Traumatic lower extremity amputation as a risk factor for venous thromboembolism

BACKGROUND

This study aimed to evaluate whether lower extremity (LE) amputation among civilian casualties is a risk factor for venous thromboembolism.

METHODS

All patients with severe LE injuries (AIS ≥3) derived from the ACS-TQIP (2013-2020) were divided into those who underwent trauma-associated amputation and those with limb salvage. Propensity score matching was used to mitigate selection bias and confounding and compare the rates of pulmonary embolism (PE) and deep vein thrombosis (DVT).

RESULTS

A total of 145,667 patients with severe LE injuries were included, with 3443 patients requiring LE amputation. After successful matching, patients sustaining LE amputation still experienced significantly higher rates of PE (4.2% vs. 2.5%, p ​< ​0.001) and DVT (6.5% vs. 3.4%, p ​< ​0.001). A sensitivity analysis examining patients with isolated major LE trauma similarly showed a higher rate of thromboembolic complications, including higher incidences of PE (3.2% vs. 2.0%, p ​= ​0.015) and DVT (4.7% vs. 2.6%, p ​< ​0.001).

CONCLUSIONS

In this nationwide analysis, traumatic lower extremity amputation is associated with a significantly higher risk of VTE events, including PE and DVT.

Traumatic Transradial Forearm Amputation Temporized With Extracorporeal Membrane Oxygenation: A Brief Report

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) is typically used to provide mechanical perfusion and gas exchange to critically ill patients with cardiopulmonary failure. We present a case of a traumatic high transradial amputation in which the amputated limb was placed on ECMO to allow for limb perfusion during bony fixation and preparations and coordination of orthopedic and vascular soft tissue reconstructions.

MATERIALS AND METHODS

This is a descriptive single case report which underwent managment at a level 1 trauma center. Instutional review board (IRB) approval was obtained.

RESULTS

This case highlights many important factors of limb salvage. First, complex limb salvage requires a well-organized, pre-planned multi-disciplinary approach to optimize patient outcomes. Second, advancements in trauma resuscitation and reconstructive techniques over the past 20 years have drastically expanded the ability of treating surgeons to preserve limbs that would have otherwise been indicated for amputation. Lastly, which will be the focus of further discussion, ECMO and EP have a role in the limb salvage algorithm to extend current timing limitations for ischemia, allow for multidisciplinary planning, and prevent reperfusion injury with increasing literature to support its use.

CONCLUSIONS

ECMO is an emerging technology that may have clinical utility for traumatic amputations, limb salvage, and free flap cases. In particular, it may extend current limitations of ischemia time and reduce the incidence of ischemia reperfusion injury in proximal amputation, thus expanding the current indications for proximal limb replantation. It is clear that developing a multi-disciplinary limb salvage team with standardized treatment protocols is paramount to optimize patient outcomes and allows limb salvage to be pursued in increasingly complex cases.

Heterotopic Ossification Formation in Military Beneficiaries Following Hip- and Pelvic-Level Amputations

INTRODUCTION

Traumatic hip and pelvic level amputations are uncommon but devastating injuries and associated with numerous complications that can significantly affect quality of life for these patients. While heterotopic ossification (HO) formation has been reported at rates of up to 90% following traumatic, combat-related amputations, previous studies included few patients with more proximal hip and pelvic level amputations.

MATERIALS AND METHODS

We conducted a retrospective review of the Military Health System medical record and identified patients with both traumatic and disease-related hip- and pelvic-level amputations performed between 2001 and 2017. We reviewed the most recent pelvis radiograph at least 3 months following amputation to determine bony resection level and the association between HO formation and reason for amputation (trauma versus disease related).

RESULTS

Of 93 patients with post-amputation pelvis radiographs available, 66% (n = 61) had hip-level amputations and 34% (n = 32) had a hemipelvectomy. The median duration from the initial injury or surgery to the most recent radiograph was 393 days (interquartile range, 73-1,094). HO occurred in 75% of patients. Amputation secondary to trauma was a significant predictor of HO formation (χ2 = 24.58; P < .0001); however, there was no apparent relationship between the severity of HO and traumatic versus non-traumatic etiology (χ2 = 2.92; P = .09).

CONCLUSIONS

Amputations at the hip were more common than pelvic-level amputations in this study population, and three-fourths of hip- and pelvic-level amputation patients had radiographic evidence of HO. The rate of HO formation following blast injuries and other trauma was significantly higher compared with patients with non-traumatic amputations.

The relationship between combat-related traumatic amputation and subclinical cardiovascular risk

BACKGROUND

The relationship between acute combat-related traumatic injury (CRTI) to coronary flow reserve (CFR) and subclinical cardiovascular risk have not been examined and was the primary aim of this study.

METHODS AND RESULTS

UK combat veterans from the ADVANCE cohort study (UK-Afghanistan War 2003-14) with traumatic limb amputations were compared to injured non-amputees and to a group of uninjured veterans from the same conflict. Subclinical cardiovascular risk measures included fasted blood atherogenic index of plasma (AIP), triglyceride-glucose index (TyG; insulin resistance), the neutrophil-lymphocyte ratio (NLR) and high-sensitivity C-reactive protein (hs-CRP; vascular inflammation), body mass index (BMI) and visceral fat volume (dual-energy X-ray absorptiometry) and 6-min walk distance (6MWD; physical performance). The subendocardial viability ratio (SEVR), to estimate CFR, was calculated using arterial pulse waveform analysis (Vicorder device). In total 1144 adult male combat veterans were investigated, comprising 579 injured (161 amputees, 418 non-amputees) and 565 uninjured men. AIP, TyG, NLR, hs-CRP, BMI, total body fat and visceral fat volume were significantly higher and the SEVR and 6MWD significantly lower in the amputees versus the injured-non-amputees and uninjured groups. The SEVR was lowest in those with above knee and multiple limb amputations. CRTI (ExpB 0.96; 95% CI 0.94-0.98: p < 0.0001) and amputation (ExpB 0.94: 95% CI 0.91-0.97: p < 0.0001) were independently associated with lower SEVR after adjusting for age, rank, ethnicity and time from injury.

CONCLUSION

CRTI, traumatic amputation and its worsening physical deficit are associated with lower coronary flow reserve and heightened subclinical cardiovascular risk.

Prosthetic fitting in a double-digit amputation with concomitant postoperative shortening and contracture of the adjacent digits: optimizing aesthetic and functional outcomes

This report discusses the considerations behind the special modifications made on the finger prostheses fitted for a patient with crushed index, middle, ring, and little fingers resulting in a double-digit amputation with significant postoperative scarring, discoloration, shortening, and contracture of the salvaged index and middle fingers. The deformity and discoloration of the salvaged fingers were factored into the approach taken in the planning, fabrication, and fitting of prosthesis for the amputated digits. Length reduction with increased flexion planned into the prostheses, in addition to color matching them in two different shades, contributed to good aesthetic and functional outcomes.

