+ What are the key components of this patient’s history and physical examination?

Relevant History:

• Which limb(s) was/were amputated and at what level(s)?
• What is the reason and medical history for the amputation(s)?
• Unilateral or bilateral?
• Was there trauma involved?
• Is there pain? Phantom sensation or phantom pain?
• Is there a history of dysvascular disease?
• Past medical and surgical history? Are chronic conditions controlled?
• Were there any premorbid pain or functional issues?
• Is the patient willing to do physical and/or occupational therapy extensively?
• Does the patient want a prosthesis? If so, have they researched any options?
• What sort of postoperative residual limb care has been advised?
• Does the patient have and wear a shrinker? If so, how often?
• Functional history and current functional status, including equipment usage?
• Social history? Work status? Support network?
• Past Medical and Surgical History?
• Medications?

Relevant Physical Examination:

• Vital signs, weight, BMI
• Inspection
• Palpation
• Gait analysis
• Manual muscle testing, sensation, reflex examination of bilateral upper and lower extremities
• Amputated limb compared to intact limb (size, length, diameter, skin, edema, color comparisons)
• Surgical wound inspection, suture evaluation
• Special testing as indicated by history.

+ Challenge Question

• Why is the length of the residual limb important to know?

+ Challenge Answer

• The length of the residual limb determines the type of prosthesis the patient is a candidate to receive, as well as the components of that prosthesis, depending on how much space there is to fit those components into. In general, the shorter the residual limb length, the less functional the residual limb is.

+ Challenge Question

• In a transfemoral amputation, what is the ideal residual limb shape? Please also describe the differences between a quadrilateral and ischial containment socket.

+ Challenge Answer

• The ideal residual limb shape in a transfemoral amputation is conical. A quadrilateral socket is narrow in the anteroposterior dimension and wide in the mediolateral dimension. This is an older socket type. The ischial containment socket allows for weight-bearing upon the medial ischium, and has narrow mediolateral dimensions in contrast to the quadrilateral socket. It encourages a more adducted and flexed position of the femur to facilitate a normal gait, in addition to improved distribution of weight-bearing forces by the residual limb in comparison to the quadrilateral socket.

+ What are the most common causes of upper and lower limb amputation, respectively?

• Trauma and dysvascular disease (hypertension, diabetes, hyperlipidemia, etc.)

+ What further workup would you need in this patient?

• No further workup is necessary at this point from a rehabilitation standpoint.

+ What immediate prosthesis recommendations would you make for this patient?

• At this time, the immediate postoperative period, I would typically recommend no prosthesis be worn yet. We need to wait while the incision heals and ensure there are no postoperative complications before fitting the patient with a temporary prosthesis. A temporary prosthesis could be expected within 2-6 weeks following amputation surgery.

+ What are your initial recommendations for this patient?

• I would counsel the patient that losing a limb is very difficult and can both physically and psychologically challenging. I would recommend counseling and peer support groups to help cope with the loss of limb and loss of independence. I would advise that he wear his residual limb shrinker for 24 hours daily, only removing for wound/residual limb cleaning, until the limb edema has stabilized, which can take months. Wash the wound daily with gentle soap and water, pat dry and air dry. Maintain contact with the limb, desensitize the wound and skin with frequent touch, employ daily scar massage and mobility exercises. Maintain proper skin moisturization and avoid sweating excessively in the residual limb (use antiperspirant if needed). Attend physical and/or occupational therapy for functional rehabilitation prior to and after receiving the definitive prosthesis. Depending on the status of the patient's healing residual limb, we could potentially fit the limb for a temporary prosthesis approximately 2-6 weeks following amputation surgery. This would serve to condition and prepare the residual limb for weight-bearing forces it will encounter during its definitive prosthesis stage. Lie prone for 15-20 minutes three times daily to maintain adequate hip extension and avoid hip flexion contracture. When sitting, extend the knee fully to avoid knee flexion contracture. Acetaminophen and/or NSAIDs for nociceptive pain, and consider gabapentin for neuropathic pain. I will see the patient in follow-up periodically over the next several months to determine when ready for definitive prosthesis.

