Pathology leading to amputation - Physiopedia, universal access to physiotherapy knowledge.
Worldwide prevalence estimates of amputation are difficult to obtain, mainly because amputation receives very little attention and resources in countries where survival is low[1].
Peripheral Vascular Disease is also known or referred to as Peripheral Artery Disease or lower extremity occlusive disease. The peripheral vascular system consists of the veins and arteries beyond or distal to the chest and abdomen supplying the arms, hands, legs and feet. Atherosclerosis, which is the process of Peripheral Arterial Disease (PAD), affects several arterial beds including the coronary and peripheral circulation[5].
Diabetes is also another condition that has an effect on the pathology that may lead to lower limb amputation.
Diabetes Mellitus (Type 2)  Diabetes mellitus is also present in almost half of all cases, and people with diabetes mellitus have a 10 times higher risk of amputation[6].
Patients who suffer from Diabetes Mellitus are at a high risk of developing ulcers and associated complications.[9] Studies indicate that diabetic patients have up to a 25% lifetime risk of developing a foot ulcer[10]. Neuropathy in diabetic individuals affects the motor, sensory and autonomic components of the the nervous system. In the case of peripheral circulation where the the arteries of the lower limbs are affected, pain and tissue damage develop which may eventually lead to amputation in some cases.
Peripheral arterial disease is one contributing factor to ischaemia involving the lower limbs. Tissue viability is affected not only by internal factors such as PAD or Diabetes Melllitus but also by external stimuli such as smoking.
Lower limb amputation can also occur due to systemic infections such as bacterial infections. Learn about the shoulder in this month's Physiopedia Plus learn topic with 5 chapters from textbooks such as Magee's Orthopedic Physical Assessment, 2014 & Donatelli's Physical therapy of the shoulder 2012. Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Clipping is a handy way to collect and organize the most important slides from a presentation. A dermal ulcer is a sore that develops on the skin followed by destruction of the tissue surrounding it.
Your first inclination of any compromised skin areas should come if you notice an area where the skin has an increase in redness and warmth, as compared to the skin around it. Depending upon the extent to which you are affected will determine the stage of your dermal ulcer and the treatment that will be implemented to relieve your discomfort and work to resolve your ulcer. Your doctor will diagnose your dermal ulcer according to the criteria above to develop a treatment plan for you to cope in your day to day life.
Lantiseptic Skin Protectant is a unique high-lanolin emollient ointment intended to protect chafed or ulcer-prone skin, promote the healing of skin injuries and serve as a first aid treatment. The Med Aire Variable Pressure Pump and Pad is made for distributing pressure points helps alleviate bed sores and other discomforts associated with constant pressure on the skin. Mepilex Border is an all-in-one foam dressing that effectively absorbs and retains exudate and maintains a moist wound environment.
You can take it upon yourself to decrease your risk of developing a dermal ulcer, which you should definitely try first to avoid more invasive and costly measures. Reposition yourself frequently to enhance blood flow and reduce the amount of pressure that is being put on certain skin areas. Ultimately, dermal ulcers can range from being very minor to causing several complications. Partial Foot Amputation From A Diabetic Foot Ulcer, That Couldn’t Happen To Me Right? When I was young and first went to the dentist he would say ” If you don’t take care of your teeth they will go away.” I guess the same could be true for a diabetic patient and their feet. As a diabetic, you are at a higher risk for conditions such as Peripheral Neuropathy, and Peripheral Arterial Disease (PAD.)  Each of these conditions can also cause you to have a diabetic foot ulcer. Diabetic foot ulcer (DFUs) are chronic wounds that can develop on the foot or lower extremities of people with diabetes. If not properly treated, diabetic foot ulcer can result in serious complications, including amputation. EMRI is a pioneering institute with a mission to combine clinical care, research and education in diabetes, ocrine and metabolic diseases. By encouraging and supporting innovative research, the Institute aims to enhance understanding of these diseases. It affects the peripheral vascular system, mostly the arteries, and is a manifestation of systemic atherosclerosis and atherothrombotic conditions which may include stenotic, occlusive and aneurysmal disease[4]. It may be referred to as hardening of the arteries where there is generalised degeneration of the elastic tissue and muscles composing the arterial system. It is characterised by chronic compensatory hyperglycaemia that results from progressive insulin resistance especially in muscle tissue together with insufficient pancreatic secretion of insulin to aid glucose uptake in tissues [7]. Peripheral neuropathy and ischaemia from Peripheral vascular disease are two contributing factors to the development of foot ulcers.
