Department of 

Veterans Affairs 

Health 

Veterans
 

Initiative
 

Traumatic Amputation 

And Prosthetics 

Independent Study Course 

Released: May 2002 

Sponsored by 

Department of Veterans Affairs 

Employee Education System 

Employee Education System 

This is a Veterans Health Administration System-Wide Training Program sponsored by 

the Department of Veterans Affairs Employee Education System and the Office of Public 

Health and Environmental Hazards, Department of Veterans Affairs. It was produced by 

the Employee Education System. 

i Traumatic Amputation 

And Prosthetics 

Table of Contents	 Page
 

Independent Study Outline and Program Description................................................................ ii
 

Program Content and Program Implementation........................................................................ iii
 

VA Application Procedures ....................................................................................................... iv 
 

Program Development (Planning Committee, Contributing Authors, 


Editorial Staff and others)........................................................................................................... v
 

AMA and ANCC Continuing Education Credits (Accreditation, 


Continuing Education Credit, Report of Training, Disclosure Statement 


and Americans with Disabilities Act Policy)............................................................................ vii
 

Content Materials 

Chapters 

1.	 Introduction..................................................................................................................... 1
 

2.	 A Veteran’s Perspective: A Soldier’s Story by Fred Downs ........................................... 2
 

3.	 Traumatic Amputations During Military Service by Paul J. Dougherty, 


Lieutenant Colonel, U.S. Army....................................................................................... 9
 

4.	 Rehabilitation Following Amputation by Katherine M. Flood, M.D. 


and Sheila Saliman, Ph.D. ............................................................................................ 18
 

5.	 Long-term Care of the Amputee by Katherine M. Flood, M.D. and 


Sheila Saliman, Ph.D. .................................................................................................. 28
 

6.	 Prosthetics Clinical Issues by John Milani ................................................................... 40
 

7.	 Prosthetics Administrative Issues by Fred Downs........................................................ 58
 

8.	 Primary Care Related to Veterans With Traumatic Amputations 


by Vic M. Malabonga, M.D. ......................................................................................... 61
 

9.	 APPENDICES .............................................................................................................. 65
 

Independent Study Test Questions for CME Credit............................................................ 87
 

Registration/Answer/Participant Satisfaction Form ........................................................... 95
 
ii Traumatic Amputation 

And Prosthetics 

Independent Study Outline
 

Purpose 

Objectives 

Target 

Audience 

Format 

This independent study course provides participants with information about patients 

experiencing traumatic amputation during military service, rehabilitation following 

amputation, long-term care of the amputee, prosthetic clinical and administrative issues 

and primary care related to veterans with traumatic amputations. 

After completing this independent study, participants should be able to: 

• recognize common problems associated with traumatic amputations; 

• identify methods of rehabilitation used with amputee patients; 

• explain long term care of amputee patients; 

• discuss prosthetics clinical issues; 

• discuss prosthetics administrative issues; and 

• understand primary care needs of traumatic amputee patients. 

This independent study is designed for Department of Veterans Affairs’ physicians, nurses and 

other primary health care providers. Other health care providers are encouraged to complete 

the study. 

This program is available in booklet form and on the web at http://vaww.sites.lrn.va.gov/vhi. 

Participants are to read the course materials and then take the course test. If you score 

70% or higher, you should be able to print your certificate from the website according to 

the instructions. 

Program Description
 

This program includes: 

• Independent study written material 

• Test for CME Credits 

• Program evaluation 

This activity has been planned and implemented in accordance with the Essentials and 

Standards of the Accreditation Council for Continuing Medical Education (ACCME) through 

the joint sponsorship of VA Employee Education System and Department of Veterans Affairs 

Office of Public Health and Environmental Hazards. The VA Employee Education System is 

accredited by the ACCME to provide continuing medical education for physicians. 
iii Traumatic Amputation 

And Prosthetics 

Program Content Materials 


Chapters 

1. 	 Introduction 

2. 	 A Veteran’s Perspective: A Soldier’s Story 

3. 	 Traumatic Amputations During Military Service 

4. 	 Rehabilitation Following Amputation 

5. 	 Long-term Care of the Amputee 

6. 	 Prosthetics Clinical Issues 

7. 	 Prosthetics Administrative Issues 

8. 	 Primary Care Related to Veterans With Traumatic Amputations 

9. 	 Appendices 

Independent Study Test Questions for CME Credit 

Independent Registration/Answer/Participant Satisfaction Form 

Program Implementation 

1.	 Read the program materials provided in this package. 

2.	 Complete the CME test questions. 

3.	 Complete the program evaluation form. 

4.	 A passing score of 70% or higher on the CME test is required to receive credit. This test 

may be retaken. 

