Jeselo O.

Gorme, RN, MN, JD

Contusions, Strains, & Sprains
 A contusion is a soft tissue injury produced by blunt
force, such as a blow, kick, or fall. Many small blood
vessels rupture and bleed into soft tissues (ecchymosis,
or bruising)
 Hematoma develops when the bleeding is sufficient
to cause an appreciable collection of blood which may
occur anywhere in the body.
 A Strain (or a “pulled muscle”) is an injury to a
musculotendenous unit caused by overuse,
overstretching, or excessive stress.
 Types:
 A first-degree strain reflects tearing of few muscle
fibers and is accompanied by minor edema, tenderness,
and mild muscle spasm, without noticeable loss of
function.
 A second-degree strain involves tearing of more
muscle fibers and is manifested by notable loss of load-
bearing strength with accompanying edema, tenderness,
muscle spasm, and ecchymosis.
 A third-degree strain is the most severe type and
involves complete disruption of at least one
musculotendenous unit that involves separation of
muscle from muscle, muscle from tendon, or tendon
from bone. A patient with this type of strain presents
with significant pain, muscle spasm, ecchymosis,
edema, and loss of function.
 A sprain is an injury to the ligaments and supporting
muscle fibers that surround a joint. It is caused by a
wrenching or twisting motion.
 Types:
 A first-degree sprain is caused by tearing of a few
ligamentous fibers. It is manifested by mild edema, local
tenderness, and pain that is elicited when the joint is
moved; however, there is no appreciable joint instability.
 A second-degree sprain involves tearing of more
fibers. It results in increased edema, tenderness, pain
with motion, joint instability, and partial loss of normal
joint function.
 A third-degree sprain occurs when a ligament is
completely torn. It is manifested by severe pain,
tenderness, increased edema, and abnormal joint
motion.
Management
 R – rest, I – ice, C – compression, E – elevation
 Rest prevents additional injury and promotes healing.
 Intermittent application of moist or dry cold packs for
20-30 mins during the first 24-48 hours after injury to
produce vasoconstriction, which decreases bleeding,
edema, and discomfort.
 An elastic compression bandage controls bleeding,
reduces edema, and provides support for the injured
tissues.
 Elevation controls swelling.
 If the strain or sprain is third-degree, surgical repair or
immobilization by cast may be necessary.
 After the acute inflammatory stage, heat may be
applied intermittently (for 15-30 mins, four times a
day) to relieve muscle spasm and to promote
vasodilation, absorption, and repair.
 Depending on the severity, passive and active ROM
may begin in 2-5 days.
 Strains and sprains takes weeks or months to heal,
because ligaments and tendons are relatively avascular.
Joint Dislocations
 A dislocation of a joint is a condition in which the
articulating surfaces of the bones forming the joint are
no longer in anatomic contact.
 A subluxation is a partial dislocation of the
articulating surfaces.
 Joint dislocations are orthopedic emergencies because
if not treated promptly, avascular necrosis and nerve
palsy may occur.
Medical Management
 Analgesia, muscle relaxant, and possibly anesthesia are
used to facilitate closed reduction.
 The joint is immobilized by bandages, splints, casts, or
traction and is maintained in a stable position.
Nursing Management
 Nursing care is directed at providing comfort,
evaluating the patient’s neurovascular status, and
protecting the joint healing.
Sports-Related Injuries
 Contusions result from direct fall or blows. The initial
dull pain becomes greater, with edema and stiffness
occurring by the next day.
 Sprains occur most commonly in the ankles but may
also occur in fingers and knees.
 Tennis players often suffer calf muscle trains; soccer
players often experience quadriceps strains; and
swimmers, weightlifters, and tennis players often
suffer shoulder strains.
 Tendinitis is caused by overuse and is seen in tennis
player (epicondylar tendinitis or tennis elbow),
runners and gymnasts (Achilles tendinitis), and
basketball players (infrapatellar tendinitis).
 Meniscal injuries of the knee occur with excessive
rotational stress.
 Dislocations are seen with sports that involve throwing
or lifting.
