Answers
Andrew Schofield, Paul Schofield in The Complete SAQ Study Guide, 2019
Diabetic foot ulcers require complex multidisciplinary care and frequently require surgery for debridement of infected tissue. Problems arise in neuropathy and lack of sensation to trivial trauma, which is then slow to heal. Treatment starts with prevention, with regular podiatry input and education to prevent minor foot trauma. Appropriate footwear with good nail care and debridement can help with prevention of foot ulcers. Risks for developing ulcers include poor diabetic control, other diabetic complications such as nephropathy and retinopathy and concurrent arterial vascular disease. In established ulceration, infection may be from atypical organisms, so broad-spectrum antimicrobials are needed. Surgery focuses on debridement, drainage of abscesses and treatment of osteomyelitis. Vascular bypasses can help if vascular disease is also present. Amputation is a considered in failed medical and surgical therapy. Inpatients require diligent care to prevent pressure ulcers and attention to hydration and glycaemic control.
Management of Pain Related to Amputation
Gary W. Jay in Practical Guide to Chronic Pain Syndromes, 2016
Approximately 150,000 persons undergo an amputation in the United States each year (1). Amputations are commonly the result of trauma (i.e., military injury, work-related or motor vehicle accidents) or diabetes-related peripheral vascular disease. Pain after amputation remains an enigma. Phantom limb pain (PLP) typically is associated with amputation of a limb but has also been reported with other surgical procedures including removal of organs (i.e., tongue, breast, teeth, genitals, and the bladder). Sensations related to amputation or loss of limb can be divided into three separate types: (i) PLP, (ii) residual limb (stump) pain (RLP), and (iii) phantom limb sensations (PLS). Compensatory pain related to phantom sensations has been recognized more recently as an important additional condition and is usually due to musculoskeletal pain secondary to changes in body or limb movement (i.e., neck, low back, and/or joint pain proximal to the affected residual limb).
Traumatic Amputation in Childhood: Functional and Psychosocial Aspects
Harold M. Dick, David Price Roye, Penelope R. Buschman, Austin H. Kutscher, Boris Rubinstein, Francis K. Forstenzer in Dying and Disabled Children: Dealing with Loss and Grief, 2014
Amputations in childhood are of two types: (1) congenital, by which we include later ablation of a deformed limb or part of a limb, and (2) acquired, which includes the two classic categories of traumatic and elective, such as for tumor or other disease. When amputations are necessary because of a tumor, infection, or limb deformity, they are planned and prepared for by the patients and their families. In these cases, the part that is to be amputated is not “normal” and, indeed, may be a threat to the child's life. The affected limb is often a source of pain or is a functional handicap; this type of amputation can be seen as getting rid of an abnormal limb that is causing problems. In contrast, the traumatic amputation differs from others in that it is not prepared for by patients or their families. For example, when a normal, healthy child leaves for school at 7:30 AM and later the family receives a telephone call from the emergency room informing them that the child has been in an accident and has lost a limb, there has been no time for emotional preparation. When a healthy child loses a normal limb, the sudden emotional shock to both the parents and the child cannot be overstated. In this article, both the functional and psychosocial aspects of this kind of calamity will be addressed.
Understanding amputation care in England and Scotland: a qualitative exploration of patient stories posted on an online patient feedback site
Published in Disability and Rehabilitation, 2022
Many of the positive aspects of care, as detailed above, focused on the staff who patients encountered. The interpersonal aspects, and specifically the way patients were made to feel, appear from the posts to be highly important to what may constitute good care for amputation patients. Amputation is a radical surgical procedure, permanently altering the body and resultantly creating changes for patients in terms of the physical capabilities to carry out work, social, and leisure activities as well as their own sense of self and body image [15]. Given the range of emotions amputation itself can engender—as one of the posters noted “It’s like a grieving process where you experience a range of emotions, for example, anger, frustration, anxiety, guilt, and blame”—it is perhaps not surprising that the expression of caring emotions and the way patients are made to feel is important to care, and significant to understanding what patients identify as good care.
Spontaneous necrosis of a single digit: watershed necrosis
Published in Case Reports in Plastic Surgery and Hand Surgery, 2021
Alain J. Azzi, Gabriel Bouhadana, Fanyi Meng, Peter G. Davison
While our patient received a cephalic vein graft and a digital amputation at the middle phalanx, treatment options in similar situations can vary depending on the cause and chronicity of the ischemia. Medical management is reserved for chronic disease with no evidence of ischemia/ulceration and is targeted at mitigating sympathetic hyperactivity and vasospasm [11]. When the etiology is occlusive in nature, revascularization is the treatment of choice (e.g. thrombectomy, reconstruction of the radial/ulnar artery with vein grafts or reconstruction of the palmar arches using the dorsal venous arch, to name a few). A Digital Brachial Index of less than 0.7, inadequate collateral circulation and segmental occlusion with distal ‘run off’ all serve as indications for revascularization [12–14]. If irreversible damage has occurred and necrosis has developed, amputation is necessary. Allowing the digit to auto-amputate is a reasonable option in the absence of infection. However, if a ray amputation is indicated (third or fourth digit necrosis proximal to the proximal interphalangeal joint), it should be performed early to expedite recovery and return to work.
Epithelioid sarcoma of the hand: a wolf in sheep's clothing
Published in Journal of Plastic Surgery and Hand Surgery, 2021
Jonathan Persitz, Eran Beit Ner, Igal Chechik, Timoret Keren, Erez Avisar
While some evidence of moderate-positive results for anthracycline-based and gemcitabine-based chemotherapy regimens [37] or Tazemetostat which was found beneficial in cases with SMARCB1/INI1 deletion [29], surgical resection remains the mainstay of treatment [30]. Removal of the tumor is recommended by either radical excision as limb salvage procedures or by limb amputation. Even after an appropriate surgical resection, ES tend to recur, both locally and distally [38]. Recurrence is often accompanied by multiple nodules or multifocal infiltration and spread. Pre-operative or postoperative Radiotherapy showed to benefit patients in combination with more conservative surgery [18,39]. Limb amputation is generally reserved for refractory cases with multiple modules, in order to achieve control over the malignant process. Lymph node involvement is associated with worse prognosis. However, it was previously suggested that the high rate of metastases in these cases represent a stage in dissemination of the tumor rather than a truly local or regional involvement [39]. With this in mind, in the case of lymph node involvement with no evidence of metastases, therapeutic resection is indicated. Due to the radical surgical options, reconstructive surgeries are usually part of the treatment and some consideration must be taken into account when planning the resection.
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