5.	 The estimated study time for this program is 4 hours. 

6.	 For expediency, you may wish to register, take the CME test, and complete the program 

evaluation using the VA Intranet. The address is http://vaww.sites.lrn.va.gov/vhi. 

Note: If you experience difficulty reaching this website, please contact Mr. Jeffrey Henry at 

(847) 699-1900 extension 81736, your local computer support staff or librarian for assistance. 
iv Traumatic Amputation 

And Prosthetics 

VA Application Procedures
 

To receive credit for this course, you must read the independent study materials, complete the 

Registration Form, take the CME test and complete the Independent Study Program Evaluation. 

You may submit the Registration/Independent Study Test Answers and Program Evaluation 

responses in either of two ways: by using the VA website if you have access to Internet 

Explorer 4.0 or Netscape 4.0 or higher, or by using the independent study booklet and 

included form. 

For expediency, you may wish to register, take the CME test, and complete the program 

evaluation using the VA Intranet. The address is 

http://vaww.sites.lrn.va.gov/vhi. 

Note: If you experience difficulty reaching this website please contact Mr. Jeffery Henry at 

(847) 688-1900 extension 81736, your local computer support staff or librarian for assistance. 

After you take the test, you will receive immediate feedback as to pass or fail. You will be 

allowed to retake the test. Upon passing the test and completing the program evaluation, 

you will be able to immediately print your certificate according to instructions. 

If you are using the Registration/Answer/Evaluation Form (two sided) at the back of the 

independent study booklet, please send the completed form within two weeks after reading 

the material to: 

Employee Education Resource Center
 

Attn: SDU
 

Medical Forum, Suite 500
 

950 North 22nd Street
 

Birmingham, AL 35203-5300
 

If you have attained a passing score of 70% or higher, a certificate will be mailed to you 

approximately 6-8 weeks after your test has been graded. The test may be retaken. 

For extra copies of this independent study or for other VHI Independent Study Modules, 

please contact your facility education contact person. 

If you have questions or special needs concerning this independent study, please contact: John 

C. Whatley, Ph.D. at (205) 731-1812 extension 312 or e-mail at John.Whatley@lrn.va.gov. 

Note: This program no longer will be authorized for CME credit after December 2003. 
v Traumatic Amputation 

And Prosthetics 

Program Development: Planning Committee and Contributing Authors 


Ralph DePalma, M.D. 

Director, Surgical Service 

VA Central Office 

Washington, DC 

Paul J. Dougherty 

Lieutenant Colonel 

Medical Corps U.S. Army 

William Beaumont Army Medical Center 

El Paso, TX 

Frederick Downs, Jr. 

Chief Consultant 

Prosthetics and Sensory Aids Service 

Department of Veterans Affairs 

Washington, DC 

Katherine M. Flood, M.D. 

Program Leader 

Physical Medicine and Rehabilitation Services 

VA Pittsburgh Healthcare System 

Pittsburgh, PA 

Eleanor Haven, R.N., M.Ed. 

Education Service Representative 

Birmingham Employee Education Resource Center 

Birmingham, AL 

Pamela Hebert, Dr. P.H. 

Patient Education Coordinator 

Birmingham Employee Education Resource Center 

Birmingham, AL 

Susan H. Mather, M.D., M.P.H. 

Chief Public Health & Environmental Hazards Officer 

Office of Public Health and Environmental Hazards 

VA Central Office 

Washington, DC 

Vic M. Malabonga, M.D. 

Physician 

Central Texas VHCS 

Temple, TX 

John R. Milani 

Chief 

Prosthetics Laboratory 

VA Medical Center 

New York, NY 

Neil S. Otchin, M.D. 

Program Chief for Clinical Matters 

Office of Public Health and Environmental Hazards 

VA Central Office 

Washington, DC 

Sheila M. Saliman, Ph.D. 

Clinical Psychologist 

VA Medical Center 

Denver, CO 

John C. Whatley, Ph.D. 

Program Manager 

Birmingham Employee Education Resource Center 

Birmingham, AL 
vi Traumatic Amputation 

And Prosthetics 

Program Development continued 

Editorial Staff 

Editors 

Susan H. Mather, M.D., M.P.H. 

Chief Public Health & Environmental Hazards Officer 

Office of Public Health and Environmental Hazards 

VA Central Office 

Washington, DC 

Neil S. Otchin, M.D. 

Program Chief for Clinical Matters 

Office of Public Health and Environmental Hazards 

VA Central Office 

Washington, DC 

Editorial Assistant 

Dorothy R. Hartung 

Program Specialist 

Office of Public Health and Environmental Hazards 

VA Central Office 

Washington, DC 

Program Director 

John C. Whatley, Ph.D. 