In-Hospital Morbidity and Mortality of Traumatic Lower-Extremity Amputations

Traumatic lower-extremity amputations often result in complications and surgical revisions. The authors report the in-hospital morbidity and mortality of traumatic lower-extremity amputations at a metropolitan level I trauma center for a large rural region and compare below-knee (BK) vs higher-level amputation complications. They retrospectively reviewed 168 adult patients during a 10-year period (2005 to 2015) who had a traumatic injury to the lower extremity that required an amputation. Main outcome measurements included amputation level, complication rates, intensive care unit (ICU) admission rates, length of stay, total trips to the operating room (OR), and Injury Severity Score (ISS). A total of 95 patients had through-knee/above-knee (TK/AK) amputations, and 73 patients had BK amputations. The majority of injuries occurred in the non-urban setting. The TK/AK group had higher ICU admission rates (76% vs 35%, P<.0001), longer overall hospital length of stay (22.0 vs 15.5 days, P=.01), more total OR trips (6.5 vs 5.0, P=.04), and higher ISS (17.0 vs 11.5, P<.0001). A complication was experienced by 64% of all patients during the initial hospitalization. The TK/AK group had higher complication rates than the BK group, including wound infection, pulmonary embolus, rhabdomyolysis, compartment syndrome, and death. Patients with TK/AK traumatic amputations have a greater burden of injury with higher complication rates, increased ICU admissions, increased length of stay, and increased ISS and require more return trips to the OR compared with patients with BK amputations. [Orthopedics. 2020;43(6):e561-e566.].

Disturbing medical findings in war-related traumatic amputation patients: a clinical descriptive study from Gaza

OBJECTIVES

The aim of this study was to explore possible long-term negative health effects of injuries sustained by modern weaponry.

SETTING

The study was conducted in Gaza's main hospital, Al-Shifa Hospital.

PARTICIPANTS

During the last 10 to 15 years, thousands of civilian Palestinians in Gaza have survived numerous military incursions, but with war-related traumatic injuries caused by explosive weapons. It is unclear to which extent the injuries sustained by such modern weaponry may increase survivors' risks of negative long-term health effects and serious illness. We have reported mechanisms and severity of injury, demographics and psychosocial status among 254 Palestinian patients in Gaza with war-related extremity amputations. Among the same amputees, subgroups of patients presented a variety of alarming symptoms and findings. 94 patients received further diagnostic clinical exploration, radiology imaging and clinical chemistry laboratory tests at the main clinical centre in Gaza, the Al-Shifa Hospital.

RESULTS

Nine out of ten of the referred patients were young (median 31.5 years) males (88/94, 92.6%). Ultrasound imaging revealed that 19 of 90 patients (20%) had fatty liver infiltration, 3 patients had lung nodules and 10 patients had lung atelectasis on chest CT. Twelve had remaining shrapnel(s) in the chest, five patients had shrapnel(s) in the abdomen and one in the scrotum. We found shrapnel(s) in the amputation stumps of 26 patient's amputated limbs, while 8 patients had shrapnel in the non-amputated limb. Three patients had liver lesions. Nineteen patients had elevated liver enzymes, 32 patients had elevated erythrocyte sedimentation rate and 12 were anaemic. Two patients tested positive for hepatitis C virus and three were positive for hepatitis B virus (HBV). One of the 19 patients with fatty liver tested positive for HBV. Two of the patients with fatty liver infiltration had elevated glycatedhaemoglobin levels and confirmed diabetes mellitus type II.

CONCLUSION

Nearly half (44, 8%) had remaining metal fragments from explosives of unknown composition harboured in various parts of their bodies. All patients identified with lesions and nodules are being followed up locally. As of now, we cannot anticipate the long-term health consequences of living with metal residuals from modern explosive weapons embedded in body organs and tissue.

Wound infection with Vibrio harveyi following a traumatic leg amputation after a motorboat propeller injury in Mallorca, Spain: a case report and review of literature

BACKGROUND

Vibrio spp. are aquatic bacteria that are ubiquitous in warm estuarine and marine environments, of which 12 species are currently known to cause infections in humans. So far, only five human infections with V. harveyi have been reported.

CASE PRESENTATION

A 26-year old patient was transferred to our center by inter-hospital air transfer from Mallorca, Spain. Seven days before, he had suffered a complete amputation injury of his left lower leg combined with an open, multi-fragment, distal femur fracture after he had been struck by the propeller of a passing motorboat while snorkeling in the Mediterranean Sea. On admission he was febrile; laboratory studies showed markedly elevated inflammatory parameters and antibiotic treatment with ampicillin/sulbactam was initiated. Physical examination showed a tender and erythematous amputation stump, so surgical revision was performed and confirmed a putrid infection with necrosis of the subcutaneous tissue and the muscles. Tissue cultures subsequently grew V. harveyi with a minimal inhibitory concentration (MIC) of 16 mg/L for ampicillin, and antibiotic treatment was switched to ceftriaxone and ciprofloxacin. Throughout the following days, the patient repeatedly had to undergo surgical debridement but eventually the infection could be controlled, and he was discharged.

CONCLUSIONS

We report the first human infection with V. harveyi acquired in Spain and the second infection acquired in the Mediterranean Sea. This case suggests that physicians and microbiologists should be aware of the possibility of wound infections caused by Vibrio spp. acquired in the ocean environment, especially during hot summer months. Since Vibrio spp. preferentially grow at water temperatures above 18 °C, global warming is responsible for an abundance of these bacteria in coastal waters. This will likely lead to a worldwide increase in reports of Vibrio-associated diseases in the future.

Combined treatment with vacuum sealing drainage, TopClosure device, and Ilizarov technique for traumatic hemipelvectomy: A rare case report of successful repairing of large-size soft tissue defects

RATIONALE

Traumatic hemipelvectomy is a rare but lethal catastrophic injury.

PATIENT CONCERNS

A case of a very young child with open fracture of left sacroiliac joint dislocation and pubic symphysis diastasis, suffered from a severe large-size soft tissue defects.

DIAGNOSIS

Traumatic hemipelvectomy.

INTERVENTIONS

Complete amputation was performed and three kinds of surgical techniques including regulated negative pressure-assisted wound therapy (RNPT), TopClosure device, and Ilizarov technique were jointly utilized to secure closure in the further revisions of the soft tissue injury and reconstruct reconstructive surgery.

