Case Study 15: Patient With Transfemoral Amputation

Examination

History

• Demographic Information:

  The patient is a 23-year-old man, status posttraumatic left transfemoral amputation secondary to military trauma. In addition to the amputation, he sustained bilateral femoral fractures, comminuted right fibular and medial malleolar fractures, and trauma to internal organs. He is status post-open reduction internal fixation of the distal fibula with side plate and screw fixation.

• History of Present Illness:

  Owing to his age and excellent premorbid fitness level, the patient progressed rapidly through an initial intensive (5 day per week) rehabilitation program. Within 4 months of injury, he achieved modified independence in ambulation (single point cane) on level surfaces, uneven terrain and elevations (community distances). At 6 months, the patient was cleared to pursue college classes. Although pain was not an issue, efficiency of gait was impaired, and the patient was having difficulty negotiating on campus.

• Medical History:

  Unremarkable

• Social History/Prior Level of Function:

  Patient was an active-duty service member in peak physical condition. He lives with his girlfriend on the lower floor of an elevator building. He has recently obtained a service dog. The dog's role is to provide physical support and assistance to his owner. An additional benefit is the emotional calming that comes from the bond established. This emotional support is especially important when the service member is walking in a new or busy environment.

  He returns to outpatient physical therapy to achieve his long-term goal of being able to run. In the short term, he would like to improve the quality and efficiency of walking without using a cane in the community. At initial examination, he is wearing his prosthesis 10 hours per day without excess pressure or compromised skin integrity. He has a definitive carbon fiber socket with flexible inner liner, suction suspension, four-ply socks, microprocessor knee, and a K4 level energy storage and return foot. Dual x-ray absorptiometry (DEXA) scan results are acceptable, indicating that bone density is sufficient to progress to higher impact activities without increased risk of fracture.

Systems Review

• Cardiovascular System:

  • Vital signs: within normal limits (WNL)

  • Patient reports ongoing use of rowing machine and hand crank bike for 30 minutes, three times per week.

• Integumentary System:

  • Skin on residual limb is intact without evidence of focal pressure points, callous, blisters, or adhesions. (See Fig. CS15.1.)

  • Intact limb presents mild adhesions at scared area (anteriorly at level of midtibia and malleoli). Femoral scars from external fixation hardware are mobile.

• Neuromuscular System:

  • Denies phantom sensation or pain

  • Right foot intact for light touch with paresthesia at scars sites

  • Proprioception intact

  • Balance impaired

• Musculoskeletal System:

  • Well-developed upper body and core musculature

  • Posture in standing: Center of mass (COM) is shifted over the intact limb. Although subtle, it results in relative adduction of the right lower extremity (LE). In addition, the pelvis is slightly retracted on the left as determined by palpation of the iliac crests. Palpation helps to ...