 Traumatic fractures occur with falls. Skaters and bikers
frequently suffer Colle’s fractures of the wrist when
they fall on outstretched arms, and ballet dancers and
track and field athletes may experience metatarsal
fractures.
Colle’s Fracture
 Stress fractures occur with repeated bone trauma from
activities such as running, jumping, and throwing as
well as from sports that include track and field,
gymnastics, basketball, rowing, baseball, and tennis.
Occupational-Related Injuries
 Nursing is consistently ranked among the top ten
occupations that are most involved in occupation-
related injuries and lost work days.
 Most of these injuries have occurred during the patient
handling and movement activities.
 Evidence-based methods to deter occupational-related
injuries among nursing personnel:
1. Hospitals, long-term care facilities, and other health
care organizations should purchase patient handling
equipment (eg. Hoyer lifts) and train nursing
personnel in their appropriate use.
 Health care organizations should institute “no lift”
policies for individual nursing personnel. Rather,
patient lift teams should be organized.
 Health care organizations should devise methods to
assess their patient care ergonomic risks and develop
algorithms for patient handling and movement that
include patient transfer and movement activities.
Specific Musculoskeletal Injuries
Rotator Cuff Tears
 S&Sx include:
 Pain
 Limited ROM
 Joint dysfunction
 Muscle weakness
 In some cases, patient experiences night pain and
cannot sleep on the involved side
 Patient cannot perform over-the-head activities.
 Management includes:
 NSAIDs
 Rest with modification of activities
 Injection of a corticosteroid into the shoulder joint
 Progressive stretching, ROM and strengthening
exercises
 Arthroscopic debridement or arthroscopic or open
acromioplasty with tendon repair
 (Full recovery is expected in 6-12 months)
Epicondylitis (Tennis Elbow)
 It is a chronic, painful condition that is caused by
excessive, repetitive extension, flexion, pronation, and
supination activities of the forearm.
 S&Sx include:
 Pain radiates extensor (dorsal) surface of the forearm
and relief is obtained by rest and avoidance of the
aggravating activity
 Weakened grasp
 Management:
 Application of ice after the activity and administration
of NSAIDs to relieve pain
 Arm is immobilized in a molded splint or cast
 Injection of corticosteroids is reserved for patients with
severe pain who do not respond to NSAIDs and
immobilization
 A tennis elbow counterforce strap that limits extension
of the elbow may be prescribed when activity is
resumed.
Lateral & Medial Collateral Ligament Injury
 Injury occurs when the foot is firmly planted and the
knee is struck – either medially, causing stretching and
tearing injury.
 The patient experiences an acute onset of pain, point
tenderness (tenderness at the site of the injury), joint
instability, and inability to walk without assistance.
 Medical Management:
 RICE
 Hemarthrosis (bleeding into the joint) may develop,
contributing to pain, so the joint fluid may be aspirated
to relieve pressure.
 Limited weight bearing and use of elastic bandaging or a
brace.
 As pain subsides, ROM is encouraged.
 Generally, the leg is immobilized and weight bearing is
restricted for 6-8 weeks.
 A progressive rehabilitation program occurs over many
months.
 Nursing Management:
 Health teaching regarding:
 Proper use of ambulatory devices
 The healing process
 Activity limitation
 Pain management
 Medications
 Brace use
 Wound care
 Possible complication (eg. Infection)
 Self-care
Rupture of the Achilles Tendon
 It occurs during activities when there is a sudden
contraction of the calf muscle with the foot fixed
firmly to the floor or ground.
 The patient experiences sharp pain and cannot planter
flex the foot.
 Immediate surgical repair is done to achieve
satisfactory results.
 After surgery, a cast or brace is used to immobilize the
joint.
Fractures
 It is a break in the continuity of bone.
 Types:
 Complete fracture involves a break across the entire
cross-section of the bone and is frequently displaced
(removed from its normal position).
 Incomplete fracture involves a break through only part
of the cross-section of the bone.
 Closed fracture (simple fracture) is one that does not
cause a break in the skin.
 Open fracture (compound/complex fracture) is one in
which the skin or mucous membrane wound extends to
the fractured bone.