OUTCOMES

Six months after hospital discharge, the patient was able to ambulate with a single limb and a prosthesis and she is independent in many activities of daily living currently.

LESSONS

We report this case to share experience with other clinicians in the management of this deadly extensive defects after traumatic hemipelvectomy in patients.

Ultrasonographic evaluation of the ankle after unilateral traumatic lower limb amputations

BACKGROUND

Unilateral lower limb amputation can alter the tissue morphology leading to increase future risk of degenerative secondary disorders.

METHODS

Thirty-four consecutive male patients with unilateral lower limb amputations of different levels and 34 well matched male controls were included. To explore whether the ankles of traumatic lower limb amputees were undergoing morphological changes, three different tissue types i.e. talar cartilage, plantar fascia and Achilles tendon thicknesses in the intact limb of the lower limb amputee and healthy controls were measured by using ultrasound.

RESULTS

Plantar fascia was found to be thicker (p=0.013) and talar cartilage was thinner (p<0.001) on the intact sides of the patients than those of the controls. Achilles tendon thickness was found to be similar. In patients group, plantar fascia thickness was positively correlated with age (r=0.601, p<0.001), BMI (r=0.454, p=0.007) and durations of amputation (r=0.443, p=0.009) and prosthetic use (r=0.429, p=0.011). Achilles tendon thickness was positively correlated with durations of amputation (r=0.338, p=0.05) and prosthetic use (r=0.468, p=0.005). In controls group, talar cartilage thickness was negatively correlated with age (r=-0.640, p<0.001) and BMI (r=-0.401, p=0.019).

CONCLUSIONS

The talar cartilage seemed to be thinner and the plantar fascia to be thicker on the intact sides of the unilateral limb amputees.

Factors Influencing Functional Outcomes and Return-to-Work After Amputation: A Review of the Literature

Purpose Amputation is a life changing event that can significantly impact an individual's physical and mental well-being. Our objective was to review literature exploring the impact of amputation upon a person's functioning and inclusion in the workplace. Methods Medline, CINAHL, and PsycINFO were searched using keywords related to amputation, employment and community reintegration. Eligible studies were published since 2000 and one of the following study designs: randomized controlled trial, non-randomized controlled trial, retrospective study, prospective study, concurrent cohort study, or cross sectional study. Studies for civilians with amputation as well as service members and Veterans with amputation were considered for inclusion. Results The search identified 995 articles, 25 of which met inclusion/exclusion criteria and were included in the review. While strong evidence for correlations and predictors of outcomes after amputation were limited, multiple factors were identified as contributing to physical functioning and employment after amputation. Conclusions Outcomes after amputation can vary widely with many potentially inter-related factors contributing. The factors identified may also serve to inform the development of interventions aiming to improve functional performance and reintegration after amputation. Furthermore, the review highlights the need for more high quality prospective studies.

Predictors of Acute Complications Following Traumatic Upper Extremity Amputation

Current literature is deficient in its description of acute complications following major traumatic upper extremity amputations (UEAs). This study sought to identify acute complications following major UEAs by the 2009-2012 National Trauma Databank to extract demographics, comorbidities, concomitant injuries, and surgical characteristics for major traumatic UEA patients. Multivariate analyses identified significant predictors of mortality and major systemic complications. Major traumatic upper extremity amputations were identified in 1190 patients. Major systemic complications occurred in 13% of patients and most often involved pulmonary (7.4%) or renal (4.7%) systems. Overall in-hospital mortality rate was 11%. Male sex, prehospital systolic blood pressure less than 90, Injury Severity Score > 16, and initial Glasgow Coma Scale > 8 were risk factors for complications or in-hospital mortality. Acute replantation was performed in 0.12%. Systemic complications following major traumatic UEA typically affect the pulmonary system. Injury or patient-dependent factors did not influence acute treatment with revision amputation versus replantation. (Journal of Surgical Orthopaedic Advances 27(2):113-118, 2018).

Prehospital Administration of Tranexamic Acid by Ground Forces in Afghanistan: The Prehospital Trauma Registry Experience

BACKGROUND

Tranexamic acid (TXA) was shown to reduce overall mortality and death secondary to hemorrhage in a large prospective study. This intervention is time sensitive. As such, the Tactical Combat Casualty Care (TCCC) guidelines recommend use of this low-cost, safe intervention among patients with possible hemorrhagic shock, penetrating trauma to the thorax or trunk, or extremity amputation.

OBJECTIVE

Prehospital administration of TXA by ground forces in the Afghanistan combat theater is described.

METHODS

We obtained data from the Prehospital Trauma Registry. We searched for all patients with documented hypotension, amputation, or penetrating trauma to the torso.

RESULTS

From January 2013 to September 2014, there were 272 patients who met inclusion criteria. Most injuries (97.8%; n = 266) were battle injuries. Of the 272 patients who met criteria to receive prehospital TXA, 51 (18.8%) received TXA, whereas the remaining 221 (81.2%) did not. Higher proportions of patients receiving TXA versus patients not receiving TXA received hemostatic dressings, pressure dressings, and tourniquet placement. Conversely, the proportion of patients receiving intravenous fluids was higher in the no-TXA group.

CONCLUSION

Overall, proportions of eligible patients receiving TXA were low despite emphasis in the guidelines. The reasons for this low adherence to TCCC guidelines are likely multifactorial. Future research should seek to identify reasons TXA is not given when indicated and to develop training and technology to increase prehospital TXA administration.

Study protocol for a randomized controlled pilot-trial on the semiocclusive treatment of fingertip amputation injuries using a novel finger cap

INTRODUCTION

Fingertip amputation injuries are common in all ages. Conservatively treated fingertips can regenerate skin and soft tissues to form a functionally and cosmetically excellent new fingertip. Little is known about this ability that, in humans, is confined to the fingertips. Even less is known about the role of the bacteria that regularly colonize these wounds without negative impact on regeneration and healing.As an alternative to surgery, self-adhesive film dressings are commonly used to establish a wet chamber around the injury. These dressings leak malodorous wound fluid eventually until the wound is dry. Having that into consideration, we have therefore developed a silicone finger cap that forms a mechanically protected, wet chamber around the injury for optimal regeneration conditions. It contains a puncturable reservoir for excess wound fluid, which can be thus routinely analyzed for diagnostic and research purposes.This study protocol explains the first randomized controlled trial (RCT) on the semiocclusive treatment of fingertip amputations in both children and adults comparing traditional film dressings with the novel silicone finger cap. Being the first RCT using 2 medical devices not yet certified for this indication, it will gather valuable information for the understanding of fingertip regeneration and the design of future definitive studies.

