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Lower Limb Amputation - Orthopedic Examination & Documentation

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1. HISTORY

Patient Demographics

• Age, sex, dominant side
• Date and level of amputation
• Surgeon and institution

Reason for Amputation (document clearly)

Relevant Medical History

• Diabetes mellitus, peripheral arterial disease, renal failure
• Cardiac status, hypertension, smoking history
• Trauma mechanism (if traumatic amputation)
• Prior vascular interventions (bypass, angioplasty)
• Functional status pre-amputation

Symptoms to Document

• Residual limb pain (stump pain)
• Phantom limb sensation - patient feels the amputated part is still present
• Phantom limb pain - painful sensation in the amputated part
• Back pain (biomechanical consequence of altered gait)
• Contralateral limb symptoms (critical - see below)

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2. LEVEL OF AMPUTATION - DOCUMENT PRECISELY

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3. LOOK (Inspection)

Residual Limb (Stump)

• Cylindrical (ideal for prosthetic fitting) vs. bulbous (poor fit) vs. conical
• Stump length in centimeters (from fixed bony landmark - e.g. tibial tuberosity for transtibial, greater trochanter for transfemoral)

• Healed vs. open wound
• Scar: position (end, posterior, medial, lateral), adherence to underlying bone/fascia
• Skin condition: redundant dog-ears, skin folds, adherent scarring
• Discoloration, erythema, breakdown, pressure ulcers
• Oedema/swelling (use figure-of-8 measurement or volumetry)
• Sinuses (suggest osteitis or sequestrum)

• Wound dehiscence: partial vs. complete
• Flap viability: evidence of ischaemia, necrosis
• Signs of infection: purulence, warmth, cellulitis

• Hip/knee contracture: critically important - document early
  • Transtibial: look for knee flexion contracture
  • Transfemoral: look for hip flexion/abduction contracture
• Standing posture and trunk balance (if bilateral amputee)

Contralateral Limb

• Skin: ulcers, callus, nail care
• Vascular: colour, hair loss, atrophy
• Oedema

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4. FEEL (Palpation)

• Tenderness over bony prominences - suggests bone spur, inadequate soft tissue padding
• Point tenderness along scar - suggests neuroma
• Palpable bony spur or prominent bone end
• Skin mobility over bone (adherent = poor prosthetic tolerance)

• Warmth (infection, inflammation)
• Coolness (vascular compromise)

• Tinel's sign: percuss along the course of divided nerves; a shooting electric pain into the stump/phantom territory = positive; suggests neuroma formation

• Pitting vs. non-pitting
• Measure circumference at fixed distances from bony landmark (e.g. 5 cm, 10 cm, 15 cm distal to tibial tuberosity)

• Adequate muscle bulk for padding
• Subcutaneous tissue firmness
• Bony prominences (fibular head, tibial crest, condyles)

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5. MOVE (Range of Motion)

Transtibial Amputee

Transfemoral Amputee

Contralateral Lower Limb

• Full ROM documentation of ankle, knee, hip
• Any contracture on the sound side will impair ambulation with prosthesis

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6. MUSCLE STRENGTH TESTING

• Transtibial: Hip flexors, extensors, abductors; knee flexors and extensors
• Transfemoral: Hip flexors, extensors, abductors, adductors; contralateral full assessment
• Bilateral amputee: Upper limb strength (critical for transfers and crutch walking)
• Core strength (stability for prosthetic gait)

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7. NEUROVASCULAR ASSESSMENT

Residual Limb

• Sensation: light touch, pinprick along stump and around scar
• Identify areas of altered sensation (potential neuroma territory)
• Document phantom sensations if present

Contralateral Limb (mandatory)

• Peripheral pulses: femoral, popliteal, dorsalis pedis, posterior tibial
• ABPI (Ankle-Brachial Pressure Index) if vascular cause
• Capillary refill time
• Sensation: peripheral neuropathy testing (10g monofilament in diabetics)
• Vibration sense (128 Hz tuning fork)

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8. COMPLICATIONS - ASSESS AND DOCUMENT

Early (Post-Operative)

Late (Chronic Amputee)