Program Manager 

Birmingham Employee Education Resource Center 

Birmingham, AL 

Program Assistant 

Donna K. Burnett 

Education Technician 

Birmingham Employee Education Resource Center 

Birmingham, AL 

Graphics and Media Development 

R. John Brix, B.F.A. 

Visual Information Specialist 

Minneapolis Employee Education Resource Center 

Minneapolis, MN 

Jeffery L. Henry 

Media Producer, EES 

North Chicago VA Medical Center 

North Chicago, IL 

Journal Summaries prepared by 

Michael Howe, M.S.L.S 

Director, AIDS Information Center 

VA Central Office 

Washington DC 
vii Traumatic Amputation 

And Prosthetics 

AMA and ANCC Continuing Education Credits
 

Accreditation 

The VA Employee Education System is accredited by the Accreditation Council for 

Continuing Medical Education to sponsor continuing medical education for physicians. The 

VA Employee Education System takes responsibility for the content, quality and scientific 

integrity of this CME activity. 

The VA Employee Education System is accredited as a provider of continuing education in 

nursing by the American Nurses Credentialing Center’s Commission on Accreditation. 

Continuing Education Credit 

The VA Employee Education System designates this education activity for a maximum 

of 4 hours in Category 1 credit towards the American Medical Association Physicians’ 

Recognition Award (each physician should claim only those hours of credit that he/she 

actually spent in the education activity). 

The VA Employee Education System designates this education activity for 4.8 contact hours 

as determined by the standards of the American Nurses Credentialing Center’s Commission 

on Accreditation. 

The VA Employee Education System maintains responsibility for the program. A certificate 

of attendance will be awarded to VA employees and accreditation records will be on file at the 

VA Employee Education System. In order to receive continuing education credit, participants 

must attain a passing score of 70%, or higher on the test. 

Report of Training 

It is the program participant’s responsibility to ensure that this training is documented in the 

appropriate location according to his/her locally prescribed process. 

Disclosure Statement 

The VA Employee Education System (EES) must ensure balance, independence, objectivity and 

scientific rigor to all VA EES educational activities. The intent of this disclosure is not to prevent 

faculty/writers/editors with a significant financial or other relationship from presenting materials, 

but rather to provide the participant with information on which they can make their own judgments. It remains for the participant to determine whether the faculty/writers/editors interests or 
viii Traumatic Amputation 

And Prosthetics 

relationships influence the materials presented with regard to exposition or conclusion. When an 

unapproved use of an FDA-approved drug or medical device, or an investigational product not yet 

FDA-approved for any purpose is mentioned, EES requires disclosure to the participants. Each 

faculty/writer/editor reported no disclosable relationships or FDA issues. 

Americans with Disabilities Act Policy 

The Employee Education System wishes to ensure no individual with a disability is excluded, 

denied services, segregated or otherwise treated differently from other individuals completing 

this program because of the absence of auxiliary aids and services. If you require any special 

arrangements to complete this educational program, please contact John C. Whatley, Ph.D., 

Program Manager, Birmingham Employee Education Resource System, Medical Forum 

Building, Suite 500, 950 North 22nd Street, Birmingham, Alabama, 35203, or by telephone 

(205) 731-1812 extension 312. 
1 Traumatic Amputation 

And Prosthetics 

1. INTRODUCTION 


A veteran with a traumatic amputation presents a stark reminder of the tragedy of warfare. 

Battlefield trauma has necessitated amputations since even before the establishment of military 

medicine. While the advent of antibiotics, prompt trauma care, and vascular repairs have 

reduced the need for some amputations, even today, these continue to be a risk for American 

military personnel carrying out combat missions. 

Almost 21,000 major amputations were documented in the Union Army during the Civil War. 

Over 4,000 amputations were performed on U.S. service personnel during World War I and 

almost 15,000 service members had major amputations during World War II. During the 

Korean War, over 1,000 Army personnel suffered traumatic amputations, while others lost 

body parts due to frostbite and other cold injuries. An estimated 6,000 amputations occurred 

during the Vietnam War and 15 were documented during the Gulf War. Even during peacetime, an estimated 20 members of the Army per year experience traumatic amputations. 

Clearly the VA has a special obligation to ensure that individuals with service-related traumatic 

amputations receive high-quality care at our facilities. 

Patients with diabetes and vascular disease comprise the majority of amputee veterans and 

individuals at risk for amputation treated in the VA system. These patients are familiar to 

many VA health care providers and the VA recently has developed a CD-ROM based training 

program titled “Preservation-Amputation Care and Treatment” (PACT), which provides 

recommendations for primary care staff involved in their care. 