METHODS AND ANALYSIS

By employing an innovative pseudo-cross-over-design with a dichotomous primary endpoint based on patients preference, this pilot study will gain statistically significant data with a very limited sample size. Our RCT will investigate acceptance, safety, effectiveness, and efficacy of this novel medical device while gathering information on the clinical course and outcome of conservatively treated fingertip injuries. A total of 22 patients older than 2 years will be randomly assigned to start the conservative treatment with either the traditional film-dressing or the novel finger cap. The treatment will be changed to the other alternative for another 2 weeks before the patient or the guardian is confronted with the decision of which method they would prefer for the rest of the treatment (if required).

ETHICS AND DISSEMINATION

Ethical approval (EK 148042015) of the study protocol has been obtained from Institutional Review Board at the TU Dresden. The trial is registered at the European Database on Medical Devices (EUDAMED-No.: CIV-15-03-013246) and at ClinicalTrials.gov (NCT03089060).

Effective local anesthesia for onabotulinumtoxin A injections to treat hyperhidrosis associated with traumatic amputation

BACKGROUND

Botulinum toxin type A (BTX-A) injections are an effective treatment for controlling hyperhidrosis at sites of amputation. Hyperesthesia associated with amputated limbs is a major barrier to performing this procedure under local anesthesia.

OBJECTIVE

To present a novel method for improving local anesthesia with BTX-A injections. Methods &amp;

RESULTS

A 29-year-old military veteran with a below-the-knee amputation of his right leg was suffering from amputation site hyperhidrosis, which was impeding his ability to comfortably wear a prosthesis. Prior to presenting to our clinic, the patient received one treatment of BTX-A injections to his amputation stump while under general anesthesia for surgical repair of trauma-related injuries. In our dermatology clinic, we repeated the procedure using topical lidocaine-prilocaine (30 gm total) for local anesthesia. This provided effective relief of hyperhidrosis for 6 months, but the procedure was very painful (9/10 intensity). We repeated the same procedure 6 months later, using ice in addition to topical lidocaine-prilocaine (30 gm) for local anesthesia; this resulted in reduced pain (3/10 intensity) for the patient.

CONCLUSIONS

We suggest using ice in combination with a topical anesthetic as an effective method for pain control that avoids general anesthesia in treating amputation-associated hyperhidrosis.

A Different Presentation of Mal De Meleda: New Skin Lesions in a Residual Limb after Traumatic Amputation

Mal de Meleda is a rare autosomal recessive skin disease which is known as keratoderma palmoplantaris transgradiens. Here we report a case of Mal de Meleda who had skin lesions in the residual limb and pseudoainhum in the thigh after traumatic lower leg amputation. A 71-year-old female was admitted to our tertiary hospital for prosthetic rehabilitation. On the physical examination, thickening of the skin on palms, left sole and residual limb was present. The patient reported that she had these skin lesions since infancy and she realized new skin lesions after amputation in the residual limb. We requested dermatology consultation and she was diagnosed as Mal de Meleda. To our knowledge, this is the first Mal de Meleda case in the literature with new lesions at the residual limb. Although exact pathophysiological mechanisms are not well known in Mal de Meleda, prosthesis use might have accelerated disease process in our patient.

Early, Prehospital Activation of the Walking Blood Bank Based on Mechanism of Injury Improves Time to Fresh Whole Blood Transfusion

Balanced component therapy (BCT) remains the mainstay in trauma resuscitation of the critically battle injured. In austere medical environments, access to packed red blood cells, apheresis platelets, and fresh frozen plasma is often limited. Transfusion of warm, fresh whole blood (FWB) has been used to augment limited access to full BCT in these settings. The main limitation of FWB is that it is not readily available for transfusion on casualty arrival. This small case series evaluates the impact early, mechanism-of-injury (MOI)-based, preactivation of the walking blood bank has on time to transfusion. We report an average time of 18 minutes to FWB transfusion from patient arrival. Early activation of the walking blood bank based on prehospital MOI may further reduce the time to FWB transfusion.

[Advanced methods of prehospital bleeding management based on the experience and standards of tactical medicine]

Hemostatic agents are currently used in the form of special granules or soaked gauze. Their use is particularly advantageous in difficult body location (e.g. on neck, armpit or groin), where other methods of bleeding control are impossible to use or fail. In a tactical environment tranexamic acid received first class recommendation for use in case of severe bleeding in the US Army. Its application should be considered in case of traumatic amputation, penetrating chest and abdominal trauma or hemorrhagic shock. The aim of the implementation of hypotensive resuscitation is to maintain perfusion of vital organs in patient with hypovolemia, without excessive fluid infusion. Modern method of bleeding control in combat condition are compression clamps. The purpose of these devices is to compress blood vessel by external pressure pads, especially in difficult to access arteries and large veins in the pelvis or in the distal abdominal aorta.

Prehospital analgesia with ketamine for combat wounds: a case series

BACKGROUND

No data have been published on the use of ketamine at the point of injury in combat.

OBJECTIVE

To provide adequate pain management for severely injured Rangers, ketamine was chosen for its analgesic and dissociative properties. Ketamine was first used in the 75th Ranger Regiment in 2005 but fell out of favor because medical providers had limited experience with its use. In 2009, with new providers and change in medic training at the battalion level, the Regiment implemented a protocol using doses of ketamine that exceed the current Tactical Combat Casualty Care recommendations.

METHODS

Medical after-action reports were reviewed for all Ranger casualties who received ketamine at the point of injury for combat wounds from January 2009 to October 2014. Patients and medics were also interviewed.

RESULTS

Unit medical protocols authorize ketamine for tourniquet pain, amputations, long-bone fractures, and pain refractory to other agents. Nine of the 11 patients were US Forces; two were local nationals (one female, one male). The average initial dose given intramuscularly was 183 mg, about 2 to 3 mg/kg and intravenously 65 mg, about 1 mg/kg. The patients also received an opioid, a benzodiazepine, or both. There was one episode of apnea that was corrected quickly with stimulus. Eight of the 11 patients required the application of at least one tourniquet; four patients needed between two and four tourniquets to control hemorrhage. Pain was assessed with a subjective 1-10 scale. Before ketamine, the pain was rated as 9-10, with one patient claiming a pain level of 8. Of the US Forces, seven of the nine had no pain after receiving ketamine and two had a pain level of four. Two of the eight had posttraumatic stress disorder.

CONCLUSIONS

In this small, retrospective sample of combat casualties, ketamine appeared to be a safe and effective battlefield analgesic.

The incidence of pelvic fractures with traumatic lower limb amputation in modern warfare due to improvised explosive devices

AIMS

A frequently-seen injury pattern in current military experience is traumatic lower limb amputation as a result of improvised explosive devices (IEDs). This injury can coexist with fractures involving the pelvic ring. This study aims to assess the frequency of concomitant pelvic fracture in IED-related lower limb amputation.