Complete Fracture
Incomplete Fracture
Closed Fracture
Open Fracture
 Avulsion is a fracture in which a fragment of bone has
been pulled away by a tendon and its attachment.
 Comminuted is a fracture in which bone has splintered
into several fragments.
 Compression is a fracture in which bone has been
compressed.
 Depressed is a fracture in which fragments are driven
inward.
 Epiphyseal is a fracture through the epiphysis.
Avulsion Fracture
Comminuted
Compression
Depressed
Epiphyseal
 Greenstick is a fracture in which one side of a bone is
broken and the other side is bent.
 Impacted is a fracture in which a bone fragment is
driven into another bone fragment.
 Oblique is a fracture occurring at an angle across the
bone (less stable).
 Pathologic is a fracture that occurs through an area of
diseased bone (osteoporosis, bone cyst, bony metastasis,
tumor; can occur without trauma or a fall.
Greenstick
Impacted
Oblique
 Spiral is a fracture that twists around the shaft of the
bone.
 Stress is a fracture that results from repeated loading
without bone and muscle recovery.
 Transverse is a fracture that is straight across the bone
shaft.
Spiral
Transverse
Clinical Manifestations
 Pain
 Continuous and increases in severity until the bone
fragment are immobilized.
 Loss of Function
 After the fracture, the extremity cannot function
properly because normal function of the muscles
depends on the integrity of the bones to which they are
attached.
 Deformity
 Displacement, angulation, or rotation of the fragments
in a fracture of the arm or leg causes a deformity (either
visible or palpable) that is detectable when the limb is
compared with the uninjured extremity.
 Shortening
 In fractures of the long bones, there is actual shortening
of the extremity because of the contraction of the
muscles that are attached distal and proximal to the site
of the fracture.
 Crepitus
 A grating sensation when the extremity is examined
with the hands and is caused by the rubbing of the bone
fragments against each other.
 Swelling and Discoloration
 Localized edema and discoloration of the skin occur
after a fracture as a result of trauma and bleeding into
the tissues.
Emergency Management
 Immediately after injury, whenever a fracture is
suspected, it is important to immobilize the body part
before the patient is moved.
 Splinting is done by immobilizing joints proximal and
distal to the fracture to prevent rotation as well as
angular motion.
 Immobilization of the long bones in the lower
extremities may be accomplished by bandaging the
legs together, with the unaffected extremity serving as
a splint.
 In an upper extremity injury, the arm may be
bandaged to the chest, or an injured forearm may be
placed in a sling.
 With an open fracture, the wound is covered with a
sterile dressing to prevent contamination of deeper
tissues. No attempt is made to reduce the fracture.
Medical Management
 Reduction
 Refers to restoration of the fracture fragments to anatomic
alignment and rotation.
 Closed Reduction
 It is accomplished by bringing the bone fragments into
apposition (placing the ends in contact) through
manipulation and manual traction.
 The immobilizing device maintains the reduction and
stabilizes the extremity for bone healing. X-rays are obtained
to verify that the bone fragments are correctly aligned.
 Traction (skin or skeletal) may be used to effect fracture
reduction and immobilization.
  Open Reduction
 Through a surgical approach, the fracture fragments are
reduced.
 Internal fixation devices (metallic pins, wires, screws,
plates, nails, or rods) may be used to hold the bone
fragments in position until solid bone healing occurs.
 Immobilization
 It may be accomplished by external or internal fixation.
 Methods of external fixation include bandages, casts,
splints, continuous traction, and external fixators.
 Metal implants used for internal fixation serve as
internal splints to immobilize fracture.
 Maintaining and Restoring Function
 Reduction and immobilization are maintained as
prescribed to promote bone soft tissue healing.
 Edema is controlled by elevating the injured extremity
and applying ice as prescribed.
 Neurovascular status is monitored.
 Restlessness, anxiety, and discomfort are controlled by
reassurance, position changes, and pain relief strategies
 Isometric and muscle-setting exercises are encouraged
to minimize disuse atrophy and to promote circulation.