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9. PROSTHETIC ASSESSMENT

• Current prosthesis: type, age, condition
• Socket fit: comfortable, loose, tight, skin breakdown areas
• Suspension mechanism: suction, pin lock, sleeve, belt
• Liner condition: integrity, hygiene
• Prosthetic components: foot type (SACH, dynamic response, hydraulic), knee joint type (transfemoral)
• Walking aids used: none, crutch, stick, frame

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10. FUNCTIONAL & REHABILITATION ASSESSMENT

Mobility Level (K-Level / Medicare Functional Classification)

Activities of Daily Living

• Transfers: independent / supervised / assisted
• Stair ascent/descent
• Donning/doffing prosthesis
• Distance walked (metres or blocks)
• Walking speed (Timed Up and Go test)
• Falls history and fall risk

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11. PSYCHOLOGICAL & SOCIAL ASSESSMENT

• Body image and acceptance of amputation
• Depression/anxiety screening (PHQ-9 or similar)
• Social support at home
• Home environment (stairs, accessibility)
• Occupation and vocational goals
• Patient's prosthetic expectations and motivation

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12. INVESTIGATIONS TO DOCUMENT

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13. DOCUMENTATION TEMPLATE (SOAP FORMAT)

SUBJECTIVE:
- Age/sex, side, level of amputation, date
- Reason for amputation (vascular/traumatic/oncological/septic)
- Chief complaint: stump pain / phantom pain / poor prosthetic fit / wound breakdown
- Functional status: K-level, walking aids, distance

OBJECTIVE:
LOOK:
- Stump shape: cylindrical / bulbous / conical
- Length: ___ cm from [landmark]
- Skin: healed / wound (___ x ___ cm) / sinus / ulcer / adherent scar
- Oedema: present / absent; circumference at ___ cm = ___ cm
- Contracture: knee FFD ___°, hip FFD ___°
- Contralateral limb: [findings]

FEEL:
- Tenderness: stump end / over scar / neuroma (Tinel positive/negative)
- Temperature: warm / cool
- Skin mobility: free / adherent
- Oedema: pitting / non-pitting

MOVE:
- Knee: Flexion ___° / Extension ___° (FFD ___°)
- Hip: Flexion ___° / Extension ___° / Abduction ___° (FFD ___°)
- Muscle strength: [MRC grades]

NEUROVASCULAR:
- Sensation: intact / impaired [distribution]
- Pulses: [bilateral documentation]
- ABPI: ___

SPECIAL TESTS:
- Tinel's: positive / negative at [location]
- Thomas test: FFD ___°

PROSTHETIC:
- Type: [BK/AK], socket fit: good / loose / tight
- Skin under socket: intact / pressure areas at ___

ASSESSMENT:
- Level: [Transtibial / Transfemoral / etc.]
- Complications present: [list]
- Rehabilitation potential: [K-level]

PLAN:
- Wound management / compression therapy / physiotherapy
- Prosthetic review / socket revision
- Pain management (gabapentin/amitriptyline for phantom pain)
- Contralateral limb protection
- MDT referral: prosthetist / physio / OT / vascular / psychologist

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Key Documentation Pearls

1. Always document the contralateral limb - a pressure ulcer on the remaining foot will delay mobilisation despite satisfactory stump healing.
2. Contracture prevention starts at surgery - document flexion deformities early because they prevent prosthetic fitting.
3. Amputation is not failure - document it as a reconstructive procedure; studies show improved quality of life and satisfaction after appropriate amputation.
4. Energy expenditure matters - AKA requires ~50% more energy than BKA for ambulation; this directly affects whether a patient will achieve community walking.
5. Phantom pain - document its character, severity (VAS/NRS), and current management. It is real and requires treatment.
6. Nutritional and vascular status - document these for every wound/healing assessment.

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Lisfranc & Chopart - Orthopedic Exam Documentation

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PART 1: ANATOMY - THE LEVELS

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PART 2: LISFRANC

A. Lisfranc INJURY (Fracture-Dislocation)

Anatomy

• The tarsometatarsal (TMT) joint complex sits at the apex of the longitudinal arch - a high-stress zone
• The Lisfranc ligament runs from the medial cuneiform to the base of the 2nd metatarsal - the key stabiliser
• The 2nd metatarsal is recessed as the "keystone" between medial and lateral cuneiforms - providing transverse stability
• There is no intermetatarsal ligament between the 1st and 2nd metatarsal bases (hence the vulnerability)
• Three columns:
  • Medial: 1st MT + medial cuneiform + navicular facet
  • Middle: 2nd & 3rd MT + corresponding cuneiforms
  • Lateral: 4th & 5th MT + cuboid