METHODS

A retrospective analysis of the trauma charts, medical notes, and digital imaging was undertaken for all patients arriving at the Emergency Department at the UK military field hospital in Camp Bastion, Afghanistan, with a traumatic lower limb amputation in the six months between September 2009 and April 2010, in order to determine the incidence of associated pelvic ring fractures.

RESULTS

Of 77 consecutive patients with traumatic lower limb amputations, 17 (22%) had an associated pelvic fracture (eleven with displaced pelvic ring fractures, five undisplaced fractures and one acetabular fracture). Unilateral amputees (n = 31) had a 10% incidence of associated pelvic fracture, whilst 30 % of bilateral amputees (n = 46) had a concurrent pelvic fracture. However, in bilateral, trans-femoral amputations (n = 28) the incidence of pelvic fracture was 39%.

CONCLUSIONS

The study demonstrates a high incidence of pelvic fractures in patients with traumatic lower limb amputations, supporting the routine pre-hospital application of pelvic binders in this patient group.

[Applications of myo-periosteal fibular bone bridging for traumatic transtibial amputation]

OBJECTIVE

To compare the effectiveness between the myo-periosteal fibular bone bridging and traditional transtibial amputation in the treatment of amputation below knee so as to provide theoretical basis for choosing transtibial amputation in clinical application.

METHODS

Between November 2001 and November 2011, 38 patients with mangled lower extremity were treated by transtibial amputation. Among 38 patients, 17 (group A) underwent myo-periosteal fibular bone bridging (the operation techniques of an attached peroneal muscle myo-periosteal fibular strut bridge between the end of the tibia and fibula below knee amputation), and other 21 (group B) underwent traditional transtibial amputation. There was no significant difference in age, gender, injury cause, amputation cause, side, and disease duration between 2 groups (P > 0.05). The quality of life (QOL) was analyzed using 36-item short form health survey (SF-36), and prosthesis satisfaction by Trinity amputation and prosthesis experience scale (TAPES).

RESULTS

Healing of incision by first intention was obtained in all patients of 2 groups; no necrosis, infection, or poor stumps was observed. The mean follow-up time was 22 months (range, 14-30 months) in group A, and 26 months (range, 15-30 months) in group B. The patients achieved good healing of bone bridging, no bone nonunion occurred. The healing time was (5.1 +/- 1.1) months in group A and (3.3 +/- 0.6) months in group B, showing significant difference between 2 groups (t=9.82, P=-0.00). Spur occurred at the distal fibula in an 11-year-old boy of group B after 2 years of operation, which blocked use of prosthesis; prosthesis was well used in the other patients. After 12 months of operation, SF-36 score was 55.84 +/- 14.01 in group A and 49.93 +/- 12.78 in group B, showing significant difference (P < 0. 05); the physical functioning, social functioning, role-physical, vitality, body pain, general health scores in group A were significantly higher than those in group B (P < 0.05), but no significant difference was found in role-emotional and mental health scores between 2 groups (P > 0.05). TAPES score was 12.12 +/- 2.23 in group A and 10.10 +/- 2.00 in group B, showing significant difference (t=2.891, P=0.006).

CONCLUSION

It is a very effective method to treat traumatic amputation using an attached myo- periosteal fibular bone bridging between the end of the tibia and fibula below knee, which can afford better quality of life and prosthesis satisfaction.

Traumatic forequarter amputation associated acute lung injury (ALI): report of one case

One case of traumatic forequarter amputation associated acute lung injury (ALI) was presented. A discussion reviewing the treatment guidelines for this devastating injury, and pointing out the importance of supporting the lung and preventing the development of acute respiratory distress syndrome (ARDS) was included.

The effect of conservative management in extensor plus finger after partial amputation to the ulnar digits--a case report

The extensor plus finger after partial amputation of ulnar digits can affect the functions of the hand. The therapist intricate knowledge of intrinsic and extrinsic mechanism of fingers and creative approach in therapy would solve the puzzle when managing complex problem (extensor plus finger). Here we study a case of extensor plus finger after partial amputation of ulnar digits, its mechanism, and our experience with conservative management in managing extensor plus finger.

Continuous brachial plexus blockade in combination with the NMDA receptor antagonist memantine prevents phantom pain in acute traumatic upper limb amputees

BACKGROUND

Hyperexcitability of N-methyl-d-aspartate acid (NMDA) receptors may play an important role in the development of phantom limb pain (PLP).

AIM OF THE STUDY

To investigate whether early treatment with the NMDA antagonist memantine attenuates phantom pain memory formation in traumatic amputees.

METHODS

In a randomized, double-blind, controlled trial 19 patients with acute traumatic amputation of the upper extremity were investigated. All patients received postoperative analgesia by continuous brachial plexus anesthesia (ropivacaine 0.375% 5 ml/h) for at least 7 days. In addition, the patients received either memantine (20-30 mg daily, n=10) or placebo (n=9) for 4 weeks.

RESULTS

Memantine treatment reduced the number of requested ropivacacine bolus injections during the first week and resulted in a significant decrease of PLP prevalence and intensity at 4 weeks and 6 months follow up, but not at 12 months follow up.

CONCLUSIONS

We conclude that memantine can reduce intensity of phantom limb pain and might also prevent the development of PLP. However, despite the very early begin of treatment; no long-term effect on established PLP was evident.

Sex differences in pain and psychological functioning in persons with limb loss

Sex differences in pain are frequently reported in the literature. However, less is known about possible sex differences in the experience of pain secondary to a disability. The current study explored these issues in persons with limb loss (n = 335, 72% men) who were recruited as part of a postal survey. Participants provided ratings of phantom limb pain (PLP), residual limb pain (RLP), and general pain intensity. Participants also completed measures of pain-related interference, catastrophizing, coping, and beliefs. Results indicated that a greater proportion of males than females (86% vs 77%, respectively) reported the presence of PLP; however, this difference was no longer prominent when cause of limb loss was controlled. No sex differences were found in the presence of RLP, or in average intensity ratings of PLP or RLP. In contrast, females reported greater overall average pain intensity and interference than males. Females also endorsed significantly greater catastrophizing, use of certain pain-coping strategies, and beliefs related to several aspects of pain. This study did not find prominent sex differences in pain specific to limb loss. However, several sex differences in the overall biopsychosocial experience of pain did emerge that are consistent with the broader literature.

PERSPECTIVE

The current study contributes to the literature on sex differences in the experience of pain. Although males and females with limb loss did not significantly differ in their disability-specific pain, sex differences in their broader experience of pain were significant and are worthy of future clinical and empirical attention.