Health care professionals may be less familiar with the treatment needs of individuals with 

traumatic amputations. For instance, such patients usually are younger at the time of amputation 

and are more likely to have upper extremity amputations than older amputee veterans with 

diabetes and vascular disease. Also, a larger percentage may be employed and participate in 

sports or other activities, requiring specially designed prosthetic devices. 

This program is intended to provide information to primary health care providers and others 

so they can better care for veterans with traumatic amputations, including prevention and 

recognition of complications and prompt referral for specialty care when needed. 

We also would like to encourage VA staff to complete other VHI educational modules and 

the PACT program. For additional information, please contact your facility’s Educational 

Coordinator. 
 

 

2 Traumatic Amputation 

And Prosthetics 

2. A VETERAN’S PERSPECTIVE 


A Soldier’s Story by Fred Downs 

I was a 23-year-old Army Infantry Second Lieutenant in Vietnam when I stepped on a 

Bounding Mine we called a “Bouncing Betty.” The mine was designed to bound out of the 

ground, when triggered, and explode at waist height. It was designed to kill the man who 

stepped on it. The mine had a killing radius of 30 meters. 

I had just looked at the watch on my left wrist to determine if the combat patrol I was leading 

was on schedule. The Army issue watch read 0745 hours on January 11, 1968. The sun had 

been up for an hour and a half. My orders that morning were to lead a combat patrol into a 

war-ravaged deserted village in an area through which we had been fighting back and forth 

for over a week. The village was located next to a beautiful white sandy beach bordering 

the South China Sea in the central part of Vietnam. The bamboo and mud homes we called 

“Hootches” were burned, smoking hulks, or torn, shattered wrecks. One of our fighter-bombers 

had dropped a 1,000-pound bomb in the middle of the village a few days earlier, leaving 

a gigantic crater that became a refuge when we took incoming fire. The debris of battle 

lay everywhere. 

The operational area, Quang Ngh Province in Central Vietnam near the DMZ, was under the 

control of the Viet Cong, and would prove to be one of five provinces in South Vietnam that 

would never be under the control of the Americans or South Vietnamese government. The Viet 

Cong was strongly supported by the people in the Province. Twenty years after the war, when 

I returned to Vietnam, I met the Province Leader who explained to me that he left home to 

become an officer in the North Vietnamese Army, but his brothers and cousins stayed in the 

Province to become Viet Cong Guerrilla fighters. He told me they were all committed to 

fighting to the death. His comments helped me understand why 20 years earlier, Quang Ngh 

Province was a very tough area for U.S. to occupy. The enemy was all around and they were 

determined never to be defeated. 

In January 1968, our Battalion, in which I was the Platoon Leader of the 1st Platoon, Delta 

Company, the 1/14 Infantry, 3rd Brigade, 4th Infantry Division, was given the task of trying to 

regain control of a section of the Province and had been inserted into the area in a combat 

assault by helicopter “Slicks” and “Gun Ships” the previous week. The Battalion had taken 

numerous causalities since the assault. My platoon had had numerous firefights and encounters 

with the Viet Cong. We had fought through the area around the village the day before, killing a 

squad of Viet Cong, flushing them out of their tunnels with our “Tunnel Rats” if we could, or 

engaging them in brief firefights in the hedgerows and thick jungle growth. Other squads of 

Viet Cong engaged our units with gunfire and mortar attacks. Four of my men had been 
3 Traumatic Amputation 

And Prosthetics 

wounded by booby traps and mines. Three days earlier, I had been knocked to the ground 

when one of my men stepped in front of me to enter a hedgerow and triggered a land mine. 

I was blown off my feet and stunned, but was not otherwise injured. Two soldiers were 

wounded and had to be air evaced out with a “Dust Off” helicopter. 

Although shaken, I continued to lead the platoon. I had been “in-country” six months, and 

had already received four wounds during that time. They were considered minor or “flesh 

wounds” because they were not serious enough to take me out of the field. My platoon medic, 

an 18-year-old kid from Texas whom everyone called Doc, would patch me up and we would 

continue with the combat patrol. The first time I was wounded was at night during an artillery 

barrage; a spent piece of artillery shrapnel grazed my head and knocked me down. The second 

wound I received was when a North Vietnamese Army (NVA) soldier popped out of a hole in 

the jungle floor 30 feet in front of me and fired at my head. The bullet grazed the tip of my left 

ear. The third wound was from grenade shrapnel. One of my soldiers and I were in a furious 

close-in fight with three NVA soldiers when a hand grenade exploded, sending a piece of 

shrapnel into my upper left arm. The fourth wound, actually a series of multiple flesh wounds, 

occurred when my platoon was ambushed in the jungle. During the course of the ambush, I 

received rock shrapnel wounds in the face when an enemy machine gun fired into the rock 

next to my face. A few minutes later both of my hips were bruised when bullets slammed into 

the ammo pouches carried around my waist and bullets tore through my jungle fatigues. I 

was knocked to the ground when my boot heel was hit with a bullet. Later in the ambush, 

a machine gun bullet grazed my left hand. 

