Part VII: Injuries and Damages


Traumatic injury is the most common reason for an amputation among people younger than 50. The leading causes of those injuries include motor vehicle and motorcycle accidents, farm machines, power tools, and factory/industrial machines and equipment. Another source can be products that are dangerously designed, do not have sufficient safety measures built in, and/or lack a properly placed “off” switch. Traumatic amputation usually occurs at the scene of the accident, when the limb is completely or partially severed. Sometimes the injured person will make it to the hospital with the limb still attached but so badly crushed or mangled that amputation is necessary.

The amputation may be of one or more toes or fingers, a foot or a hand, a leg below or above the knee, or an arm below or above the elbow. A person may sustain amputations of more than one limb, such as both legs, both arms, or one of each. For instance, when a person comes into contact with an exposed, downed high-voltage power line, it is not at all unusual for the person to suffer the amputation of more than one limb as the electricity seeks paths to leave the body. Hemicorporectomy, or amputation at the waist downward, is the most radical—and rare—of all the types of amputations.

The majority of trauma-related amputations are of the arms (approximately 65 percent compared to 35 percent for leg amputations), and men are at a significantly higher risk than women for trauma-related amputations. However, the number of amputations in women is on the rise, as is the age of the victim who requires an amputation. If an accident or other trauma results in the complete amputation of a limb (i.e., the body part is totally severed), that part sometimes can be reattached, especially when proper care is taken of the severed part and the stump. However, often the victim will have a better outcome from having a well-fitting, functional prosthesis than a nonfunctional reattached limb.

The long-term outcome for persons who have lost a limb has improved greatly due to a better understanding of the management of traumatic amputation, early emergency and critical care management, new surgical techniques, early rehabilitation, and new prosthetic designs. But make no mistake about it: the loss of a limb is still a serious injury that requires major changes to your life. No amount of money and no prosthesis can ever replace a natural, fully functional limb. Severe and persistent pain can be a fact of life for someone who has suffered a traumatic amputation. Up to 80 percent of all amputees still experience pain in their residual limb (the “stump”) and in the part that is now missing, known as “phantom pain.” Doctors are unsure exactly how this works, but to the injured victim the phantom pain in his missing limb feels as real and painful as if the missing limb were still attached. Rather than feeling pain in the missing limb, some amputees feel only phantom sensations, such as itching, burning, aching, pressure, touch, wetness or dryness, hot or cold, or movement in the missing limb.

Pain management is essential to the proper medical treatment of amputees. There are two types of pain in amputation cases: acute and persistent. Acute pain is usually severe in intensity but lasts a relatively short time. Persistent pain generally ranges from mild to severe and lasts for long periods of time, sometimes years. In the beginning of treatment, when pain is new and at its peak, it may be necessary to prescribe a drug from that group of pain medications known as “opioids.” This category of drugs includes morphine, oxycodone, and codeine. Because of the risk of becoming addicted to an opioid drug, after the critical stage has ended and the pain is less intense, the doctor may switch the victim to a non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen (e.g., Advil or Motrin), aspirin, acetaminophen (Tylenol), or naproxen (Aleve). If severe pain persists despite the use of medications and physical therapy, the victim may be referred to a pain management doctor or clinic.

In many cases, a prosthesis (artificial limb) will enhance an amputee’s mobility and ability to perform the “activities of daily living” (ADLs), such as using the restroom by themselves, dressing themselves, making their own meals, showering, brushing their teeth, etc. A prosthesis must be fitted to the individual and should be comfortable, functional, and cosmetically appealing. Training by a skilled physical and/or occupational therapist is necessary before and after receiving a prosthesis. This training will help to maximize the functional use of the artificial limb, and it will also help to prevent the development of bad habits that may be difficult to break later.

While advances in medical treatments and surgical techniques continue, over the past decade, improved outcomes following amputation have largely been the result of advances in prosthetic technology. For instance, for lower-limb (i.e., leg) amputees, the number of prosthetic feet that provide “dynamic response” and the ability to maneuver on uneven surfaces continues to increase. Additionally, at least one microprocessor-controlled prosthetic foot-ankle unit is now available. For above-the-knee amputees, there are currently five different prosthetic knee units that use microprocessorcontrol. These units allow for more normal knee motion and stability through computerized parts that monitor motions and forces and make extremely rapid real-time adjustments while walking. This results in improved walking ability that requires less effort.