Phantom limb related phenomena and their rehabilitation after lower limb amputation

This paper reviewed the various hypotheses on phantom limb and phantom limb pain as well as all the related rehabilitation techniques to control these symptoms. The uncertainty in their pathophysiology strongly affects all the rehabilitation approaches so far used, as no single parameter has been found to predict or control phantom limb pain as well as no single factor can be quoted as an indicator of rehabilitation success for lower limb amputation. Within a comprehensive rehabilitation plan, behavioral interventions, stimulation techniques, feedback, physical therapies designed to possibly reverse the maladaptive memory traces and enhance its extinction have been described. Although substantially not clinically useful, pharmacological and surgical interventions also have been briefly considered. A reassessment of the actual strategies used is suggested with a role for rehabilitation not only after the amputation but also in the pre-emptive control of the pre-existing painful condition. In this process, rehabilitation should take into account many parameters, not always related to the traditional role of rehabilitation. Pain assessment before and after amputation, its natural history and clinical picture such as its quality, variations, level of the amputation, dominance, time interval between amputation and rehabilitation, as well as all the other phantom limb related phenomena should be considered and treated.

Effects of long-term immobilisation on cortical bone mass after traumatic amputation of the phalanges estimated by digital X-ray radiogrammetry

Osteopenia of the cortical and trabecular bone partition is a common finding after immobilisation. Digital X-ray radiogrammetry (DXR) seems to quantify cortical demineralisation caused by circular saw amputation already few days after accident.

INTRODUCTION

The study analyses the extent of demineralisation caused by immobilisation in patients with digital amputation after a circular saw injury, and elucidates the period of time which discloses a significant deprivation of bone mineral density estimated at the metacarpalia II-IV using DXR.

METHODS

Twenty-eight patients with digital amputations underwent measurements of bone mineral density, cortical thickness, bone width and metacarpal index using DXR-technology in a follow-up up to 902 days.

RESULTS

The data showed a significant decline of bone mineral density (-10.47%), the metacarpal index (-4.38%), the bone width (-12.06%) and the cortical thickness (-7.04%) after trauma-related amputation. The cortical demineralisation of the metacarpals could already be revealed in two patients after the second day, according to the amputation of phalanges (-3.65%).

CONCLUSIONS

The inhibition of the periosteal bone formation detected by DXR-technique seems to be a specific finding caused by amputation, which thus differs from normal age-related (i.e., endosteal) bone loss and from demineralisation following acute immobilisation (i.e., trabecular osteopenia).

Why traumatic leg amputees are at increased risk for cardiovascular diseases

BACKGROUND

Post-traumatic lower limb amputees have an increased morbidity and mortality from cardiovascular disease. Risk factors for this amplified morbidity and the involved pathophysiologic mechanisms have not been comprehensively studied.

METHODS

The MEDLINE database was reviewed, with case-controlled studies and nested in cohort studies eligible for inclusion in this analysis.

RESULTS

Insulin resistance, psychological stress and patients' deviant behaviors are prevalent in traumatic lower limb amputees. Each of these factors may have systemic consequences on the arterial system and may contribute to the increased cardiovascular morbidity in traumatic amputees. Abnormalities of arterial flow proximal to the amputation site may hold the explanation for the linkage between the extent of leg amputation and the magnitude of the cardiovascular risk: proximal leg amputation is associated with greater risk than distal amputation and bilateral amputation with greater risk than unilateral amputation. This review focuses on hemodynamic culprits (shear stress, circumferential strain, reflected waves), hemodynamic consequences in proximity to the occluded femoral artery and hemodynamic consequences at a distance.

CONCLUSION

Coronary risk in lower limb amputees may be substantially greater than predicted by available algorithms, given that neither hemodynamic nor psychological factors concern the current prediction models. It seems reasonable to take early prophylactic measures in lower limb amputees by discouraging smoking, excessive alcohol consumption and adherence to a low fat diet. Studies are needed to evaluate the optimal intensity of physical exercise effects on reflected pulse waves and their possible long-term consequences. Guidelines for optimal blood pressure, blood glucose and lipid control in amputees need to be convened.

Fat embolism syndrome after lower extremity replantation associated with tibia fracture: case report

We report a patient who was diagnosed as fat embolism syndrome after replantation surgery of left amputated foot. This diagnosis was based on the presence of a long bone fracture with an amputation of a major extremity, supported by the signs of pulmonary and cerebral dysfunction and confirmed by the demonstration of arterial hypoxemia in the absence of other disorders.

Prosthesis use in persons with lower- and upper-limb amputation

This study identified clinical (e.g., etiology) and demographic factors related to prosthesis use in persons with upper- and lower-limb amputation (ULA and LLA, respectively) and the effect of phantom limb pain (PLP) and residual limb pain (RLP) on prosthesis use. A total of 752 respondents with LLA and 107 respondents with ULA completed surveys. Factors related to greater use (hours per day) for persons with LLA included younger age, full- or part-time employment, marriage, a distal amputation, an amputation of traumatic etiology, and an absence of PLP. Less use was associated with reports that prosthesis use worsened RLP, and greater prosthesis use was associated with reports that prosthesis use did not affect PLP. Having a proximal amputation and reporting lower average PLP were related to greater use in hours per day for persons with an ULA, while having a distal amputation and being married were associated with greater use in days per month. Finally, participants with LLA were significantly more likely to wear a prosthesis than those with ULA. These results underscore the importance of examining factors related to prosthesis use and the differential effect that these variables may have when the etiology and location of amputation are considered.

From Baghdad to Germany: Use of a New Pumpless Extracorporeal Lung Assist System in Two Severely Injured US Soldiers

The authors describe a new extracorporeal pumpless interventional lung assist system (iLA) that was implemented in two US soldiers with severe acute respiratory distress syndrome received from enemy action in Iraq, who were at risk for critical hypoxemia/hypercapnia. The system is characterized by a new low-resistance gas exchange membrane that is integrated in an arterial-venous bypass established by cannulation of the femoral artery and vein. Cardiovascular stability is essential to produce sufficiently high blood flow rates over the gas exchange unit. After implantation of the interventional lung assist, oxygenation increased and carbon dioxide elimination improved rapidly. Ventilator settings were able to be adjusted to the decreased pulmonary gas exchange needs, making protective lung strategies possible. Air transport of both patients with the running iLA system was uneventful. The iLA was removed after 15 and 8 days of continuous operation, respectively, and both soldiers were successfully weaned from mechanical ventilation. Interventional, extracorporeal pump-free pulmonary support opens up new possibilities for pulmonary protection due to ease of use, effectiveness, and low costs; however, there is concern of distal limb ischemia. Experiences to date are encouraging, although randomized studies are lacking, and the procedure carries significant risks.