I was so surprised each time I was wounded. I would feel a sharp pain and was astonished to 

see blood flowing from my body. “I’ve been hit!” I would think. “This can’t be happening to 

me!” I had seen many of our men killed and others who had been wounded to various degrees. 

Some had their limbs torn off or had huge gaping wounds in their chest or stomach. Head 

wounds were more frightening when the skull was opened up to expose the brain. Other men 

just had a gunshot hole or shrapnel wounds. I always thought bad things happen to other men, 

but never to me. I was lucky. 

My luck ran out on January 11, 1968. My platoon was strung out in a long line as we 

entered the abandoned village. I carried my M-16 rifle in my right hand. I inhaled a drag 

off a cigarette and looked at the watch on my left wrist. 0745 hours. 

I never heard the explosion. Instantly I was flying through the air, surrounded in total silence 

as black clouds of powder flew by me. I threw my arms out in front to catch myself and was 

horror stricken to see my left arm was gone above the elbow. “Oh God, Oh God!” my mind 

flashed. A jagged white bone stuck out of the stump. Shreds of bloody muscle, tendons and 

flesh whipped back from the stump. Sickened by the sight, I turned my head to see in terror 
4 Traumatic Amputation 

And Prosthetics 

that my right arm was also shredded to the bone. My horror was intensified as I saw the two 

brilliantly white forearm bones from my wrist to the elbow. They were lying in a bed of 

bloody flesh. My stomach heaved in revulsion. 

Strangely enough, my mind struggled with the swirl of shocking events, but seemed to split 

into parallel operations so that it could continue to function normally. My thoughts continued 

as a combat officer, analyzing what was happening, I deduced I had stepped on a “Bouncing 

Betty” land mine and I wondered if this was the beginning of another ambush. 

I landed on my feet and staggered forward a few steps before falling forward. I attempted to 

land on my left shoulder so my stump and arm would not be jammed into the earth. I rolled 

onto my back to hold my stump and arm out of the dirt. I did not realize the “Bouncing Betty,” 

which had exploded next to my left hip, had caused massive damage to my waist, buttocks, 

legs and feet. I lay there, bleeding profusely into the ground. 

I was covered in blood and dirt. I stared in fascination at the white splintered bone jutting from 

my left stump. Gorge raised in my throat as depression and abject despair swept over me in 

waves. I tried to lift my right arm out of the dirt, but I couldn’t control movement. The arm 

flopped grotesquely; the muscles, tendons and nerves destroyed or too damaged to respond 

properly. More waves of depression swept through me. 

I looked around, realizing how silent it was. Both my eardrums had been ripped by the blast. 

Sound began to return. I heard men screaming. How strange that I didn’t feel great pain, only a 

high intensity tingling. I was quiet, thinking about what was happening to me. Maybe I had 

had so many wounds my brain was overloaded with so many pain signals, like a circuit board 

with too many signals, that none of the signals were getting through. 

I looked back towards my platoon. The Radio/Telephone Operator, who had been walking 

behind me, was sitting in a pool of blood, his uniform covered with blood. He was screaming. 

I heard another man screaming. Who is he, I wondered? There was activity all around me as 

some men rushed to the wounded and others took up defensive positions against attack. 

One of the M-60 Machine Gunners ran up next to me and pulled out his knife. He cut away 

my web gear with the four hand grenades fastened to it. He asked what he could do for me. 

I told him to go over, pick up my arm, and bring it back to me. I told him and the other men 

gathered around me that I did not want to leave my arm in the village because I did not want 

the enemy to know they had severely wounded me. 
 

5 Traumatic Amputation 

And Prosthetics 

The Machine Gunner ran over to where my arm was laying and gingerly picked it up. He 

carried it back, laid it on my stomach, lifted my right arm out of the dirt and draped it across 

my severed arm. I thanked him. My platoon sergeant, squad leaders, and some of the men 

circled around where I lay to talk to me. The medic was busy patching up the other men. I was 

badly wounded and realized I would be the last one to be cared for by him. He had to first treat 

the men he thought would survive, and treat me last. 

