MAART 1978 F I S I O T E R A P I E 9

REHABILITATION AFTER TRAUMATIC AMPUTATION OF 
THE LOWER LIMBt

M ISS M. H U M P H R E Y *

Traumatiese am putasies, as gevolg van landm ynonl- 
ploffings word genoem . D rie fases van posl-operaliew e 
behandeling word bespreek, naam lik die vroee fase in 
die saal, die interm ediere fase in die gim nasium  en die 
finale stadium wanneer ’n prostese gepas is en loopgang 
rehabilitasie plaasvind.

It has been said th a t we are  rap id ly  becom ing a race 
of one-legged people —  p ro b a b ly  an exaggeration — 
nevertheless a sign o f the times.

People have been, to date, m ore fa m ilia r w ith am p u ­
tations owing to road, in d u strial and ag ricu ltu ral acci­

dents. H owever, of all the causes o f tra u m a tic  am puta- 
lons w ar injuries are the m ost devastating.

•J Anti-personnel m ines are  designed to m aim  ra th e r 
than to kill, w hile land m ines and high velocity, m issiles 
have a “sh atterin g ” effect —  in m ore senses th a n  one — 
on soldiers and civilians alike. '

Blast injuries are  a new dim ension in tra u m a tic  a m ­
putations and, together w ith those o th e r in ju ries m en­
tioned previously, add to th e fo rm id ab le to tal o f lim bs 
lost during a year. T h is num ber, n atu rally , covers men 
and women fro m  all walks o f life and includes all races. 
However, because o f n u m erical su p erio rity , th e greatest 
incidence o f am putees occurs am ong the A fric a n  p o p u ­
lation as a large n u m b er a re  victim s o f terro rism .

After all th e necessary life-saving m easures have been 
performed, the in itial treatm en t is “w ound to ile t” . In  
blast injuries this is essential as shrapnel fro m  the 
mine, vehicle p arts, stones and clothing, m ay be em ­
bedded in th e w ound. In  such cases the w ound is left 
open until all danger o f sepsis is past. T h is m ay take 
a considerable tim e. Secondary closure is then p e r­
formed and a soft dressing applied. T h is is held in place 
by a pressure bandage to give m axim um  su p p o rt to the 
wound and prevent oedem a.

The most satisfacto ry  stum ps a re  those w hich are end 
bearing and w here m uscle fixation is achieved by m yo­
fascial closure over the bone end o r by m yodesis, a tta c h ­
ing the m uscles d irectly  to the tib ia  o r fem u r by way 

-<if sutures thro u g h  drill holes in th e bone. T h is allows 
ae severed m uscles to be exercised th ereb y  retaining 

nnuscle bulk an d  p ro m o tin g  g ood circu latio n  w hich 
keeps the skin h ealth y  an d  w hich in tu rn  prevents 
ulceration o f the stum p.

Length is equally im p o rta n t because the longer the 
stump th e g reater th e leverage an d  th e  less effort is 
required to m an ip u late the prosthesis.

R ehabilitation starts im m ediately a fte r surgery. P o st­
operative physical treatm en t is divided into three 
phases:

The early phase in th e ward.
The interm ediate phase in  the gym.
The final stage when th e prosthesis is fitted.

Early Phase

Initially a fra c tu re  b o a rd  sh o u ld  be placed :under th e 
mattress allow ing fo r good p o sitio n in g  o f th e  stum p; 
where possible th e p a tie n t is nursed on his back as side

* Physiotherapist, W o rk m en ’s R e h a b ilita tio n  C entre, 
Bulawayo.

t  Paper presented a t a C ongress on T ra u m a  in D u rb an , 
May 1977.

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lying encourages h ip  flexion. F lex io n  co n tractio n  of the 
h ip  jo in t especially in above-knee am putee is in ev itab le 
unless the th e ra p ist is o n  th e lo o k o u t and ready to 
co u n ter any tendency th e  p a tie n t m ay have w hich w ill 
e n co u rag e this. N o pillow s are allow ed un d er th e  stum p 
fo r the sam e reason. H ow ever if you can p rev en t a 
p a tie n t sneaking a pillow  u n d e r th e  stum p at some tim e 
during th e n ig h t o r day you are a lot cleverer th a n  I 
am!

A s soon as the p a tie n t is w ell enough he should be 
asked if he can still feel his leg. W h atev er his reply it 
is im p o rta n t to ex p lain  th a t p h a n to m  pains m ig h t occur 
and th a t the lim b w ill g rad u ally  ap p e a r to sh rin k  and 
get sh o rte r u n til it eventually disappears.

T h is ex p lan a tio n  is p a rtic u la rly  im p o rta n t w hen tre a t­
ing A fric a n  p atien ts as they are a fra id  to m ention it in 
case it is som e kind o f w itchcraft.

F ro m  the first to the fifth d ay  b reath in g  exercises and 
general bed exercises a re  encouraged.

O n the th ird  day, if o th e r in ju ries p erm it, p ro n e lying 
fo r 15 m inutes, th ree tim es p e r day, is introduced.

