Amputation and stump care

1Definition

Amputation is the surgical removal of all or part of a limb. The part that remains is the residual limb (stump). In this syllabus the focus is lower-limb amputation for vascular disease and diabetes, and stump care.

2Classification: levels

Ideal stump (3 marks in W18)

• Adequate length: transtibial about 12–15 cm below the knee joint line (longer in tall people); transfemoral about 25 cm from the greater trochanter, leaving room above the knee for a prosthetic knee joint.
• Conical (cylindrical) shape, firm, not bulbous or flabby.
• Well-healed, mobile scar that is not adherent and not over the weight-bearing end.
• Good soft-tissue padding over the bone ends; bone ends smooth and bevelled (in transtibial, the fibula a little shorter than the tibia).
• Muscles anchored to bone (myodesis) so they stay strong and the stump is stable.
• Good circulation and sensation; no neuroma or painful spots.
• Full range of the joint above, with no contracture.

Functional level (K-levels)

3Causes and risk factors

• Peripheral arterial disease and diabetes: the commonest cause in adults (S18 diabetes with gangrene; S19 uncontrolled diabetes and hypertension; S21 PAD).
• Trauma: road and rail accidents, machinery, crush injuries; the commonest cause in young people.
• Infection: gas gangrene, severe diabetic foot infection.
• Tumours of bone or soft tissue.
• Burns, frostbite, congenital limb deficiency.

4Pathophysiology to impairments

1. Loss of the limb removes the ankle and foot (and the knee in higher levels), so balance, push-off and shock absorption are lost.
2. The stump swells after surgery (oedema). It must shrink and shape before a socket can fit.
3. Sitting and lying with a pillow under the stump pull it into the strongest flexors' position: knee flexion after transtibial, hip flexion, abduction and external rotation after transfemoral. These contractures make prosthetic walking hard or impossible.
4. Cut nerves continue to send signals: phantom limb sensation (feeling the missing part) and phantom limb pain; a neuroma at a nerve end causes local pain.
5. Bed rest and underlying disease cause weakness and low fitness. Walking with a prosthesis uses much more energy, especially at higher levels and in patients with heart disease.
6. In vascular patients the other leg often has the same disease and is at risk.

5Clinical features after amputation

• Stump pain and swelling; wound and drains in the first days.
• Phantom sensation (common) and phantom pain (burning, cramping, shooting in the missing limb).
• Reduced balance on one leg; risk of falls, especially at night when getting up to the toilet.
• Weakness of hip extensors and abductors and knee extensors; reduced fitness.
• Grief, anxiety about work and income, altered body image.

6Investigations

7Medical and surgical management

• The level is chosen to remove all dead or infected tissue while keeping as much length as will heal, ideally keeping the knee.
• Transtibial for vascular disease usually uses a long posterior flap; muscles are anchored to bone (myodesis) or to each other (myoplasty).
• Post-op: wound care, pain relief (including for phantom pain), control of diabetes and blood pressure, nutrition.
• Dressings: soft dressings with bandaging, a rigid removable dressing, or a shrinker sock once the wound has healed.
• Prosthetic fitting once the wound has healed and the stump volume has stabilised (often several weeks).

Prosthesis basics (transtibial; W19: suitable prosthesis with reasoning)

• Socket: patellar-tendon-bearing (PTB) or total-surface-bearing.
• Suspension: supracondylar cuff strap, sleeve, pin-lock liner or suction.
• Pylon (shank) and foot: SACH (solid ankle cushion heel) foot or, in India, the Jaipur foot, a flexible rubber foot that allows squatting, sitting cross-legged and walking barefoot on uneven ground.

Choosing for a diabetic patient with vascular disease (W19): his skin heals poorly and may be numb, so choose a socket that spreads pressure widely: a total-surface-bearing socket with a gel or silicone liner (less shear on fragile skin), or a PTB socket with a soft foam liner where cost matters. Use a secure, comfortable suspension (sleeve or pin-lock liner) and a light endoskeletal pylon. He is likely to be a limited community walker, so a stable SACH or Jaipur foot suits him; the Jaipur foot fits Indian floor-level living. Before the definitive limb, an early walking aid in physiotherapy sessions and an interim prosthesis help gait and shape the stump. Teach daily checks of the stump and the other foot.