I was astonished when the thought occurred to me that I was dying. The medic ran to me and 

dropped to his knees, fumbling in his medic bag for a capsule of morphine, ripping off the 

cover and pushing the needle into my arm. He pushed the empty capsule’s needle into the 

lapels of my fatigue shirt and bent the needle back to hold it securely so the medical staff back 

in the rear would know how many shots of morphine I had received. I asked him how bad I 

was wounded. He replied I was in pretty bad shape. 

The “Dust-Off” helicopter, called in by my platoon sergeant, landed nearby and the rotor wash 

blew a cloud of sand and dirt over us. Two men ran to me, unfolded a stretcher, and laid it next 

to me. I was loaded onto the stretcher. As the men hurried towards the open doors of the 

“Dust-Off,” the man carrying the head end of the stretcher began to vomit and he dropped the 

stretcher, jarring my whole body. Another man took over carrying. They hooked my litter into 

the bottom of a 3-tier rack in the helicopter. The pilot lifted off with three of the wounded in 

tiers and three lying on the floor of the helicopter. 

There were six men wounded when I stepped on the “Bouncing Betty.” The Radio-Telephone 

Operator, who was walking behind me, was shredded in the front of his body from the waist 

down. Another man was hit in the stomach with shrapnel; he was the other man who had been 

screaming. The point man was hit in the back of the knee, and two other men were hit in their 

bodies by shrapnel. 

Blood dripped on me from the two men in the stretchers above. The pilot turned to look at me. 

He studied me for a minute; I saw his lips move as he talked into the helmet’s microphone. 

The medic who flew with the crew was sitting behind the pilot. He nodded and leaned down 

close to my head to yell above the cacophonic noise of the helicopter, “Ten minutes to Chi Lai. 

Can you make it?” I nodded my head yes. He lit a cigarette and stuck it in my mouth. He 

yelled, “Can I do anything for you?” I yelled back “Yeah, cut off my boot. My foot hurts 

like hell.” 

For some reason, the pain from a shrapnel wound in my foot was the only specific pain signal 

that was getting through to my brain. The medic cut off my boot to relieve the pain. I struggled 

to stay conscious because I knew that men who lost consciousness would die faster than men 

who did not. I was determined to make it back to the surgical unit in the rear, where I was 
6 Traumatic Amputation 

And Prosthetics 

confident the medical team would save my life. I would stay alert by paying close attention to 

everything around me. 

The “Dust-Off” jolted as it landed hard on the pad. My litter was lifted out of the helicopter 

amidst much commotion of men talking and jostling me around. I was loaded into a square 

truck and after a short ride, my litter was carried into a room where men and women in white 

gowns and masks were standing. They were in groups around different operating tables. I 

guessed they were waiting for the six wounded men. I was transferred to an operating table 

and the circle of white closed in around me in a bustle of activity. I was surprised when two 

nurses, one on each side, started cutting off my remaining boot, sock, and clothes with scissors. 

I had never seen anyone’s clothes cut off. 

I stared in sickening fascination as an orderly removed my wedding ring and watch from my 

severed arm and dropped the arm into a plastic bag. I thought the bloody, mangled arm looked 

awful, but the wrist and hand looked pretty good. I wondered if they would sew it back on. 

There were two doctors standing on each side of my shoulders. They were talking to each 

other. The one on my left said, ”Who the hell tied this God Damn tourniquet.” I watched in 

amazement as he used a scalpel to cut through the flesh on my stump down to a blood vessel, 

which he tied off. I thought, “Jesus Christ! I didn’t even feel that. I must be in really bad shape.” 

There were people standing shoulder-to-shoulder all around the table. I looked at each one of 

the masked strangers, busy with their manipulations of my body. Cleaning, wiping, picking 

ragged clothing off me, probing with instruments, talking to each other and exclaiming when 

they found another wound. 

A Red Cross lady stood at the foot of the table holding a clipboard and pencil. She kept asking 

me to tell her my name, rank and serial number. I kept repeating it. “My name is Frederick 

Downs, Jr., Second Lieutenant, 05337689.” I finally yelled, “What’s the matter with your God 

Damn ears?”, not realizing she was trying to keep me conscious as long as possible. 

I remembered something that was important. My brother was on the USS America aircraft 

carrier and he needed to know I was wounded. “Tell my brother, Mike, I have been wounded. 

He is on the USS ....” I lost consciousness as my heart stopped. 