D ra in s o r suction m ay be rem oved fro m  the w ound 
a t th is tim e and if the p a tie n t is allow ed u p, encourage 
standing and balancing w ith support. C rutch w alking is 
started the fo u rth  day. W henever possible use elbow  
crutches, n o t a x illary  crutches o r a w heeled w alker. 
Specific stum p exercises in lying o r standing are started. 
T hese include ad d u ctio n  and extension exercises in 
above-knee am putees and in below -knee am putees, exer­
cises to strengthen the quadriceps. S titches are rem oved 
on the tenth day and if the incision is well healed, firm 
stum p bandaging should start.

It is im p o rta n t to use a bandage o f the correct width. 
A  150 m m  w oven co tto n  an d  elastic bandage should 
be used fo r an above-knee stum p an d  a 100 mm  bandage 
fo r a  below -knee stum p. W h en  a p p ly in g  th e  bandage 
ensure th a t it is applied in a spiral. In  a below -knee 
am putee sta rt the bandage above the knee and include 
th e  joint. T h is prevents o cclusion o f th e  vessels behind 
the knee jo in t and strangling o f th e  stum p. I t also 
ensures a b etter shape fo r p ro s th e tic  fitting.

In  the above-knee am putee see th a t the bandage goes 
rig h t up into th e g ro in  to av o id  getting a flesh roll 
fo rm in g  th ere as th is m akes lim b fitting difficult. C oning 
is essential fo r a p rosthesis to be fitted to a stum p. F o r 
it to fu n ctio n  adequately, th e stum p m ust be fully shrunk 
a n d  sh ap ed  b efo re m easurem ents fo r a lim b are taken.

A t first the p a tie n t will only to lerate pressure fo r a 
sh o rt p erio d  so th a t th e  bandage will have to be re­
ap p lied  frequently. H ow ever, tolerance soon builds up 
until the bandage need o n ly  be ap p lied  fo u r tim es per 
day. T h e  p a tie n t should be ta u g h t how  to ap p ly  his 
ow n bandage. T h e  bandage should be w orn a t n ight 
an d  even w hen he has received his prosthesis this 
p ractice should continue. H e  should also be to ld  a t this 
stage th a t if in th e fu tu re  he has to d iscard  his p ro s­
thesis fo r an y  length o f tim e, e.g. if it is being repaired, 
he m ust ensure th a t his stum p is bandaged du rin g  the 
interval. F a ilu re  to do so m ay resu lt in  swelling o f the 
stum p an d  d isco m fo rt w hen h e p u ts on his prothesis 
again.

The Intermediate Phase

T h is includes a full pro g ram m e o f general exercises 
in the gym an d  pool to w hich are  added specific stum p

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exercises. T hese progress fro m  free exercises to resisted 
exercises using springs o r weights. B alance exercises are 
o f p a ra m o u n t im p ortance and should be practised until 
th e p a tie n t is alm ost as m obile o n  o n e leg as h e  was on 
two.

T his p o in t w ill be appreciated should he stum ble when 
he starts w alking on h is pylon. If he has been well 
tau gh t he w ill usually be able to recover his e q u ilib riu m  
w ith o u t falling. It is both physically an d  psychologically 
im p o rtan t to get the p atien t w alking as early  as p o s­
sible an d  the use o f a tem p o rary  pylon cannot be over 
stressed. H e is gradually encouraged to dispense w ith 
crutches o r a cane. T his is very necessary fo r a m an 
w hose job m ay en tail carry ing loads o r eq u ip m en t once 
he returns to w ork.

At this stage the exercise program m e is extended to 
the occu p aito n al th erap y  d epartm ent and an assessm ent 
is m ade as to w hether o r n o t th e p a tie n t w ill be able 
to re tu rn  to h is fo rm er em ploym ent. If this is not 
possible arrangem ents should be set in m o tion fo r 
vocational train in g  so th a t th ere is no h ia tu s in his 
recovery program m e.

T h e  afo rem en tio n ed  p rogram m e w ill have to be 
m odified to accom m odate associated injuries, th e  m ost 
com m on being fractu res o f the o th e r lim b o r pelvis 
and in b last injuries fractu re o f the skull o r spine.

A fter 6 - 8  weeks the stum p shou ld  be ready fo r 
m easuring fo r a prosthesis.

T o digress, a p a rt fro m  the injuries w hich a re  obvious 
at the tim e o f the accident, in blast injuries w hich are 
caused by m ines o r bom bs the p h y sio th erap ist w ho has 
pro b ab ly  th e closest and lengthiest association w ith the 
p a tie n t should be on th e a le rt fo r com plications w hich 
m ay only be m anifested a t a later date. D eafness and 
eye sym ptom s are th e m ost com m on, and in th e below 
knee am p u tatio n  som e fo rm  o f internal derangem ent 
m ay be present w hich shows up only w hen the p atient 
starts w alking.