Mechanism

• Forced plantarflexion of the midfoot (e.g. fall from height, horsefall - historically Jacques Lisfranc noted this in cavalry)
• Crush injury (heavy weight forcing foot flat)
• Low-energy: twisting in sport (often purely ligamentous "subtle" injury)

Classification (Myerson modification of Quénu-Küss / Hardcastle)

Clinical Examination

• Swelling over the dorsal midfoot (can be massive in high-energy)
• Plantar ecchymosis - a highly specific sign of significant ligamentous disruption; examine the sole carefully
• Inability to bear weight
• Gross deformity / step deformity visible in complete dislocations

• Tenderness directly over the TMT joints - palpate each joint individually:
  • 1st MT-medial cuneiform joint
  • 2nd MT-middle cuneiform joint (most commonly involved)
  • Lateral column (4th/5th MT-cuboid)
• Tenderness at the Lisfranc ligament (between medial cuneiform and 2nd MT base)

• Piano key test (axial load test): dorsally applied axial force along the shaft of each metatarsal - pain at the TMT joint = positive
• Passive pronation-abduction stress: reproduction of pain at midfoot
• Inability to perform single-leg heel rise (painful / weak)
• Check for compartment syndrome in high-energy injuries (tight compartments, pain on passive stretch of toes, sensory deficit)

Radiology Documentation

• Weight-bearing AP, oblique, and lateral X-rays of both feet (compare sides) - must be weight-bearing to detect subtle instability
• Key radiographic alignments to document:
  1. AP view: Medial shaft of 2nd MT aligns with medial border of middle cuneiform
  2. Oblique view: Medial border of 4th MT aligns with medial border of cuboid
  3. AP view: Medial border of 2nd MT aligns with medial border of 2nd cuneiform
  4. "Fleck sign": avulsion fracture at base of 2nd MT or medial cuneiform = pathognomonic of Lisfranc ligament avulsion
• CT foot if X-ray equivocal - superior for detecting subtle injuries and fracture comminution
• A standing radiograph of both feet on the same cassette allows comparison and highlights subtle diastasis

Treatment Options (document which was performed)

• Conservative (non-displaced, stable): Non-weight-bearing cast x 6 weeks
• ORIF (displaced): Screws or dorsal bridge plating across TMT joints
• Primary arthrodesis: For purely ligamentous injuries (recent RCT evidence favours this for medial column)
• Post-fixation: Hardware removal typically at 3-6 months if symptomatic

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B. Lisfranc AMPUTATION

Definition

Surgical Key Points (document intraoperatively)

• Uses a long plantar flap (preferred over fish-mouth dorsal-plantar flaps)
• 1st, 3rd, 4th, 5th TMT joints are disarticulated
• 2nd metatarsal is transected 2 cm distal to the medial cuneiform (not disarticulated, to preserve stability)
• Base of 5th metatarsal is preserved with peroneus brevis and tertius insertion to prevent inversion deformity during gait
• Achilles tendon lengthening (percutaneous) is performed to prevent equinus/equinovarus deformity
• Plantar fascia approximated to dorsal fascia/periosteum
• Plaster cast applied with talus in slight dorsiflexion

Critical Complication to Document and Examine For

Functional Outcome

• 85% of patients can ambulate without prosthesis for short distances (direct end-loading possible) - [systematic review, PMC9997832]
• Requires custom footwear with toe filler and rocker sole for longer distances
• Better functional outcome than transtibial amputation for low-demand patients

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PART 3: CHOPART

A. Chopart INJURY

Anatomy

• Talonavicular joint (medial)
• Calcaneocuboid joint (lateral)

Clinical Examination of Chopart Injury

• Swelling over the dorsal midfoot/hindfoot junction
• Bruising at mid-arch (dorsal and plantar)
• Deformity in severe dislocations (foot deviated relative to hindfoot)

• Tenderness over:
  • Talonavicular joint (just distal to the talar head, medial side)
  • Calcaneocuboid joint (lateral, distal to the anterior calcaneus)
• Palpate navicular tuberosity (common fracture site)
• Palpate anterior process of calcaneus (frequently fractured in Chopart injuries)

