There are several diagnoses that may lead to a below the knee amputation (BKA). For example, Diabetic neuropathy with a foot wound that does not heal or which becomes infected, or vascular insufficiency leading to poor blood circulation in the legs. The majority of patients with below the knee amputations I see in clinic result from wounds associated with Diabetes. However, I have also seen patients who have lost limbs due to trauma (i.e. car accidents) and due to complications after a myocardial infarction (heart attack). The remaining tissue after an amputation is called a "stump" or "residual limb". Amputations can occur at any level or the leg or arm. This and next month's articles will address below the knee amputation, or BKA.
Phantom pain: Medications can be prescribed by the physician to help manage symptoms such as burning, itching, numbness and/or pain which may be perceived/felt in areas of the limb that are no longer present. Desensitization exercises with a towel or soft cloth can help to decrease hypersensitivity of skin on the distal end of the residual limb.
Amputee board for wheelchair: A firm wheel chair cushion with a detachable board to support residual limb and to position the affected knee in a straightened or extended position when the person is sitting. Use or the amputee board helps to prevent knee flexion contractures (inability to straighten knee fully) which is very important if a patient is being considered for a prosthesis (artificial leg) in the future.
Pressure relief: Patient and caregiver education regarding pressure relief via strategic positioning and weight shifting when patient is lying/sitting for a prolonged period of time should be completed in the inpatient setting. Sedentary patients should be encouraged to practice pressure relief techniques 1 minute for every hour of sitting to prevent decubitus ulcers (pressure sores).
Hygiene: Nursing staff in the inpatient hospital setting can educate patient and family proper wound care and dressing change techniques. Once stitches and staples are removed from the incision site, the patient should make sure the residual limb's skin stays clean and dry. Patient and/or caregiver should perform daily skin checks and report any skin breakdown (redness, oozing, blistering) to MD immediately.
Swelling management: The residual limb should be kept elevated when lying unless advised otherwise by the physician. Patient and family education is completed in the inpatient setting regarding ace wrapping the residual limb for compression and cone shaping. Avoidance of a bulbous/rounded residual limb through use of ace wrap or shrinker sock is important if the patient will be getting a prosthesis. The stump shrinker sock is sometimes issued from the inpatient physician or later issued in outpatient when the patient sees a prosthetist (specialist in fabrication and training regarding fitting and use of articificial limbs).
Physical therapy: Often times physical therapy is ordered by the physician in the inpatient hospital setting for general reconditioning and transfer and gait (walking) training pending a patient's discharge disposition. After being discharged from the hospital, outpatient physical therapy is beneficial to regain full active range of motion and strength of the legs and arms and to further gain independence and safety with walking and transfers (sit to stand, sit to lying, etc.). If the Doctor feels a patient is appropriate for eventual prosthesis fitting and training, the patient may then be referred to a prosthetist for consultation regarding fitting and training with a prosthesis.
Consult with a prosthetist: Once the physician feels a patient is appropriate for prosthesis fabrication, he/she can write a prescription and send it to a prosthetist. The prosthetist arranges a consult with the patient to take measurements of the residual limb and the uninvolved limb in preparation for prosthesis fabrication.
Next month's article will discuss strengthening exercises that are often included in treatment of patients in the outpatient physical therapy setting as well as discuss different types of prostheses for patient's who have had a BKA.
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