Final Stage

T he F ittin g  o f a P rosthesis: W hen discussing th e type 
o f prosthesis w hich is to be ordered fo r the p a tie n t the 
follow ing p o in ts should be tak en  in to  consideration:—
1. O f p rim e im po rtance is th e distance he lives from  

th e n earest O rth o p aed ic C entre o r lim b factory. 
M any o f th e sm aller countries have only one or 
two lim b fitting centres serving the w hole area. 
Q ualified prosthetists in m ost cou ntries are extrem ely 
scarce. T h ose th a t are  available are usually grossly 
overw orked and have a trem endous backlog so that 
even th e  sim plest re p a ir m ay m ean th a t th e m an is 
derived o f the use o f his lim b fo r several weeks.

2. T h e  next p o in t to be considered is th e  n a tu re  of his 
w ork, if h e  has a sedentary job, o r w hether he is 
an industrial o r farm  la b o u re r w hich could entail a 
lot o f w alking.

3. T hirdly, w h eth er th e p a tie n t lives in a tow n o r 
trib a l village. A  fully a rticu lated  leg m ay be satis­
facto ry  in an u rb an  area, but in a ru ra l area w here 
the recip ien t has to w alk long distances in all 
w eathers, S.A.C.H. feet and ankle joints do n o t take 
kindly to constant im m ersion in w ater o r the rigours 
of w alking in a m uddy field in ad d itio n  to w hich the 
n earest m ain  ro ad  and bus o r tra in  ro u te m ay be 
m any m iles fro m  his home. In  these circum stances 
a peg is m ore p ractical and w ill give m uch better 
service.

In m y o p in io n  the fitting o f a m odular nroctk 
w ould ap p e a r to be the best solution to some of th ls 
problem s. A  m odular prosthesis is one th at ca 
assem bled to a high degree fro m  prefabricated ” ^  
an d  can be adjusted on the am putee very rapid|Parts 
bring it to o p tim um  function. It w ould also be m to 
m ore satisfactory and less costly to fit the patient 
a tem p o rary  lim b, w hich can be assembled by "'t'^ 
physiotherapist, as soon as possible and to send k- 
hom e as soon as he is w alking well. H e should k 
instructed to rep o rt to th e nearest P hysiotherapy dena 
m ent or P h y sio th erap ist should th e lim b need adi 
m ent until such tim e as he is ready fo r a definiY 
prosthesis. 1Ve

T h e  W innipeg m o d u lar prosthesis was introduced ' 
1965 and has now  becom e standardised. T here is ' n 
G erm an  m odel w hich is proving satisfactory and the & 
is a Japanese v ariatio n  w hich is even simpler ^  
assem ble an d  adjust. In th e interest of the patient this 
should be th e  prosthesis o f choice w hich should be nwj  
in th e future.

T here is one snag. N o t m any physiotherapists havej 
th e  know ledge to fit the patient, assem ble the prosthesis? 
an d  do the adjustm ents. Prosthetics and O rthotics seem 
to be a blind spot in the scope o f o u r w ork and 1 feei 
th a t this m ay stem  from  an a p p a re n t lack in initial 
training. T he need fo r th erap ist involvem ent is great 
A  few o f us w ere fo rtu n a te  enough to do o u r training 
d u rin g  the last w ar when a situ atio n  sim ilar to the one 
today, existed and o u r interest in this field was 
stim ulated. T o d ay  we are much m ore fo rtu n ate in that 
we have the m aterials to m ake th e do-it-yourself splint 
com paratively easily and, given th e necessary instruc­
tion, a g reat c o n trib u tio n  could be m ade to the existing 
need to fit a brace o r lim b prom ptly.

I  do n o t p ropose to discuss the v ario u s types o f lower 
lim b prosthesis. Two categories o f patients deserve 
special m ention. T h e  first is the b ilateral above-knee 
am putee w ith sh o rt stum ps w ho poses the question — 
Is he going to be a successful w alker o r is he going to 
find the effort too great an d  becom e a d isp irited  wheel­
ch air addict?

I t  seems the answ er is n o t to be too am bitious when 
ord erin g  his prosthesis. If you can convince th e patient 
th a t sh o rter legs will req u ire less physical effort to 
w alk an d  th a t th e closer he is to the ground the greater 
his confidence will be, you w ill have a h ap p y  walker.

B ew are o f the enthusiast who tries to persuade you 
and th e p a tie n t th a t his psyche w ill suffer because he i« 
several feet sh o rter than his fellow m en. If you should 
subm it and o rd e r long legs, the result w ill be th a t in a 
very short tim e you w ill have a  fa t m iserable squatter 
on your hands.

In the second category is the m an w ho has had a 
hem ipelvectom y. A lthough great strides have been made 
in p roducing a fa irly  sound prosthesis som e patient? 
will p ro test th a t this is too heavy and they p re fe r to us~ 
crutches. D o n ’t be too h ard  on them  as they have a 
point.

T h e  m ost successful w alkers are those w ith a well- 
fitting end-bearing prosthesis. T hey should present few 
problem s p rovided they have been given adequate in­
stru ctio n  in stum p hygiene and m anagem ent. T h e least 
successful are  those who have been given lim bs where 
th e  effort re q u ire d  to  m an ip u late th e  leg out-w eighs its 
usefulness.

MARCH i 978P H Y S I O T H E R A P Y

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