Nursing Management
 Patients with Closed Fractures
 Encourage patients to return to their usual activities as
rapidly as possible.
 Teach exercises to maintain the health of unaffected
muscles and to increase the strength of muscles needed
for transferring and for using assistive devices.
 Other health teachings would include self-care,
medication information, monitoring for potential
complications, and the need for continuing health care
supervision. tethered
 Patients with Open Fractures
 There is increased risk for osteomyelitis, tetanus, and
gas gangrene.
 Objectives of management:
 Prevent infection of the wound, soft tissue, and bone
 Promote healing of soft tissue and bone
 Administer tetanus prophylaxis if indicated
 Serial irrigation and debridement are used to remove
anaerobic organisms.
 IV antibiotics are prescribed.
 Primary wound closure is usually delayed.
 Heavily contaminated wounds are left unsutured and
dressed with sterile gauze to permit edema and wound
drainage.
 After it has been determined that infection is not
present, the wound is closed in 5 to 7 days, and all dead
space is obliterated by grafting of autogenous skin or
flap.
 Elevate the extremity to minimize edema.
 Assess for neurovascular status frequently.
 Assess the temperature at regular intervals and monitor
for any signs of infection.
Fracture Healing and Complications
 Factors that Enhance Fracture Healing
 Immobilization of fracture fragments
 Maximum bone fragment contact
 Sufficient blood supply
 Proper nutrition
 Exercise: weight bearing for long bones
 Hormones: growth hormone, thyroid, calcitonin,
vitamin D, anabolic steroids
 Factors that Inhibit Fracture Healing
 Extensive local trauma
 Bone loss
 Inadequate mobilization
 Space or tissue between bone fragments
 Infection
 Local malignancy
 Metabolic bone disease (Paget’s disease)
 Irradiated bone (radiation necrosis)
 Avascular necrosis
 Intra-articular fracture (synovial fluid contains fibrolysins,
which lyse the intial clot and retard clot formation)
 Age
 Cortecosteroids (inhibit the repair state)
Early Complications: Shock
 Hypovolemic shock resulting from hemorrhage and
from loss of intravascular volume into the interstitial
space, particularly within damaged tissue, may occur
in fractures of the extremities, thorax, pelvis, or spine.
 Treatment includes stabilizing the fracture to prevent
further hemorrhage, restoring blood volume and
circulation, relieving the patient’s pain, providing
adequate splinting, and protecting the patient from
further injury.
Fat Embolism Syndrome
 Risk factors:
 Young adults (20-30 y.o.)
 Elderly adults who experience fractures of the proximal
femur (hip fracture).
 Fat globules may diffuse into the vascular
compartment because the marrow pressure is greater
than the capillary pressure or because catecholamines
elevated by the patient’s stress reaction mobilize the
fatty acids and promote the development of fat
globules in the bloodstream.
 Onset of symptoms is rapid, usually within 24-72
hours of injury, but may occur up to a week after
injury.
 Presenting features include hypoxia, tacypnea,
tachycardia, and pyrexia.
 The respiratory distress response includes tachypnea,
dyspnea, crackles, wheezes, precordial chest pain,
ough, large amounts of thick white sputum, and
tachycardia.
 There is increase of pulmonary pressure due to
occlusion of a large number of small blood vessels.
 Edema and hemorrhages in the alveoli impair oxygen
transport, leading to hypoxia.
 ABG results shows PaO2 to be less than 60 mmHg.
 Chest X-ray shows a typical “snowstorm” infiltrate.
 Cerebral disturbances are manifested by mental status
changes varying from headache and mild agitation to
delirium and coma.
 NURSING ALERT!
Subtle personality changes, restlessness,
irritability, or confusion in a patient who has
sustained a fracture are indications for
immediate arterial blood gas studies.
 Preventive measures:
 Immediate immobilization of fractures (including early
surgical fixation)
 Minimal fracture manipulation
 Adequate support for fractured bones during turning
and positioning
 Maintenance of fluid and electrolyte balance
 Management:
 Objective: support the respiratory system, prevent
respiratory failure, correct homeostatic disturbances
 Most common cause of death is from acute pulmonary
edema and ARDS.