Later, I would be known as the Lieutenant they brought back from the dead when they used 

closed heart massage and direct IV to get my heart going again. But all I knew when I became 

conscious after the surgery was the most unbelievable, excruciating pain imaginable over most 

of my body including left stump, right arm, left hip, both buttocks, back of both legs and left 

foot. God! All the nerves in my body were sending searing torrents of pain to my brain. The 
7 Traumatic Amputation 

And Prosthetics 

morphine was a weak barrier to that much pain. I was terrified that my arm was gone. Tears 

ran down my cheek. I gritted my teeth against the waves of pain. I was frantic. This could not 

be happening to me. This was a terrible thing that had happened. I was so depressed with the 

realization that I would be crippled the rest of my life. “Oh God,” I prayed for another chance 

to go back and take a different path from the land mine, but I knew it was impossible. My fate 

as a cripple was a final, irrevocable, inescapable future. 

I cried for more painkiller, but the nurses explained I was only allowed so much. Otherwise, 

I would become addicted to the drug. I didn’t care. I needed to survive the pain now, or I 

wouldn’t live at all. 

But I did live and I survived weeks and months of reconstructive surgery, misery and pain. 

The pain was excruciating and there was never a respite from it. I was air evaced from military 

hospital to military hospital in a continuous chain through Vietnam, the Philippines and Japan, 

and finally ended up at Fitzsimons Army Hospital near Denver, Colorado, a month after I was 

wounded. I hated the moves because they jostled my body adding to the pain, and twice I 

nearly died during the flights. After each move, the new clinical staff inflicted more pain on 

me as they debrided the wounds twice a day, and performed operation after operation in their 

attempts to save my right arm and legs. There were operations for skin grafts and operations 

for pedicle grafts. I developed a love/hate feeling towards all medical staff. 

In addition to all the other pain, I suffered from Phantom pain. This was a strange sensation of 

my arm and hand, feeling as if it was still there. The pain was a sharp tingling, similar to the 

painful tingling one feels when they hit their crazy bone, only this did not go away. The pain 

was constant. My hand felt as if it were out on the end of my arm, like it always was. As the 

weeks and months progressed, the pain became bearable and oddly enough, my hand drew 

slowly back until it felt as if it were right at the end of my stump. I decided early on that the 

Phantom pain was caused by the severed nerve endings sending signals to the cells in the area 

around the severed nerve end. My mind still sent signals to my arm and hand, but when the 

signals reached the end of the severed nerves, those signals flashed around like a live electric 

wire that is knocked down in a storm and thrashes about, throwing sparks in all directions. 

I got used to it within half a year, but the Phantom pain still flares up occasionally. 

The surgeons at the various military hospitals patched my body together so the right arm and 

both legs functioned again. At Fitzsimons Army Hospital, I was introduced to my first artificial arm. I hated everything about it. It was ugly, uncomfortable and difficult to operate. No 

one prepared me for it. I was led by a physical therapist one day over to the limb shop behind 

the main hospital and fitted for a socket. The team of doctors had prescribed an artificial limb 

for me, but no one had explained anything about it. I learned very little from the clinical staff 

about how to use my artificial arm or how to adapt to using it day to day. I learned most about 
8 Traumatic Amputation 

And Prosthetics 

the arm from fellow amputees. Fitzsimons had hundreds of amputees in 1968, and we helped
 

each other adapt to our new, unfortunate circumstances. 


When I first put the arm on, I was again depressed at how alien it felt and looked. The plastic
 

and steel arm did not look natural or feel comfortable. However, I was determined to do 


everything I used to do. That meant I would force myself to learn to use the arm and I would
 

not let myself be embarrassed to wear it in public. 


I quickly adjusted to wearing the arm and have worn an above-elbow prosthetic arm for 


33 years. I married a woman I met while at Fitzsimons and we have two daughters. I have a
 

pilot’s license, drive a car and do just about anything I did with two arms. A person’s disability
 

is based on their frame of mind. I decided from the beginning that I was not going to let losing
 

a limb get me down. I was determined to enjoy my life, and I have had a good life with lots of
 

friends and family. 


Fourteen years after that fateful day when I was brought into the combat surgical unit in Vietnam,
 

I met Dr. Dave Pilcher, the surgeon who asked “Who tied this God Damn tourniquet?”. 


He had asked me to lecture to his class of residents where he taught Trauma Surgery at the
 

Medical School at the University of Vermont. The residents laughed when I related the incident,
 

because he was famous for his outbursts when people tied a bad tourniquet. I thought how
 

lucky I had been to have had Dr. Pilcher on duty the day I lost my arm. His skill and surgical
 

techniques in the operating room saved my life and contributed to the salvage of my right arm
 

and both my legs. 


He was part of the larger team that saved my life. That team had included the field combat
 

medic, the medivac helicopter crew and the medical staff at the 2nd Surg, and 85th Evac. 


