comorbidities, pallor, cyanosis, status of pulse, temperature, respiratory rate, active bleeding, viability of distal part, neural injury, compartment syndrome at the time of presentation has not been mentioned in other studies done in past. Our study shows one female patient having RHD at the time of presentation, no patient having cyanosis or active bleeding, all patients having normal respiratory rate, one patient having high rate of pulse, temperature was increased in 4 out of 16 patients and none of the patients had viability of distal part, 2 out of 16 patients came with compartment syndrome.
Drain, length of stump and type of dressing has not been mentioned clearly in previous studies. 18.8% of the patients had drain application at the time of primary closure and in 50% of the patient rigid dressing was done. Ideal length of the stump was not possible in most of the patients due to patient not willing or injury was like so that we can’t make it ideal.
Post-operative complications like stump infection, stump sore, wound infection were not major problem in our study. This data well corroborates with otjher studies done in past., Phantom limb and phantom pain (31%) was major complication seen in our patients. This data well corroborates with.,
Traumatic major limb amputation can occur both in upper and lower limb. Most commonly involved population is of younger working individuals. Loss of limb or a part of limb leads to major psychological and economical loss for the family as well as for the country. Major cause in our study is crush injury by machine and road traffic accident. These can be controlled or minimized by certain precautions while working and strict traffic rules. Better prosthetic fitting at low cost and rehabilitation is needed to make the patient conduct his near normal life style.
| References|| |
Galinos B et al. Epidemiology of Post-Traumiatc Limb Amputatìon: A Natìonal Trauma Databank Analysis The American Surgeon November 2010;76:1214-1222.
Masood J et al. Current Indicatìons For Major Lower Limb Amputatìons At Civil Hospital, Karachi Pakistan journal of surgery 2008;24(4):228-231.
Van der Meij WKN. No leg to stand on. Historical relatìon between amputations surgery and prostheseology 1995;1: 1-256.
Solomon L, Warwick D J, Nayagam S. Orthopaedic operatìons In: Solomon L, Warwick D J, Nayagam S, eds. Apley’s system of orthopedics and fractures.
8th ed. Arnold; 2001. P. 267.
Seymour R. Prosthetìcs and orthotìcs: lower limb and spinal. Philadelphia: Lippincott Williams & Wilkins; 2002.
Horne CE, Neil JA. Quality of life inpatìents with prosthetìc legs: a comparison study. J Prosthet Orthot 2009;21(3):154-9.
Gallagher P et al. Environmental barriers, actìvity limitatìons and partìcipatìon restrictìons experienced by people with major limb amputatìon. J Prosthet Orthot Int 2011;35(3):278-84.
Asano M et al. Predictors of quality of life among individuals who have a lower limb amputatìon. J Prosthet Orthot Int 2008;32(2):231- 43.
Pierce RO et al. The plight of the traumatìc amputee. J Orthop 1993;16(7):793- 797.
Smith DG et al. Atlas of Amputatìons and Limb Deficiencies: Surgical, Prosthetìc, and Rehabilitation Principles, pp. xvii, 965, American Academy of Orthopaedic Surgeons, Rosemont, IL, 2004.
LT Scott M et al. Lower Extremity Combat-Related Amputatìons. J Surg Orthop Adv 2010;19(1):35-43.
Burgess EM et al. Amputatìons of the leg for peripheral vascular insufficiency. J Bone Joint Surg 1971;53-A(5):874- 890.
Pedersen HE Treatment of ischemic gangrene and infection in the foot. J Clin Orthop 1960;16:199- 202.
Pedersen HE The problem of the geriatric amputee. J Artif Limbs 1968;12(2)(suppl.):1-3.
MacKenzie EJ et al. Functional outcomes following trauma related lower-extremity amputation. J Bone Joint Surg 2004;86-A(8):1636- 1645.
Smith DG et al. Transtibial amputations. J Clin Orthop Relat Res 1999;361:108- 115.
Pinzur MS et al. Controversies in lower extremity amputation. J Instr Course Lect 2008;57:663- 672.
Harris AM et al. Complicatìons following limb-threatening lower extremity J trauma Orthop 2009;23(1):1- 6.
Ducic I et al. The role of peripheral nerve surgery in the treatment of chronic pain associated with amputatìon stumps. J Plast Reconstr Surg 2008;121(3):908- 917.
Hanley MA et al. Pre amputatìon pain and acute pain predict chronic pain after lower extremity amputatìon. J Pain 2007;8(2):102- 109.
Wilder-Smith CH et al. Post amputatìon pain and sensory changes in treatment-naive patìents: characteristìcs and responses to treatment with tramadol, amitriptyline, and placebo. J Anesthesiology 2005;103(3):619- 628.
Waters RL et al. Energy cost of walking of amputees: the influence of level of amputatìon. J Bone Joint Surg 1976;58-A(1):42- 46.
Waters RL et al. Energy speed relatìonship of walking: standard tables. J Orthop Res 1988;6(2):215- 222.
Pinzur MS et al. Controversies in lower-extremity amputatìon. J Bone Joint Surg 2007;89-A(5):1118- 1127.