 Respiratory support by high flow oxygen.
 Corticosteroids may be administered IV to treat
inflammatory lung reaction and to control cerebral
edema.
 Vasopressor medications to support cardiovascular
functions to prevent hypotension, shock, and interstitial
pulmonary edema.
 Accurate fluid intake and output records facilitate
adequate fluid replacement therapy.
 Morphine for patients who are on ventilator.
 IV benzodiazepine to relieve anxiety.
 Provide calm reassurance to allay apprehension.
 Respiratory support must be instituted early.
Compartment Syndrome
 Anatomic compartment is an area of the body
encased by bone or fascia (fibrous membrane that
covers and separates muscles) that contains muscle,
nerves, and blood vessels.
 The human body has 46 anatomic compartments and
36 are found in the extremities.
 Compartment syndrome is a complication that
develops when pressure within a compartment is
greater than normal. (N=8 mmHg and below)
 Types:
 Acute compartment syndrome
 It involves a sudden and severe decrease in blood flow to
the tissues distal to an area of injury that results in
ischemic necrosis. More common in fractures.
 Chronic compartment syndrome
 It is characterized by pain, aching, and tightness in a
muscle or muscle group that has been subjected to
inordinate stress or exercise.
 Crush compartment syndrome
 It is caused by massive external compression or crushing
of a compartment. This type results in systemic effects
that include rhabdomyolysis that causes acute renal
failure and that may eventually lead to multiple organ
dysfunction syndrome.
 Signs and Symptoms:
 Deep, throbbing, unrelenting pain, which continues to
increase despite the administration of opioids and seems
out of proportion to the injury.
 Hallmark sign is pain that occurs or intensifies with
passive ROM.
 If not treated immediately, the pressure within the
compartment might increase leading to such an extent
as decrease in microcirculation, causing nerve and
muscle anoxia and necrosis.
 Permanent function can be lost if the anoxic situation
continues for longer than 6 hours.
 Frequent neurovascular assessment which focuses on 5
“P’s”:
 Pain
 Paralysis
 Paresthesias
 Pallor
 Pulselessness
 Motion is evaluated by asking the patient to move the
fingers or toes distal to the potential problem.
 If not treated, hypoesthesia (diminished sensitivity to
stimulation) and then absence of feeling might occur.
 No movement (paralysis) suggests nerve damage.
 Peripheral circulation is evaluated by assessing color,
temperature, capillary refill time, swelling, and pulses.
 Edema reduces tissue perfusion.
 Cyanotic nail beds suggest venous congestion.
 Pallor or dusky and cold fingers or toes and prolonged
capillary refill time suggest diminished arterial
perfusion.
 Pulselessness is a very late sign that may signify lack of
distal tissue perfusion.
 Medical Management:
 Notify the physician immediately if neurovascular
compromise is suspected.
 Elevate the extremity to the heart level.
 Release of restrictive devices (dressings or cast).
 If these measures do not restore tissue perfusion and
relieve pain within 1 hour, a fasciotomy (surgical
decompression with excision of the fascia) may be
needed.
 After fasciotomy, the wound is not sutured but instead is
left open to allow the muscle tissues to expand and is
covered with moist, sterile, saline dressings.
 The affected arm or leg is splinted in a functional
position and elevated, and prescribed passive ROM
exercises are performed every 4-6 hours.
 In 3-5 days, when the swelling has resolved, the wound
is debrided and closed (possibly with skin grafts).
Other Early Complications
 Venous thromboemboli including:
 Deep vein thrombosis
 Pulmonary embolism
 Disseminated intravascular coagulation
 Infection
Delayed Complications: Delayed Union,
Malunion, Nonunion
 Delayed Union occurs when healing does not occur
at a normal rate for the location and type of fracture. It
is usually associated with distraction (pulling apart) of
bone fragments, systemic or local infection, poor
nutrition, or co-morbidity (diabetes mellitus,
autoimmune disease).
 The fracture eventually heals.
 Nonunion results from failure of the ends of a
fractured bone to unite.
