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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. If your toes are always cold, one reason could be poor blood flow — a circulatory problem sometimes linked to smoking, high blood pressure, or heart disease. Raynaud’s disease can cause your toes to turn white, then bluish, and then redden again and return to their natural tone.
The most common cause of heel pain is plantar fasciitis, inflammation where this long ligament attaches to the heel bone.
Sometimes the first sign of a problem is a change in the way you walk — a wider gait or slight foot dragging. This is usually a temporary nuisance caused by standing too long  or a long flight — especially if you are pregnant.
Gout is a notorious cause of sudden pain in the big toe joint, along with redness and swelling (seen here).
If you feel like you’re walking on a marble, or if pain burns in the ball of your foot and radiates to the toes, you may have Morton’s neuroma, a thickening of tissue around a nerve, usually between the third and fourth toes. Itchy, scaly skin may be athlete’s foot, a fungal infection that’s common in men between the ages of 20 and 40. This foot deformity can be caused by shoes that are tight and pinch your toes or by a disease that damages nerves, such as diabetes, alcoholism, or other neurological disorder. A sudden, sharp pain in the foot is the hallmark of a muscle spasm or cramp, which can last many minutes. We associate skin cancer with the sun, so we’re not as likely to check our feet for unusual spots. Sometimes an injury to the nail or frequent exposure to petroleum-based solvents can create a concave, spoon-like shape.
Pitting, or punctured-looking depressions in the surface of the nail, is caused by a disruption in the growth of the nail at the nail plate. Anthrax infection is deep and confluent of several pilosebaceous follicles neighborhood leading to the formation of an inflammatory, which then festers in the skin. Our organization hosts many germs, including staphylococcus aureus, which occurs most often in the nose, ear canals, scalp and navel.
Predisposing factors should be investigated: poor hygiene, friction and wearing tight clothing, seborrhea very abundant, fertile soil, such as diabetes, immunosuppression or alcoholism. Boils are often located in areas where the skin is oilier: back, buttocks, but they can occur wherever there are sebaceous glands producing sebum. Hospitalization is recommended in emergency blood culture should be performed, then a local levy to identify the toxicity of Staphylococcus; an antibiotic will also be performed before starting antibiotics.
This wash is also applied to the inner circle, and especially the nursing staff when necessary. Breach of the folds of the buttocks or, in cases of furunculosis seat, avoid wearing tight clothing (jeans). Copyright © 2012 Rayur, All trademarks are the property of the respective trademark owners.
If you think that any photos appearing on this site infringe on your copyright, please let me know right away. Surgical incisions take a long time to heal in diabetic patients due to abnormal insulin levels. This is why physicians make sure sugar levels of diabetic patients are in control before surgery. There are various diabetic complications with surgery because diabetes affects different functions in human body. 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.
The cause may be the slow loss of normal sensation in your feet, brought on by peripheral nerve damage.
It can also be caused by a vitamin B deficiency, athlete’s foot, chronic kidney disease, poor circulation in the legs and feet (peripheral arterial disease), or hypothyroidism. Diabetes can impair sensation in the feet, circulation, and normal wound healing, so even a blister can become a troublesome wound. Your toes will be bent upward as they extend from the ball of the foot, then downward from the middle joint, resembling a claw.
However, a melanoma, the most dangerous form of skin cancer, can develop even in areas that are not regularly exposed to the sun. If part or all of a nail separates from the nail bed (shown here), it can appear white — and may be due to an injury, nail infection, or psoriasis. The areas most commonly affected areas of skin are the fattest: back, buttocks, waist, nasolabial folds. Hygiene care of the patient and carers will be more stringent in case of immunosuppression known. It is a widely known fact that diabetes can lead to various other diseases due to imbalance it creates in human body. Abnormal rise or fall in blood sugar levels can have adverse consequences on patient’s health post surgery. When our body has less insulin levels, it starts burning fat to release energy and ketones as a by product. High blood sugar levels can result in slow healing of surgical wounds and delay suture removal. Ischemia is caused in diabetic patients after surgery as a consequence of abnormal heart rate and rhythm. Reading about these complications is a great way to enhance your understanding and knowledge about post surgical diabetic complications. 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. But pain that’s not due to sky-high heels may come from a stress fracture, a small crack in a bone. Stress or changes in temperature can trigger vasospasms, which usually don’t lead to other health concerns.
Arthritis, excessive exercise, and poorly fitting shoes also can cause heel pain, as can tendonitis. Lung disease is the most common underlying cause, but it also can be caused by heart disease, liver and digestive disorders, or certain infections.
If the joint is rigid, it may be hallux rigidus, a complication of arthritis where a bone spur develops. If the skin on your itchy feet is thick and pimple-like, it may be psoriasis, an over-reaction of the immune system. They may respond to stretching and exercises of the toes or you may need special shoes or even surgery. Other causes include poor circulation, dehydration, or imbalances in potassium, magnesium, calcium, or vitamin D levels in the body. Thick, yellow nails also can be a sign of an underlying disease, including lymphedema (swelling related to the lymphatic system), lung problems, or rheumatoid arthritis. If the nail is intact and most of it is white, it can sometimes be a sign of a more serious condition including liver disease, congestive heart failure, or diabetes.
In case of furunculosis, local antiseptic treatment must be part of daily hygiene and disinfection sites carry germs: nose, ears, navel, scars of boils. A lifestyle food will be introduced in case of unbalanced diet, malnutrition or alcoholism.
A diabetic patient undergoing surgery has to be aware of surgical complications with diabetes. Let us try to understand more about surgical complications in patients who suffer from diabetes.

Sepsis means increased presence of bacteria in the blood stream due to infection caused as a result of ulcers or incisions at surgical sites. 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. A doctor can look for any underlying problems — or let you know that you simply have cold feet. One possible cause: Exercise that was too intense, particularly high-impact sports like basketball and distance running. Raynaud’s may also be related to rheumatoid arthritis, Sjogren’s disease, or thyroid problems.
Less common causes include a bone spur on the bottom of the heel, a bone infection,  tumor, or  fracture. Blood transfusion sites and surgical wounds become primary sites for bacterial activity in most cases.
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. Slow-healing of sores also can be caused by poor circulation from conditions such as peripheral artery disease. Sepsis caused due to diabetes is a critical condition and takes a lot of time to get under control after surgery. 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. Loss of optimum level of water after surgery can further complicate cardiac function resulting in rapid heart rate. 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]. This is the why ischemic episodes are closely monitored in diabetic patients after surgery. 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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