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Causes of Amputation

Lower Limb Amputations

Cause and level: Seventy per cent of all 2004 referrals following a lower limb amputation are caused by dysvascularity. Within this group 39 per cent are caused by Diabetes Mellitus. Within each cause (apart from neoplasia) the most common level of amputation is trans-tibial. Patients whose amputation was as a result of neoplasia are more likely to have had a trans-femoral amputation.Dysvascularity is the most common cause of lower limb amputation amongst all age groups. The most common age group for Dysvascularity referrals is 75 years and over. For all other aetiologies the most commonly referred age group is 16 – 54 years.

There is a strong association between age and cause of amputation. Dysvascularity was cited as the cause in 13 per cent of new referrals aged under 55 compared with 36 per cent aged over 75. Trauma, on the other hand, mainly occurred in the younger age groups with 71 per cent of lower limb referrals aged less than 55 and 8 per cent aged over 75.It is surprising that cases of Dysvascularity are reported in the under 16 age group (although the numbers are small).

Upper Limb Amputations

Cause and level: In 2004 Trauma accounted for 54 per cent of these of which mechanical trauma was most common. Neoplasia accounted for 14 per cent of referrals. There has been an increase in the number of referrals following upper limb amputation due to a primary malignancy from 7 per cent in 2002/03 to 13 per cent in 2003/04. Dysvascularity as a cause of upper limb amputation was recorded in 8 per cent of referrals.Trauma was the most common cause within the 16 – 54 age group, but in the older age groups more referrals are made due to neoplasia.Taken from the 2003/04, Amputee Statistical Database for theTerminology

TRAUMA

Traumatic amputation is the removal of a limb as a result of an accident or phusical injury. This is characterised as the following:

  • Mechanical, caused by machinery
  • Electrical, caused by an electrical charge
  • Thermal, caused by heat
  • Chemical, caused by chemicals
  • OtherTraumatic amputations are divided into three categories:

  • Immediate – this is uncommon
  • Early – Result of complications such as infection or ischaemia
  • Late – non-union osteomyelitis

DYSVASCULARITY

Dysvascularity is the most common cause of lower limb amputation amongst all age groups. Dysvascularity makes an injury or infection in the neuropathic limb a serious medical condition often leading to amputation.

39 per cent of lower limb dysvascularity is caused by Diabetes Mellitus

There are two main types of diabetes: diabetes mellitus and diabetes insipidus. Both are associated with increased thirst and the production of more urine than usual. For more information click here (http://www.nurseminerva.co.uk/diabetes.htm)Non-diabetic Arteriosclerosis (Atherosclerosis), hardening of the arteries, refers to the build up of plaque on the walls of the arteries, leading to a reduction in the calibre of the vessel. The narrowing builds up over several years where cholesterol, fat and the smooth muscle cells lining the blood vessels have been transformed into a thickened, and sometimes calcified, mass. The result is that the arteries become constricted, their elasticity disappears and the volume of blood able to travel through them at any given time is reduced.Embolism, (Med.) an obstruction of an artery by a clot of blood, air bubble, etc. The occlusion of a blood vessel by an embolus (an object causing an embolism).Vasocpatic Conditions (inc. Raynuad’s) – Vasospastic diseases are a group of relatively common conditions where, for unknown reasons, the peripheral vasoconstrictive reflexes are hypersensitive. This results in inappropriate vasoconstriction and tissue ischaemia, even to the point of tissue loss.Disseminated Intravascular Coagulation – (DIC) is ”an acquired syndrome characterized by the intravascular activation of coagulation with loss of localisation arising from different causes. It can originate from and cause damage to the microvasculature, which if sufficiently severe, can produce organ dysfunction”. (The subcommittee on DIC of the International Society on Thrombosis and Hemostasis).

Endovascular
Chemical trauma (Substance Abuse), Toxins and syndromes also can cause insensitivity in the limbs. Toxins include:

  • alcohol,
  • arsenic
  • lead, gold,
  • steroids,
  • sulfonamides,
  • penicillin,
  • prolonged INH use
  • uremia.

Syndromes include:

HIV/ARC/AIDS medications may also result in neuropathy.

  • Buerger’s Disease
  • Latrogenic Cascular Trauma – uncontrolled haemorrhage can rapidly lead to the demise of the trauma patient. Unrecognised and untreated ischaemia can lead to limb loss, stroke, bowel necrosis and multiple organ failure. Arterial and venous structures are most commonly injured by penetrating trauma. Blunt trauma also carries a significant vascular injury rate, and iatrogenic vascular injuries are increasing with radiological and minimal access procedures becoming more commonplace
  • Arteritis (inc. Rheumatoid Arthritis, Autoimmune Disease. Inflammation of an artery or arteries. Problems that occur in the veins are called “venous disease.” Some vascular conditions occur only in arteries, others are unique to the veins.

INFECTION

The presence of an infectious disease or virus.

OTHER NEUROLOGICAL DISORDERS

Emphasis should be placed on neuropathy (insensitivity). Historically, the neuropathic foot was treated after foot ulceration appeared. We now address neuropathy in an attempt to prevent ulceration and ensuing complications, including amputations.

Diabetic Neuropathy is “the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after exclusion of other causes.”
Diabetic neuropathy is classified into several syndromes, each with a distinct pattern of involvement of the peripheral nerves; a patient often has multiple or overlapping syndromes.

Infective

  • Leprosy, contagious bacterial disease that affects the skin, mucous membranes and nerves, causing disfigurement.
  • Madura Foot is a chronic granulomatous disease of the feet and sometimes other sites. This disorder is also known as mycetoma or maduromycosis and may be caused by a variety of organisms, such as fungi or actinomycetes.
  • Spina Bifida – A congenital malformation in which the spinal column is cleft at its lower portion, and the membranes of the spinal cord project as an elastic swelling from the gap thus formed.
  • Peripheral Nerve Injury – may occur due to trauma (e.g., a blunt or penetrating wound, trauma) or acute compression. Loss of motor function, sensory function, or both may result from an injury to a peripheral nerve.

NEOPLASIA

New and abnormal growth of tissue in some part of the body, esp. a tumour.

  • Benign – not dangerous to health; not recurrent or progressive (especially of a tumour)

  • Malignant virulent or infectious, cancerous, dangerous to health; characterised by progressive and uncontrolled growth (especially of a tumour).

CONGENITAL ABSENCE

State inborn, innate, inherent state (present at birth but not necessarily hereditary; acquired during foetal development) in which one or more bones or a limb are totally absent, partially absent or hypoplastic.

  • Congenital absence – no amputation
  • Congenital abnormality – surgical amputation