For upper-limb (i.e., arm) amputees, the original bodypowered (i.e., cable controlled) prosthetic designs remain in common use, are the most durable, and continue to improve. Although using electrical signals from the muscles (“myoelectric componentry”) to control prostheses for the upper limb has been in use for over 40 years, this technology continues to advance, with associated further enhancements in function. To improve the ability of high-level (close to or through the shoulder) upper-limb amputees to use a myoelectric prosthesis, in 2006 a surgical technique called “targeted reinnervation” was introduced, in which motor and sensory nerves are transferred to the part of the body that needs healing in order to improve motor control and sensory feedback during prosthetic use. The application of this technique is still in its early stages.

In most cases, the amputation victim is measured for a prosthesis several weeks after surgery, when the wound has healed and the tissue swelling is decreased. The medical team will be concerned with maintaining the proper shape of the residual limb, as well as increasing overall strength and function. The amputee will most likely need to make several visits for adjustments with the professional who made the prosthesis (the prosthetist), as well as extensive training with a physical therapist to learn how to use it. They can help the amputee ease pressure areas, adjust alignment, work out any problems, and regain the skills the amputee needs to adapt to life after limb loss.

Some people are not good candidates for prostheses, and these amputees will need to rely on mobility devices, such as a wheelchair or crutches. For instance, a person who has had both legs amputated (a “bilateral” amputee) may opt for a wheelchair, while a person who has had only one leg amputated (a “unilateral” amputee) may opt for a prosthesis. Of course, a unilateral lower-limb amputee who has had a prosthesis made for her may find it useful to use a cane or crutches for balance and support in the early stages of walking. Whether to use a prosthesis or a mobility device such as a wheelchair may be an individual decision based on such factors as the person’s age, balance, strength, and sense of security, as well as the location and extent of the amputation.

Once the amputee has been fitted for a prosthetic limb, has mastered (or is well on her way to mastering) its use, and feels comfortable with its function, this is not the end of the road for the amputee. She will still need to make periodic follow-up visits to her doctor and prosthetist as a normal part of her life. Proper fit of the socket and good alignment will ensure that the prosthesis is still useful to the amputee and is not causing her discomfort, pressure sores, or other problems. Artificial limbs can break down over time and with continued use, and changes in the physical shape and condition of the amputee’s residual limb (i.e., the stump) may require the amputee to go in and have adjustments made to an old prosthesis or get a new one made. Even small problems with the prosthesis should be brought to the immediate attention of the prosthetist. That way, the issue can get attention before that small problem suddenly results in the failure of the prosthesis and becomes a large problem, resulting in further injury to the amputee.

After the amputee has had her surgery and has been fitted for an artificial limb, she will need to keep a focus on the care of the wound site and maintenance of the residual limb. Any skin opening, whether it be for surgery or due to an improperly fitted prosthesis, runs the risk of becoming infected by germs entering the bloodstream through the opening. Infections can cause tenderness or pain, fever, redness, swelling, and/or discharge. These infections can lead to further complications that will require medical intervention, even surgery. If the infection is not treated in a timely manner, it is possible that the infection will grow and spread, causing death.

The amputee will always need to pay special attention to the hygiene of her residual limb, as it will be enclosed in the socket or liner of the prosthesis and thus will be more prone to skin breakdown and infections. If an amputee suspects that she is getting an infection, she should promptly see her medical doctor before it gets out of hand. If you are being fitted for a prosthetic limb, ask your prosthetist for information on caring for your residual limb to prevent infections and what to do if you suspect you have one.

In addition to the intense physical pain and emotional discomfort, the victim may suffer severe psychological trauma that will require intensive and prolonged mental health care intervention. Studies show that civilians suffering the loss of a limb in, say, a traffic accident have a greater risk of experiencing serious psychological problems than servicemen and women who have suffered a traumatic amputation as a result of, for example, the explosion of a roadside explosive device while serving her country in the Middle East.

From a psychological viewpoint, losing a limb is one of the most traumatic psychic events and losses you can suffer. Initially, the victim will feel tremendous grief over the loss of the limb. When the amputation is due to another person’s careless act, the victim will at some point usually feel anger, even rage, toward that person. And as time goes by, the victim may fall into a deep clinical depression stemming from the loss of the limb. A victim suffering from mental and emotional problems arising from the loss of a limb should be treated by a psychologist and/or psychiatrist. The victim will need psychotherapy and, particularly in the case of depression, psychoactive medication to treat her mental condition. An amputee may become so despondent over the loss of her limb(s) that she attempts or completes suicide.