8Complications and prevention

9PT assessment

• History: cause, level, date, side, other illnesses (diabetes, BP, heart), occupation and its demands (driving, walking door-to-door, lifting), home (floors, steps, toilet type), family support and earning role, previous walking level.
• Stump: length (from a bony landmark), shape, circumference at fixed points, wound, scar mobility, skin, sensation, temperature, pain, neuroma.
• Range and strength: hip and knee range on both sides (look for contracture), muscle power of both legs, trunk and arms.
• Other leg: pulses, skin, sensation, ulcers.
• Balance and function: sitting and standing balance, transfers, wheelchair skills, hopping with a walker.
• Phantom sensation and pain.
• Outcome measures: Amputee Mobility Predictor (AMPPRO), K-level, Timed Up and Go, 2- or 6-minute walk test, Houghton scale, SIGAM mobility grades.

10PT diagnosis by ICF

Draw the six-box ICF model (see the IHD page), then fill it from the case.

Worked example from a real paper (S21, 7 + 8 marks)

"48 year old driver operated for right BK amputation 7 days back, due to peripheral arterial disease. Popliteal artery on the same side is grade 1+. On the left side the dorsalis pedis and posterior tibial are 2+. Discuss ICF and PT management for him."

11Problem list and goals

12PT management

1. Before surgery (when planned)

• Assess, explain, meet another amputee if possible; teach transfers, wheelchair use and exercises; strengthen the arms and the other leg; check the other foot.

2. Early post-op (days 1–10)

• Breathing exercises, ankle pumps of the other leg, early sitting out.
• Positioning (see the box below), prone lying as soon as tolerated.
• Oedema control: stump bandaging or shrinker as the team decides; elevation without bending the knee.
• Exercises: isometric then active quadriceps, hip extensors and abductors on the amputated side; full exercises for the other leg, trunk and arms.
• Transfers and wheelchair (with a stump board to keep the knee straight); standing balance in parallel bars; hopping with a walker over short distances only.

3. Stump bandaging (stump management, 7 marks in W20)

• Use an elastic bandage about 10 cm (4 inches) wide for a transtibial stump and about 15 cm (6 inches) wide for a transfemoral stump.
• Diagonal, figure-of-eight turns; no wrinkles; firmest at the end, decreasing upwards.
• Transtibial: anchor above the knee. Transfemoral: include the groin and anchor round the waist (hip spica).
• Re-apply every 4–6 hours and whenever loose; wear day and night except for bathing and exercise.
• A shrinker sock is easier and more consistent once the wound has healed.

4. Stump pain, phantom pain and desensitisation (S25: severe pain at the amputation site)

• Stump (residual-limb) pain is felt in the stump itself. Look for a cause first: wound infection, poor blood supply, a tender neuroma, a bony end, or a tight or badly applied bandage. Report infection or ischaemia; give treatment after analgesia.
• Phantom pain is felt in the missing part (burning, cramping, shooting). It is common and usually lessens over months.
• Tapping, gentle massage and rubbing the stump with different textures (cotton, towel), several times a day.
• Mirror therapy: watch the intact leg moving in a mirror placed where the missing leg would be.
• TENS; wearing the shrinker or prosthesis; reassurance that phantom sensation is normal.

5. Prosthetic training

• Donning and doffing the prosthesis and socks; daily skin check of the stump.
• Weight shifting in parallel bars, standing on the prosthesis, stepping, then walking with fewer aids.
• Correct common gait deviations (short step, wide base, trunk lean).
• Stairs: up with the sound leg first, down with the prosthesis first ("good goes up, bad goes down").
• Uneven ground, ramps, kerbs, getting up from the floor; squatting and cross-legged sitting with a Jaipur foot.
• Build wearing time gradually (start with short periods, check the skin after each).

Above-knee (transfemoral) amputation (S23: 60-year-old, lives alone, one floor to climb)

• Contracture risk: hip flexion, abduction and external rotation. Prone lying 20–30 minutes two or three times a day; no pillow under or between the thighs; limit long sitting; keep the stump beside the other leg in lying.
• Strengthen: hip extensors and adductors (they hold the prosthesis under the body), abductors, trunk, arms and the other leg.
• Stump care: bandage with a hip spica up to the groin, or a shrinker; desensitisation.
• Prosthesis: ischial-containment or quadrilateral socket; suction or liner suspension; for an older, low-activity walker a stance-control (weight-activated) knee or a locked knee for safety, with a SACH or Jaipur foot.
• Energy: walking with an above-knee prosthesis takes far more energy than with a below-knee one, so build general fitness; in an older diabetic, independent wheelchair life comes first and prosthetic walking is a further goal if fitness, balance and the other leg allow.
• Living alone, one floor up: safe transfers, wheelchair skills, getting up from the floor after a fall; stairs with crutches and a rail (up with the sound leg, down with the crutches and the stump first), or sitting and shuffling on the stairs if unsafe; a home visit, rails, a phone within reach, help with shopping, and checks of the other foot.