 Malunion results from failure of the ends of a
fractured bone to unite in normal alignment.
 Patient complains of persistent discomfort and
abnormal movement at the fractured site.
 Contributing factors to include:
 Infection at the fracture site
 Interposition of tissue between the bone ends
 Inadequate immobilization or manipulation that
disrupts to callus formation
 Excessive space between bone fragments (bone gap)
 Limited bone contact
 Impaired blood supply
 In nonunion, fibrocartilage tissue exists between the
bone fragments.
 A false joint (pseudoarthrosis) often develops at the
site of the fracture.
 Medical Management:
 Nonunion is treated with internal fixation, bone
grafting, electrical bone stimulation, or a combination
of these therapies.
 Internal fixation stabilizes the bone fragments and
ensures bone contact.
 Bone grafts provide for osteogenesis (bone formation),
osteoconduction (provision by the graft of the
structural matrix for ingrowth of blood vessels and
osteoblasts) or osteoinduction (stimulation of host
stem cells to differentiate into osteoblasts by several
growth factors).
 Grafted bone undergoes a reconstructive process that
results in a gradual replacement of graft with new bone.
 The bone graft may be an autograft (patient’s own
tissue) or an allograft (tissue from another donor).
 After grafting, immobilization and non-weight bearing
exercises are required while the bone graft becomes
incorporated and the fracture heals.
 Healing may take 6-12 months or longer.
 Electrical bone stimulation modifies the tissue
environment, making it electronegative, which
enhances mineral deposition and bone formation that
promotes bone growth.
 It is not effective with large bone gaps or synovial
pseudoarthosis.
 Pins act as cathodes are inserted percutaneously, directly
into the fracture site, and electrical impulses are
directed to the fracture continuously.
 Noninvasive inductive coupling is another method used
to stimulate osteogenesis.
 Pulsing electromagnetic fields are delivered to the
fracture for approximately 10 hours each day by an
electromagenetic coil over the nonunion site.
 During the electrical stimulation treatment period,
which takes 3-6 months or longer, rigid fracture fixation
with adequate support is needed.
 Nursing Management
 Provide emotional support and encouragement to the patient
and encourage compliance with the treatment regimen.
 Nursing care for patient with bone graft includes pain
management, monitoring the patient for signs of infection at
the harvest and recipient sites, and patient education.
 Reinforce information concerning the objectives of the bone
graft, immobilization, non-weight bearing exercises, wound
care, signs of infection, and the importance of follow-up care
with the orthopedic surgeon.
 Nursing care for patient with electrical bone stimulation
focuses on patient education that addresses immobilization,
weight-bearing restrictions, and correct daily use of the
stimulator as prescribed.
Avascular Necrosis of Bone (AVN)
 It occurs when the bone loses its blood supply and
dies.
 Causes might include:
 Fracture with disruption of the blood supply
 Dislocations
 Bone transplantation
 Prolonged high-dose cortosteroid therapy
 Chronic renal disease
 Sickle cell anemia
 Patient develops pain and experiences limited
movement.
 X-rays reveal loss of mineralized matrix and structural
collapse.
 Treatment includes attempts to revitalize the bone
with bone grafts, prosthetic replacement, or
arthrodesis (joint fusion).
Reaction to Internal Fixation
Devices
 Internal fixation devices may be removed after bony
union has taken place. However, in most patients, the
device is not removed unless it produces symptoms.
 Pain and decreased function are prime indicators that
a problem has developed.
 Problems may include:
 Mechanical failure (inadequate insertion and
stabilization)
 Material failure (faulty or damaged device)
 Corrosion of the device causing local inflammation
 Allergic response to the metallic alloy used
 Osteoporotic remodeling adjacent to the fixation device
(in which stress needed for bone strength is transferred
to the device, causing disuse osteoporosis)
Complex Regional Pain Syndrome
(CRPS)
 It is a painful sympathetic nervous system problem.
 It is more common in women and usually occurs in an
upper extremity with trauma.