+ How would you proceed?

• I would advise the patient that feeling like the distal part of the limb is still there is a common phenomenon called phantom sensation. It can become painful, in which case neuropathic pain medication such as gabapentin can be helpful. Phantom sensation by itself is not of clinical concern unless it becomes bothersome to the patient.

+ What would you anticipate this patient’s K level to be? Please define the different K levels.

• The K levels are defined by Medicare as designations of how functional of an ambulator a patient is.

• K0: Nonambulatory.
• K1: Limited household ambulator who ambulates at a fixed cadence.
• K2: Unlimited household ambulator; limited community ambulator; ambulates at a fixed cadence.
• K3: Unlimited community ambulator; variable cadence.
• K4: High impact sports activities; variable cadence.

• This patient is projected as a K3 ambulator due to his past history of excellent ambulation distances (walking 20 miles daily as a mail carrier).

+ Describe your prosthesis prescription for this patient.

• This patient should be fitted with a prosthesis suitable for a K3 ambulator. Thus, I would order the following:

• Suspension: Locking pin. Would consider suction suspension if patient prefers.
• Socket: Patellar tendon-bearing, flexible inner socket with a hard outer shell to provide a total contact fit.
• Pylon to serve as the replacement tibia.
• Foot unit: Multiaxis foot for traversing uneven terrain and allowing motion of plantar- and dorsiflexion and inversion-eversion planes.
• Prosthetic cover for cosmesis.

Note: There is of course some wiggle room with prosthesis prescriptions. As long as you confidently state some reasonable prosthesis prescription for the patient's K level while addressing all prosthesis components, your prescription will be acceptable.

+ What is the most likely diagnosis, etiology, and treatment for this problem?

• This is most likely verrucous hyperplasia, a result of poor residual limb total contact with the socket (e.g. the distal residual limb may hang without contacting the bottom of the socket completely). Treatment involves efforts to restore a total contact fit. This may be through increasing sock ply or reshaping/refabricating the socket itself to allow for a total contact fit.

+ What would you do next for this patient?

• I would order a diagnostic ultrasound scan, as this is likely a cyst, and ultrasound will be cheaper, faster, and less claustrophobic for the patient than an MRI scan.

• Note: This is the key question for this case in this Domain. Always be mindful of cost and patient comfort with your studies. Remember that you work within a healthcare system, and paying attention to cost is going to be an important part of your practice.

+ Your choices result in the following:

• Ultrasound scan reveals a cyst lying at the confluence of the medial head of the gastrocnemius and the semimembranosus.

+ Challenge Question:

• What is the name of a cyst in this location?

+ Challenge Answer:

• Baker cyst.

+ How would you treat this problem?

• I would advise cyst drainage with corticosteroid injection under ultrasound guidance.

+ How would you handle this situation?

• It would be reasonable to continue to provide respectful, high quality care without mentioning the poor review. If you opt to mention the review, a proper conversation should start similarly to below.

• “Thank you for coming in today. It has been so wonderful to watch and be an active part of your rehabilitation and functional improvements. I know you have been on a long road to get to where you are today, and I sincerely congratulate you on your efforts. Unfortunately I did happen to come across an online review that seemed to be written by yourself, noting some inappropriate behavior on my part. I just wanted to take the moment to emphasize that I support you and will continue to remain on your side throughout your lifelong rehabilitation process, and am here to serve your rehabilitation needs regarding whatever challenges you may face. I want to assure you that I would never intentionally say or do anything to make you feel uncomfortable, offended, or unwelcome. I hope that we can have a healthy discourse and relationship going forward, and I welcome you to share your honest thoughts with my care in your case so that I can help improve the care for you and all of my patients.”