Heterotopic ossification following traumatic and combat-related amputations. Prevalence, risk factors, and preliminary results of excision

BACKGROUND

Although infrequently reported in amputees previously, heterotopic ossification has proven to be a common and problematic clinical entity in our recent experience in the treatment of traumatic and combat-related amputations related to Operation Enduring Freedom and Operation Iraqi Freedom. The purpose of the present study was to report the prevalence of and risk factors for heterotopic ossification following trauma-related amputation as well as the preliminary results of operative excision.

METHODS

We identified 330 patients with a total of 373 traumatic and combat-related amputations who had been managed at our centers between September 11, 2001 and November 30, 2005. We reviewed the medical records and radiographs of 187 patients with 213 amputations who had adequate radiographic follow-up. Additional analysis was performed for twenty-four patients with twenty-five limbs that required excision of symptomatic lesions. The mechanism and zone of injury, amputation level, timing of excision, use of prophylaxis against recurrence, and other confounding variables were examined. Outcomes were assessed by determining clinical and radiographic recurrence rates, perioperative complications, preoperative and follow-up pain medication requirements, and the ability to be fit with a functional prosthesis.

RESULTS

Heterotopic ossification was present in 134 (63%) of 213 residual limbs, with twenty-five lesions requiring excision. A final amputation level within the zone of injury was a risk factor for both the development and the grade of heterotopic ossification (p < 0.05). A blast mechanism was predictive of occurrence (p < 0.05) but did not correlate with grade. All patients who had been managed with excision were tolerating the prosthetic limb at an average of twelve months of follow-up. Twenty-three limbs demonstrated no evidence of recurrence, and two limbs had development of clinically asymptomatic, radiographically minimal recurrences. Six patients experienced wound-related complications that required reoperation, and two patients required subsequent minor revision surgery. There was a significant decrease in the use of pain medication following surgery (p < 0.05).

CONCLUSIONS

Heterotopic ossification following trauma-related amputation is more common than the literature would suggest, particularly following amputations that are performed within the initial zone of injury and those that are due to blast injuries. Many patients are asymptomatic or can be successfully managed with modification of the prosthesis. For patients with refractory symptoms, surgical excision is associated with low recurrence rates and decreased medication requirements, with acceptable complication rates.

Colistin, meropenem and rifampin in a combination therapy for multi-drug-resistant Acinetobacter baumannii multifocal infection. A case report

A 16 year-old girl underwent a multifocal (lungs, skin, soft tissues) infection due to multiresistant Acinetobacter baumannii after a car crash. To treat such a severe disease we used a combination therapy of colistin (2 millions Units twice/day), rifampicin (600 mg/day), meropenem (1 g 3 times a day) after a synergistic activity test was performed (checkerboard method on Mueller-Hinton broth and 5x10(5) cfu/mL inoculum). After 24 days, when a significant clinical improvement was gained, the 3-drugs combination therapy was replaced with i.v. levofloxacin 500 mg twice/day but, after 10 days of quinolones therapy, fever started again and the same multidrug resistant (MDR) A. baumannii was isolated from the skin grafts, central venous catheter tip and bronchial alveolar lavage. A combination therapy with colistin and meropenem was therefore started and definitive defervescence was obtained after 10 days. This therapy was continued for 70 days even if the patient was apyretic because A. baumannii was still present in the skin secretions. After 109 days of hospitalization in our intensive care unit, the patient was transferred to a rehabilitative unit. This case shows how useful is, in selected cases, rediscovering old antibiotic drugs, specially when they are adopted as a combination therapy, and highlights the importance of the clinical microbiological laboratory as it may help clinicians in choosing the best drugs combination.

Traumatic below-elbow amputations

Prehension, intelligence, and erect posture distinguish humans from lower animals. Hands are instrumental for our survival and welfare. We use our hands when we work, recreate, and communicate. A handshake, a touch, a sign, or signal has significant social and communicative meanings. Hands play a major role in defining the skill level of our activities and our level of social expression and integration. Indeed, refined psychomotor precision of hand function may distinguish some individuals among us, gifting society with its more skilled craftsmen, surgeons, artisans, musicians, athletes, and the like in a highly digital world. For others, their hands are critical in providing and caring for their families. Injury severity scores may identify the majority of patients that require amputation; however, injury severity scoring system predictions in individual patients may be problematic and should be used with caution. Amputees require comprehensive multidisciplinary treatment and compassion so that they can successfully overcome their losses. Ultimately, the patients must change, adjust, and adapt to successfully reintegrate themselves into their families, peer groups, job settings, and society as a whole. Early amputation may decrease the incidence and severity of phantom pain compared to amputation after the failure of reconstruction. Early prosthetic fitting, training, and physical rehabilitation; early psychological and sociological support; and early return to work facilitate successful functional recovery. Psychological recovery may be a more arduous and extended process than physical recovery. We must teach our amputees from the outset to use their losses as an incentive for success, assist them to regain their quality of life, and encourage them to act as role models for and to educate others.

Heterotopic ossification in the residual limbs of traumatic and combat-related amputees

Reports on the occurrence and treatment of heterotopic ossification in amputees are rare. Heterotopic ossification in the residual limbs of amputees may cause pain and skin breakdown and complicate or prevent optimal prosthetic fitting and utilization. Basic science research has shed light on the cellular and molecular basis for this disease process, but many questions remain unanswered. The recent experience of the military amputee centers with traumatic and combat-related amputations has demonstrated a surprisingly high prevalence of heterotopic ossification in residual limbs. Primary prophylactic regimens, such as nonsteroidal anti-inflammatory drugs and local irradiation, which have proved to be effective in preventing and limiting heterotopic ossification in other patient populations, have not been studied in amputees and generally are not feasible in the setting of acute traumatic amputation. When nonsurgical measures such as activity and repeated prosthetic modifications fail to provide relief, surgical excision has provided good early clinical results, with low rates of recurrence and acceptable complication rates in military amputees.

Ballistic Fractures During The 2003 Gulf Conflict - Early Prognosis And High Complication Rate

BACKGROUND

Ballistic fractures are devastating injuries often necessitating extensive reconstructive surgery or amputation, particularly if associated with high-energy transfer wounds. Infective complications are common, particularly in the austere environment encountered in war. We present the management and early outcome of these injuries with reference to the mechanism of injury and bony injury.

METHOD

Data on ballistic fractures was collected prospectively during the 'war-fighting' phase of the 2003 Gulf Conflict, between 19th March and 20th May. Fractures were scored using the Red Cross Fracture classification and early outcome analysed.