6. Return to work

• Driver (S21): right-leg amputation: an automatic vehicle with a left-foot accelerator, or hand controls; check licensing rules.
• Milkman going door to door (S19): endurance walking, stairs, carrying loads with a prosthesis; possibly a two-wheeler with adaptations; plan rest breaks; good diabetes control.

By impairment

13Precautions

14Education and stump care at home

• Inspect the stump daily with a mirror for redness, blisters or sores.
• Wash the stump daily with mild soap, dry well; wash socks and liner daily.
• Keep the bandage or shrinker on as taught; re-apply when loose.
• Do your positioning and exercises every day.
• Protect the other foot: proper footwear, daily checks, no barefoot walking.
• Control sugar and blood pressure; stop smoking.
• Keep a stable weight: stump volume changes with weight and affects the socket fit.
• At night, keep a walker or wheelchair next to the bed and a light on.

15Prognosis and discharge criteria

Prognosis: most people with a transtibial amputation who could walk before can walk again with a prosthesis. Outcomes are poorer with transfemoral level, older age, heart and lung disease, and poor diabetes control. Vascular amputees have a high risk of problems in the other leg.

Discharge: safe transfers and wheelchair or walker use at home; stump healed and shaped; full knee and hip range; knows stump and foot care; referred for prosthetic fitting and follow-up.

16Exam corner

Past questions (MUHS, 2016–2026)

• S18 Q3(a), 15 marks50-year-old man with a left transtibial amputation, referred 1 week after surgery; sole earner of a family of four; diabetes and gangrene. ICF and physiotherapy management.
• S19 Q3(b), 15 marks45-year-old milkman delivering door to door, right BKA days ago; uncontrolled diabetes and hypertension; only earner of five. Short- and long-term goals; how he can return to his previous job.
• S21 Q3(b), 7 + 8 marksThe worked example in section 10.
• W19 Q4(b), 5 + 7 + 3 marks50-year-old man with diabetes and peripheral vascular disease, referred 24 hours after a right transtibial amputation for gangrene. Functional diagnosis; short-term programme; a suitable prosthesis with clinical reasoning.
• S23 Q4(a), 15 marks60-year-old man, unilateral above-knee amputation 1 month ago for uncontrolled diabetes; has one floor to climb and lives alone. ICF; short- and long-term physiotherapy. See "Above-knee amputation" in section 12.
• S25 Q4(b), 4 + 4 + 7 marks65-year-old diabetic smoker and manual labourer, below-knee amputation 8 days ago for a non-healing ulcer over the malleoli; severe pain at the amputation site; difficulty walking because of weakness. ICF; short- and long-term goals; physiotherapy.
• 7-mark questionsPhysiotherapy after below-knee amputation (W16, S17, S26). Stump management of BKA (W20).
• 3-mark questionCharacteristics of an ideal stump (W18).

Technique cards for this topic: exercise physiology, bed rest.

Keywords to underline

transtibial ideal stump figure-of-eight bandaging shrinker knee flexion contracture prone lying stump board phantom pain desensitisation pre-prosthetic Jaipur foot K-level care of the other foot

Answer skeleton: amputation long answer

1. Restate: age, side, level, cause, day, pulses of the other leg, job and family role.
2. [ICF, 7] ICF diagram; one-line diagnosis; reasons.
3. [Management, 8] Pre-prosthetic: positioning, bandaging, exercises, transfers, balance, phantom pain. Prosthetic: gait training, stairs, uneven ground. Return to job; other-foot care; outcome measures.

Draw these

• Amputation levels (section 2)
• Figure-of-eight stump bandaging (section 12)

Viva questions

1. What are the features of an ideal transtibial stump?
2. Why are circular turns avoided in stump bandaging?
3. Which contracture is common after transfemoral amputation?
4. What is the difference between phantom sensation and phantom pain?
5. What is special about the Jaipur foot?
6. On stairs, which leg goes first going up and going down?