Autonomic neuropathy causes the reduction in sweat and oil gland function with the foot loosing its natural ability to moisturise the overlying skin. Patients suffering from peripheral arterial disease present with pain referred to as Intermittent Claudication.

The latter is one of the causal factors when amputation of the affected lower limb may be considered. Smoking is considered to be another or an added risk factor for lower limb amputation due to its effect on the circulation and potential for healing. Previously healthy individuals when affected by such infections are at a risk of amputation of limbs not only as a treatment of choice but also as a life saving measure.
In order to facilitate scientific communication the International Organization for Standardization (ISO) developed a system of accurate classification. 2005, Major lower limb amputations in the elderly observed over ten years: the role of diabetes and peripheral arterial disease. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. Tissue destruction leads to complete loss of skin; the size and depth of the ulcer depends on the severity of what exactly is causing it. This should warrant immediate medical attention to determine any possible underlying causes in order to reduce your chances for more complications or recurring skin issues. The main goals of treatment for dermal ulcers are aimed at avoiding any possible infection that could occur, maintaining an overall moist environment for healing, and easing any pain.
It is formulated to encourage the proper moisture balance of the skin, thereby supporting the body’s natural healing processes.
The Safetac layer seals the wound edges, preventing the exudate from leaking onto the surrounding skin, thus minimizing the risk for maceration.
There are special pads, mattresses and hospital beds alike that can prove to relieve pressure either on good skin or those areas that already have a dermal ulcer present.
Healthy diet habits can keep you at a healthy weight and decrease your risk for more chronic conditions that could lead to inadequate circulation and formation of dermal ulcers.
You know your body the best, so at the first sign of your skin showing an abnormality do not hesitate to consult with your provider just to be safe.
Most diabetics don’t realize how quickly a diabetic foot ulcer can lead to a partial amputation of their foot.
Some people don’t realize that they have a wound at first, and only notice it once it is infected.
Schlam for a basic diabetic foot exam.  He can determine your risk level, and teach you ways to keep your feet healthy and wound free. DFUs often occur from complications of diabetes-specifically, peripheral neuropathy, a condition in which feeling, or sensation, is lost due to reduced blood flow to the lower extremities.
Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in 12-week prospective trial. Healing of chronic foot ulcers in diabetic patients treated with a human fibroblast-derived dermis. Peripheral Vascular Disease is the most common cause of limb loss overall[2], with the rate of dysvascular amputation being nearly 8 times greater than the rate of trauma related amputations, the second leading cause of limb loss[3]. This tissue is replaced by fibrous tissue and the elastic vessels become harder with stretching of collagen and calcium depositing in the walls of the arteries causing them to become hard and tortuous. Diabetes Mellitus usually has an insidious onset and presents as persistent hyperglycaemia. Once a foot ulcer develops there is a high risk of wound progression that may lead to complications and amputation.
The innervation of the intrinsic muscles of the foot is affected and damage leads to an imbalance between the flexors and extensors of the affected foot and therefore causing anatomic deformities. The skin becomes dry and susceptible to tears or breaks with subsequent development of infection. Neuropathy (with alterations in motor, sensation, and autonomic functions) plays the central role and causes ulcerations due to trauma or excessive pressure in a deformed foot without protective sensibility. It has a detrimental effect on wound healing due to the local and systemic processes that nicotine has[15].
Infections include: Meningococcal Meningitis, Staphylococcus and MRSA infections and Necrotizing Fascitis. Whereas no other treatment but surgery is currently available for chondrosarcomas, osteosarcomas show an approximately 50–80% response rate to adjuvant chemotherapy. The mentioned classification is constructed on an anatomical bases due to a failure of formation. Keep in mind also that serious complications, such as infection of the bone or blood, may occur if the dermal ulcer progresses without treatment.
It can safely support anyone up to 250 pounds and do wonders to increase circulation and reduce the incidence of decubitus ulcers.
The Safetac layer ensures that the dressing can be changed without damaging the wound or surrounding skin or exposing the patient to additional pain.
Prevention of infection and pain can be managed with several different medications such as antibiotics, muscle relaxants and non-steroidal anti-inflammatory drugs such as Aspirin, Advil, and Motrin for example. Good exercise regimens can keep your blood flowing and help you also maintain an optimal weight.