 Clinical Manifestations include:
 Severe burning pain
 Local edema
 Hyperesthesia
 Stiffness
 Discoloration
 Vasomotor skin changes (fluctuating warm, red, dry and cold,
sweaty, cyanotic)
 Trophic changes (glossy shiny skin; increased hair and nail
growth)
  Disuse muscle atrophy and bone deossification
(osteoporosis) occurs with persistence of CRPS
 Ineffective individual coping results from chronic pain
 Management:
 Early effective pain relief is the focus of management
through analgesics, anesthetic nerve blocks, or IV
bisphosphonate pamidronate (Aredia).
 NSAIDs, corticosteroids, muscle relaxants, and
antidepressants.
 Help the patient cope with CRPS manifestations and
explore multiple ways to control pain.
 Avoid using the involved extremity for blood pressure
measurements and venipunctures.
Heterotopic Ossification
 It is also called as myositis ossificans which is the
abnormal formation of bone, near bones or in muslce,
in response to soft tissue trauma after blunt trauma,
fracture, or total joint replacement.
 The muscle is painful, and normal muscular
contraction and movement are limited.
 Early mobilization may prevent its occurrence.
AMPUTATION
 Amputation is the removal of a body part, usually an
extremity.
 Reasons for lower extremity amputation:
 Peripheral vascular dasease (from DM) – most common
 Fulminating gas gangrene
 Trauma (crushing injuries, burns, frostbite, electrical
burns)
 Congenital deformities
 Chronic osteomyelitis
 Malignant tumor
 Reasons for upper extremity amputation is most
commonly caused by either a traumatic injury or a
malignant tumor.
 The site of amputation is determined by two factors:
 Circulation in the part
 Functional usefulness (meets the requirements for the
use of a prosthesis)
 The objective of surgery is to conserve as much
extremity length as needed to preserve function and
possibility to achieve a good prosthetic fit.
 Preservation of knee and elbow joints are desired.
 Levels of amputation (Lower Extremity):
 Syme amputation (modified ankle disarticulation
amputation) is performed more frequently for extensive
foot trauma.
 Above-knee amputation (AKA) when performed, all
possible length is preserved, muscles are stabilized and
shaped, and hip contractures are prevented.
 Below-knee amputation (BKA) is more preferred than
the latter because of the importance of knee joint and
the energy requirements for walking.
 Knee disarticulations are most successful with young,
active patients who can develop precise control of the
prosthesis.
 Levels of amputation (Upper Extremity):
 Goal: To preserve the maximum functional length.
 Below elbow (BE) amputation
 Above elbow (AE) amputation
 Staged amputation may be used when gangrene and
infection exist.
 Initially, a guillotine amputation is performed to
remove the necrotic and infected tissue. In a few days,
after the infection has been controlled, a definitive
amputation with skin closure is performed.
 Complications:
 Hemorrhage
 Infection
 Skin breakdown caused by skin irritation from
prosthesis
 Phantom limb pain caused by severing of peripheral
nerves
 Joint contracture caused by positioning
 Medical Management:
 The goal is to achieve healing of the amputation wound,
the result being a non-tender residual limb (stump) with
healthy skin for prosthesis use.
 After surgery, a sterilized residual limb sock is applied to
the residual limb and it is wrapped with elastic plaster-
of-paris bandages while firm, even pressure is
maintained while not constricting circulation.
 For lower extremity amputation, the plaster cast may
be equipped to attach a temporary prosthetic
extension (pylon) and artificial foot.
 Early minimal weight bearing on the residual limb
produces little discomfort.
 The cast is changed in about 10-14 days.
 Rehabilitation:
 The patient needs psychological support in accepting
the sudden change in body image and in dealing with
the stresses of hospitalization, long term rehabilitation,
and modification of lifestyle.
 They need support as they grieve the loss, and they need
more time to work through their feelings about their
permanent loss and change in body image.
 Multidisciplinary rehabilitation team includes:
 Patient
 Nurse
 Physician
 Social worker
 Physical therapist
 Occupational therapist
 Psychologist
 Prosthetist
 Vocational rehabilitation worker
 Prosthetic clinics and amputee support group facilitate
the rehabilitation process.