RESULTS

Thirty-nine patients, with 50 ballistic fractures, were treated by British military surgeons. Patients were predominantly Iraqi (90%) and 50 per cent of ballistic fractures were caused by bullets. Seventeen upper limb fractures and 33 lower limb fractures were sustained. There were seven traumatic amputations, and a further 2 limbs were amputated primarily. Methods of primary stabilisation for the remaining 41 fractures were: external fixation (22%), POP (14.5%), K-wires (14.5%) traction (10%), and no stabilisation (39%). Seven individuals were evacuated early after primary surgery, hence 43 ballistic fractures were available for follow-up. 13/43 (30%) of wounds became infected, 5/43 (11.5%) were deep infections necessitating surgical drainage. There were 4 late amputations (9.5%), 3 of which had initially been managed by external fixation. Infection occurred significantly more often in gunshot fractures (10/21, 48%), wounds closed primarily against the principles of war surgery (415, 80%) and intra-articular fractures (3/3, 100%) (p=0.022, 0.024 and 0.023 respectively). Differing methods of stabilisation had no bearing on the rate of postoperative infection.

CONCLUSION

Ballistic fractures remain a challenge for trauma surgeons in times of war and still have a poor prognosis. Further work is required to determine the optimal treatment of these injuries during conflicts. In addition, there still seems to be a continued need to re-learn the principles of war surgery in order to minimise complications and optimise functional recovery.

Phantomschmerz - Diagnostik und Therapie - Erinnerungen an nicht mehr vorhandene Körperteile beeinflussen

Almost everyone who has amputated a limb will experience a phantom limb. They have the vivid impression, that the limb is still present. 60 to 70% of these amputees will suffer from phantom limb pain. The present paper gives an overview of the incidence and the characteristics of the so called "post amputation syndrome". Possible mechanism of this phenomena are presented, including peripheral, spinal, and central theories. Treatment of phantom limb pain is sometimes very difficult. It includes drug therapy, psychological therapy, physiotherapy as well as the prevention of phantom limb pain with regional analgesia techniques.

Chronic Low Back Pain in Individuals with Lower-limb Amputation

Low back pain (LBP) is a common condition in individuals which experienced psychology and physical trauma. LBP is usually found in persons with lower-limb amputation (LLA), as the most common sign of somatisation or inappropriately made prostheses. Our goal was to investigate cases of chronic pain syndrome in persons with LLA and to determine factors, which influence their functional inability due to LBP. Pain after LLA has been studied. 37 persons, including 26 war veterans (70.2 %) and 11 (29.8 %) civilians with LLA due to an illness, were examined. All participants gave their informed consent and filled Oswestry index of disability due to chronic LBP, divided into 10 sections with 6 questions each, with marks in the range 0-5. The average age of 37 analyzed participants with LLA was 46.2+-10.92 years. 30 participants (81.1 %) were married, 4 (10.8 %) were single and 3 (8.1 %) were widows. 27 (73.0 %) participants had below the knee amputation, 5 (13.5 %) had above the knee amputation and 5 (13.5 %) had foot amputation. 33 (89.6 %) participants experienced chronic LBP in the last 2-10 years and 4 (10.8 %) did not have pains. According to Oswestry index for chronic pain higher level of social functionality was found in civilian amputees than in war veterans (p<0.05). Married civilian amputees have higher level of disability during seating (p<0.01), sleeping (p<0.01) and traveling (p<0.05). Higher level of social disorder among civilian amputees is due to the fact that they belong to older group of participants which usually have social integration at the lower degree. More serious problems during seating, traveling and sleeping among this group are probably due to co morbidity. Chronic LBP was found among 89.6 % of the participants. Higher level of social disorder, problems during seating, traveling and sleeping were identified in the civilian amputees and the married participants.

Advances in Amputee Care

This self-directed learning module highlights the recent innovations in amputee care. It is part of the study guide on limb deficiency in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This focused review article describes the key elements of a successful comprehensive amputee program, the basic surgical considerations for upper- and lower-extremity amputation, and some of the more recent advances in prosthetic components. Further, an update is given on issues such as hand transplantation and the integration of robotics and artificial muscles for people with limb loss.

OVERALL ARTICLE OBJECTIVE

(a) To discuss current issues and advances in the care of patients with amputation, (b) to describe the key elements in designing a comprehensive amputee care program, and (c) to discuss surgical considerations of limb preservation and amputation levels.

Limb deficiency and prosthetic management. 2. Aging with limb loss

This self-directed learning module highlights the issues faced by people aging with limb loss. It is part of the study guide on limb deficiency and vascular rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the impact that limb loss has on health and physical function throughout the life span. Case examples are used to illustrate what effect limb loss in childhood or young adulthood has on the incidence and management of new impairments or disease processes commonly associated with aging.

OVERALL ARTICLE OBJECTIVE

To discuss the impact of early-life limb loss on the incidence and management of physiologic and functional changes associated with aging.

Bilateral femoral neuropathy associated with disseminated intravascular coagulopathy: a case report

We report a case of 20-year-old man who presented with bilateral femoral nerve palsy following resuscitation for traumatic massive blood loss and its consequence. A high suspicious index for this complication may lead to its early recognition. Its related pathoanatomy is discussed based on the described evidences in the literature. Nonoperative treatment remains as a recommended option for coagulopathy-related neuropathy.

Treatment of Painful Neuroma of Amputated Phalanx with Distal Toe Transfer: A Case Report

A painful neuroma in the amputation stump of a finger can be psychologically and physically disabling. Numerous surgical procedures have been attempted to prevent and treat amputation neuromas of the finger, but the results are inconsistent. Microsurgical transfer of the distal second toe to the amputated stump of the finger can provide a pathway and target for the regenerating axons and avoid recurrence of neuromas. In this article, we present the experience of successful treatment of amputation neuromas of an index finger with microsurgical distal toe transfer.

Unilateral Beau's lines associatd with a fingertip crushing injury

Beau's lines are transverse depressions or ridgings of the nail surface that are the result of the temporary arrest of nail matrix formation. They are caused by systemic diseases, local trauma, drugs, and infection. Generally, Beau's lines after a fingertip injury occur on only the affected finger, not on the unilateral extremity. In this report, we present the case of a 36-year-old man who developed transverse ridgings in the nail plates of all five fingers of the affected extremity after a fingertip (thumb) crushing injury. During the follow up, the growth rate of affected fingernails was normal. The transverse ridgings advanced with the linear growth of the nails and eventually disappeared. To the best of our knowledge, no association between unilateral Beau's lines and fingertip injury has been reported in the English literature.