Among people with diabetes, approximately 15% experience a DFU in their lifetime, and approximately 2.5% develop a DFU each year.
In the United States, approximately 60% of all lower extremity amputations occur among persons with diabetes; of these amputations, approximately 85% are preceded by a foot ulcer.
On analysing causal pathways for diabetic lower-limb amputation foot ulcers preceded around 84% of amputations[11].

Such deformities include the toes being pulled up into a hammer toe or claw foot flexion deformity.
Minor trauma is also a contributing factor to ulcers that may eventually lead to amputation.
Once the protective layer of skin is broken, deep tissues are exposed to bacterial colonization.
It is the first method of choice for arterial stenosis and occlusion, and for venous incompetence[14].
Nicotine being a vasconstrictor reduces the blood flow to the skin and thus causes tissue ischaemia together with an impairment in the healing process. Examples of traumatic injuries include: compound fractures, blood vessel rupture, severe burns, blast injuries, stab or gunshot wound, compression injuries and cold trauma[16].
Surgical removal of these tumours is currently mostly performed with limb salvage, but amputation may be required in some cases. A Review of Pathophysiology, Classification, and Treatment of Foot Ulcers in Diabetic Patients. Call Hollowbrook Foot Specialists at (845) 298 – 9074 or click here to schedule an appointment.
Additionally, the rate of amputation for people with diabetes is 10 times higher than for people without diabetes.
Foot ulcers are considered to be reasonably common and they not only affect the patient's funtional status and well being but can also identify individuals who may be at a higher risk of amputation.
These will cause abnormal bony prominences and pressure points, such as on the tops of the toes or under the metatarsal heads, which may eventually lead to skin breakdown and ulceration.
Individuals suffering from peripheral vascular disease and diabetic peripheral neuropathy experience a loss of sensation that may exacerbate the development of ulcers. Infection is facilitated by DM-related immunological deficits, especially in terms of neutrophils, and rapidly progresses to the deep tissues. In individuals suffering from PAD the blood flow in the lower limbs is reduced due to processes causing stenosis. Ultrasonic imaging is non-invasive and can provide clinical information about the site and severity of narrowing of arterial vessels or of any blockages of main vessels. Nicotine also promotes an increase in the level of platelet adhesiveness which in result raises the risk of thrombotic microvascular occlusion leading to further tissue ischaemia[15]. In cases of traumatic injury amputation of the limb is considered either as a life saving procedure or where the limb is so severely injured that reconstruction will be less functional than amputation. In addition, the tumours have a risk of local recurrences adversely affecting the prognosis compared to the primary tumour".[17].
Transverse Deficiencies resemble an amputation residual limb, where the limb has developed normally to a particular level beyond which no skeletal elements are present. Standard lays on top of your mattress, deluxe has flaps that help hold the pad securely in place. In peripheral arterial disease there is build up of fatty deposits in the walls of the arterial system.
Many times diabetic individuals are unable to detect trauma to an affected area such as the foot. Blood circulation is usually sufficient when one is at rest, however when one starts walking and the demands are greater the blood supply is not sufficient to the lower limb muscles causing cramps and pain. Where multiple stenoses are present such imaging can determine which stenosis is causing more restriction to blood flow[14]. In the case of trauma limb amputation can also take place months or years after the actual trauma when reconstructive procedures or healing hava failed. These fatty deposits, also known as atheromas, cause a reduction in the lumen of the arteries. In diabetic individuals the hyperglycaemic-induced metabolic abnormalities cause a conversion of intracellular glucose to sorbitol and fructose. This may result in injury with wounds either going unnoticed or progressively worsen when the affected area is exposed to repetitive pressure or forces such as shear forces during ambulation[12][11].
Thus such pain gets worse with greater demands example: when walking uphill and improves or is relieved after a short rest[13]. The reduction in the lumen causes stenosis and restricts the blood flow and supply to the particular area affected. The accumulation of these sugars cause a reduction in the synthesis of products required for normal nerve conduction and function. Poor healing of such wounds, due to compromised circulation, will eventually lead to amputation of the involved limb.
The chemical conversion of glucose will also increase the oxidative stress on nerve cells and lead to further ischaemia and thus causing further nerve cell injury and death. The skin surface is located at the top of the image whilst markers on the right indicate depth in cms.

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