Gallico GG et al. Free flaps to preserve below-knee amputatìon stumps: long-term evaluation. J Plast Reconstr Surg 1987;79(6):871- 878.
Ghali S et al. Leg length preservatìon with pedicled fillet of foot flaps after traumatìc amputatìons. J Plast Reconstr Surg 2005;115(2):498- 505.
Gumley GJ et al. Total cutaneous harvestìng from an amputated foot - two free flaps used for acute reconstructìon. J Br Plast Surg 1987;40(3):313- 316.
Henman PD et al. Skin grafting an amputatìon stump: considerations for the choice of donor site. J Br Plast Surg 2000;53(4):357.
Kasabian AK et al. The role of microvascular free flaps in salvaging below-knee amputatìon stumps: a review of 22 cases. J Trauma 1991;31(4):495- 501.
Kasabian AK et al. Salvage of traumatìc below-knee amputatìon stumps utilizing the filet of foot free flap: critical evaluation of six cases. J Plast Reconstr Surg 1995;96(5):1145- 1153.
Kuntscher MV et al. The concept of fillet flaps: classificatìon, indicatìons, and analysis of their clinical value. J Plast Reconstr Surg2001;108(4):885-896.
Pelissier P et al. Reconstructìon of short lower leg stumps with the osteomusculocutaneous latìssimus dorsirib flap. J Plast Reconstr Surg 2002;109(3):1013- 1017.
Shenaq SM et al. Salvage of amputatìon stumps by secondary reconstructìon utilizing microsurgical freetissue transfer. J Plast Reconstr Surg 1987;79(6):861- 870.
Wood MR et al. The value of stump split skin grafting following amputation for trauma in adult upper and lower limb amputees. J Prosthet Orthot Int 1987;11(2):71- 74.
Wieslander JB et al. Tissue expansion: a method to preserve bone length and joints following traumatic amputations of the leg - a follow-up of five legs amputated at different levels. J Plast Reconstr Surg 1996;97(5):1065- 1071.
Rees RS et al. Tissue expansion: its role in traumatic below-knee amputations. J Plast Reconstr Surg 1986;77(1):133- 137.
Jupiter JB et al. Salvage replantation of lower limb amputations. J Plast Reconstr Surg 1982;69(1):1- 8.
Dedmond BT et al. Function of skin grafts in children following acquired amputation of the lower extremity. J Bone Joint Surg 2005;87-A(5):1054- 1058.
Potter BK et al. Heterotopic ossification following traumatic and combat-related amputations. Prevalence, risk factors, and preliminary results of excision. J Bone Joint Surg 2007;89-A(3):476- 486.
Bellamy RF. The causes of death in conventional land warfare: implications for combat casualty care research. J Mil Med 1984;149:55- 62.
Holcomb JB et al. Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001-2004. J Ann Surg 2007;245:986 - 991.
Navein J et al. The tourniquet controversy. J Trauma. 2003;54(5 Suppl):S219 -S220.
Pillgram-Larsen J et al. Not a tourniquet, but compressive dressing. Experience from 68 traumatic amputations after injuries from mines. J Tidsskr Nor Laegeforen 1992;112:2188 -2190.
Welling DR et al. A balanced approach to tourniquet use: lessons learned and relearned. J Am Coll Surg 2006;203:106 -115.
Husum H et al. Prehospital tourniquets: there should be no controversy. J Trauma. 2004;56:214 -215.
John F et al. Practical use of emergency tourniquets to stop bleeding in major limb trauma. J Trauma 2008;64:S38 -S50.
Richard A et al. Quality of life for veterans and servicemembers with major traumatic limb loss from Vietnam and OIF/OEF conflicts. J Rehabilitation Research & Development November 2010;47(4):373- 386.
World Health Organization (2001) International classification of functioning, disability and health[internet] 2012 Apr 10[cited 2013 Aug 16]; available from: URL:
Munin MC et al. Predictive factors for successful early prosthetic ambulation among lower-limb amputees. J Rehabil Res Dev 2001;38(4):379-384.
Didier D et al. Post-amputation rehabilitation in an emergency crisis: from preoperative to the community International Orthopaedics (SICOT) (2012) 36:2003-2005.
Geertzen JHB et al. Lower limb amputation. Part 2: rehabilitation-a 10 year literature review. J Prosthet Orthot Int 2001;25:14-20.54. Davies B et al. Mobility outcome following unilateral lower limb amputation. J Prosthet Orthot Int 2003;27:186-190.55. Taylor SM et al. Preoperative clinical factors predict postoperative functional outcomes after major lower limb amputation: an analysis of 553 consecutive patients. J Vasc Surg 2005;42:227-235.
Murdoch G. Level of amputation and limiting factors. J Ann R Coll Surg Engl 1967;40(4):204-216.
The Sphere Project (2011) Humanitarian charter and minimum standards in disaster response. Minimum standards in health actions, 3rd edn. The Sphere Project, Geneva, pp 331-333.
Schwarz RJ. Amputation revision in an asian rehabilitation centre. J Nep Med Assoc 2004;43:288-291.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]