• Subtalar motion: restricted and painful (talocalcaneal joint stress)
• Midfoot abduction/adduction: reproduce pain at Chopart joint
• Weight-bearing: often impossible

• Weight-bearing X-rays: AP, oblique, lateral
• CT is mandatory for full characterisation of Chopart injuries (often underestimated on plain films)
• Document: talonavicular dislocation, calcaneocuboid subluxation, associated navicular/cuboid fractures

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B. Chopart AMPUTATION

Definition

Two Types

Surgical Key Points (document)

• Long plantar flap ("fish-mouth" with longer plantar limb)
• Achilles tendon tenectomy performed first (2 cm excised, sheath preserved) to prevent equinus
• Transverse tarsal joints are disarticulated by releasing dorsal and plantar ligaments
• Tibialis anterior + long extensor tendons transferred to the neck of the talus via bone tunnel or suture anchor
• Wound closed with fascial approximation plantarly and dorsally
• Well-padded dorsiflexion rigid dressing applied

Post-Operative Care

• Dorsiflexion rigid dressing changed intermittently for wound checks
• Sutures kept 4-6 weeks (longer than standard - poor vascularity)
• Splint in 5 degrees of dorsiflexion for 6-8 weeks to prevent equinus

Prosthetic / Orthotic Requirement

• Ankle-foot orthosis (AFO) in a rocker-sole shoe (e.g. running shoe) for ambulation
• Cannot use a simple toe filler like Lisfranc - needs custom AFO because the forefoot lever arm is absent

Complications - Examine For

Functional Outcome

• 74% ambulatory without prosthesis after modified Chopart (for short distances)
• Direct loading of the calcaneus is possible - an advantage over transtibial
• However, both Lisfranc and Chopart are controversial in vascular/diabetic patients due to high wound complication rates - Miller's Review of Orthopaedics 9th Ed.: "most experts recommend avoiding amputation at these levels if possible in patients with diabetes or vascular disease"

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PART 4: COMPARATIVE EXAM DOCUMENTATION TABLE

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PART 5: EXAMINATION DOCUMENTATION TEMPLATE

LISFRANC / CHOPART EXAMINATION

HISTORY:
- Level: [ ] Lisfranc disarticulation  [ ] Chopart (conventional / modified)
- Date of surgery:
- Indication: DM / vascular / trauma / tumour / infection
- Achilles released at surgery: yes / no
- Tendon transfer performed: yes / no

LOOK:
- Stump shape: adequate plantar flap / bulbous / necrotic flap
- Wound: healed / breakdown (___cm x ___cm) / sinus
- Skin: intact / callus / ulcer (location: ___; Wagner grade: ___)
- Alignment: plantigrade / equinus (degree: ___°) / varus / valgus
- Erythema / signs of infection: yes / no

FEEL:
- Tenderness: stump end / dorsum / plantar surface
- Neuroma: Tinel at ___
- Temperature: warm / cool (vascular concern)
- Oedema: present / absent

MOVE:
- Ankle dorsiflexion: ___° (Lisfranc stump)
- Hindfoot: neutral / equinus ___° / varus ___° (Chopart stump)
- Hip and knee ROM (full; document any contracture)

PROSTHETIC / ORTHOTIC:
- Lisfranc: custom shoe with toe filler - fit: good / poor
- Chopart: AFO with rocker sole - fit: good / poor; socket sores: yes / no

FUNCTIONAL:
- Weight-bearing: full / partial / non-weight-bearing
- Walking without prosthesis/orthosis: yes / no; distance: ___
- Walking with device: distance / terrain ability
- K-level: ___

INVESTIGATIONS:
- X-ray (standing): equinus / varus deformity; bony prominences
- Vascular: ABPI ___, TcPO2 ___ (if wound healing concern)
- Blood: CRP/WCC/ESR (if infection)

PLAN:
- [ ] Wound management
- [ ] Equinus correction (stretching / serial casting / surgical Achilles release)
- [ ] Varus correction (tibialis anterior tendon transfer to talus neck)
- [ ] Prosthetic / orthotic revision
- [ ] Re-amputation if healing failure (document level: Syme / BKA)
- [ ] Vascular review

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