Amputation
Performed to preserve function in a remaining part or, at times, to prevent death, amputation is a radical treatment for severe trauma, gangrene, cancer, vascular disease, congenital deformity, or thermal injury. It can take one of two basic forms. In a closed, or flap, amputation—the most commonly performed type—the surgeon uses skin flaps to cover the bone stump. In an open, or guillotine, amputation (a rarely performed emergency operation), he cuts the tissue and bone flush, leaving the wound open. A second operation completes repair and stump formation. Amputation may be performed at a number of sites, depending on the nature and extent of injury. (See Common levels of amputation, page 34.)
Procedure
The patient receives a general anesthetic (or perhaps a local anesthetic for a finger or toe amputation). In the closed technique, the surgeon incises the tissue to the bone, leaving sufficient skin to cover the end of the limb. Bleeding is controlled above the level of amputation by tying off the bleeding vessels with suture ties. The bone (or joint) is then sawed and filed until smooth and rounded, with the periosteum removed about ¼″(0.6 cm) from the bone end. After ligating all vessels and dividing the nerves, the surgeon sutures opposing muscles over the bone end and to the periosteum to provide better muscle control and circulation. Next, he sutures the skin flaps closed. Placement of an incisional drain and a soft dressing completes the procedure.
Common levels of amputation
Amputation may be performed at a wide range of sites. Review this list for common types and levels of amputation.
Partial foot: removal of one or more toes and part of the foot
Total foot: removal of the foot below the ankle joint
Ankle (Syme’s amputation): removal of the foot at the ankle joint
Below-the-knee: removal of the leg 5″ to 7″ (12.5 to 18 cm) below the knee
Knee disarticulation: removal of the patella, with the quadriceps brought over the end of the femur, or fixation of the patella to a cut surface between the condyles (known as the Gritti-Stokes amputation)
Above-the-knee: removal of the leg from 3″ (7.6 cm) above the knee
Hip disarticulation: removal of the leg and hip or the leg and pelvis
Hemipelvectomy: removal of a leg and half of the pelvis
Fingers: removal of one or more fingers at the hinge or condyloid joints
Wrist disarticulation: removal of the hand at the wrist
Below-the-elbow: removal of the lower arm about 7″ below the elbow
Elbow disarticulation: removal of the lower arm at the elbow
Above-the-elbow: removal of the arm from 3″ above the elbow
In a below-the-knee amputation, the surgeon may order a rigid dressing applied over the residual limb in the operating room. This enables immediate postoperative fitting of a prosthesis and helps prevent contractures.
In an emergency, or guillotine, amputation, the surgeon makes a perpendicular incision through the bone and all tissue, leaving the wound open and applying a large bulky dressing.
Complications
Amputation can cause several complications, including infection at the distal site, contractures in the remaining limb part (if exercise of the limb part is delayed), skin breakdown from improper care of the stump or an ill-fitting prosthetic device, and phantom pain. Phantom pain is a sensation of pain, itching, or numbness in the area of amputation, even though the limb or digit has been removed. It commonly develops after a major amputation and can occur as late as 2 to 3 months after the procedure. (See Multidisciplinary care for the patient with an amputation.)
Key nursing diagnoses and patient outcomes
Disturbed body image related to loss of limb or digit. Based on this nursing diagnosis, you’ll establish these patient outcomes. The patient will:
express feelings about the effect of amputation on his body image
participate in a rehabilitation program to help adapt to the change in his body image and function
accept his altered body image.
Risk for infection related to improper stump care. Based on this nursing diagnosis, you’ll establish these patient outcomes. The patient will:
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