Every single person was important to my survival. 

9 Traumatic Amputation 

And Prosthetics 

3. TRAUMATIC AMPUTATIONS DURING MILITARY SERVICE 

(INCLUDING ISSUES OF SURGICAL REVISION AND LIMB SALVAGE) 

by Paul J. Dougherty, Lieutenant Colonel, Medical Corps, United States Army 

INTRODUCTION 

One of the most graphic reminders of the destructiveness of war is the amputee. Every major 

conflict in the 20th century has seen large numbers of amputee veterans as the result of battle. 

During World War I, there were approximately 2,300 major amputee veterans who returned 

home from France (a major amputation is one which is proximal to the wrist or ankle). 1 

During World War II, this figure reached approximately 18,000, including U.S. Navy and 

Marine Corps amputee veterans. 2 The Korean War saw approximately 1,500 amputee veterans as a result of battle casualties. It is unknown how many patients sustained amputations 

due to battle injuries from the Vietnam War. Estimates range as high as 6,000 for all services. 3 

Amputee veterans are a major clinical problem for not only the initial care of the patient, but 

also through the patient’s rehabilitation and eventual prosthetic fitting and long term follow-up 

at the Department of Veterans’Affairs (VA) Medical Center. 

Special features of military surgery include having initial surgery performed at an austere 

forward hospital, some more advanced than others, and transportation of the patient through 

various echelons of care until the patient arrives back in the United States. 1-8 This is a much 

different situation than taking care of a patient at a trauma center in the United States, which 

has virtually unlimited resources. Military surgery is unique in the sense that we are simultaneously trying to provide care as well as moving the patient back through the evacuation 

chain. This necessitates special care that is not often seen in civilian trauma centers. 

Amputee centers were initiated by the U.S. Army in World War I and II in order to consolidate 

the care of surgeons, prosthetists, nurses and therapists and provide consistent care for 

patients. 1, 2 Only one U.S. Army hospital, Valley Forge Army General Hospital, maintained 

a separate amputee service during the Vietnam War.6 The U.S. Navy had two amputee centers 

in World War II and maintained an active amputee program through the Vietnam War (Naval 

Hospitals Oakland and Philadelphia). Experience of World War I, World War II, the Korean 

War and the Vietnam War has shown that patients benefit by being moved to a site of definitive 

care as soon as possible. 
 

10 Traumatic Amputation 

And Prosthetics 

Epidemiology 

Amputations sustained in battle are severe injuries. Battle casualties are divided into “wounded 

in action,” “killed in action,” and “died of wounds.” “Wounded in action” are those patients 

who reach hospitalization alive, “killed in action” are those patients who die before hospitalization, and those who “die of wounds” are patients who die after being admitted into a medical 

treatment facility. The mortality from a significant amputation remains high. In the Bougainville 

campaign during World War II, the mortality rate was approximately 30 percent for “killed 

in action” and “wounded in action” for patients who sustained an amputation. 9 One study 

from the Vietnam War found that there was approximately 35 percent mortality with amputee 

veterans on the battlefield. From this same study, approximately half of those who died of 

extremity wounds on the battlefield did so because of a traumatic amputation. 10 

Final levels of amputations have changed over time. During World War I, the transfemoral 

amputee was the most common. 1 During World War II and afterwards, the transtibial amputee 

became the most common. 2 The transtibial amputee also was the most common level of final 

amputation during the Korean and Vietnam wars and remains the most common level of battle 

amputee from other areas of conflict seen today.6,11 

TABLE I
 

LEVELS OF AMPUTATION
 

Level of 

Amputation 

WWI 

(1) 

WWII 

(12) 

RVN 

(6) 

Number % Number % Number % 

Transhumeral 556 24.2 203 6.70 57 

(all UE) 

13.9 

Forearm 215 9.3 243 6.80 

Hip 7 0.02 

Transfemoral 1,145 49.9 1,049 35.00 109 26.5 

Transtibial 335 14.5 1,487 49.80 175 42.6 

Multiple 44 199 7.00 69 16.8 

World War I data excludes 95 knee disarticulations. 
11 Traumatic Amputation 

And Prosthetics 

Explosive munitions were by far the greatest cause of wounds leading to amputation during 

the Vietnam War. Land mines/booby traps were the cause in 64% of the patients, followed by 

artillery/mortar/grenades/rockets in 18% of patients. 

INDICATIONS FOR SURGERY 

Amputations at forward hospitals are performed to save life and limb. The surgical indications 

for amputations have shifted with time. During World War I, 25.5 % of amputations were 

due to the direct effects of trauma and 74.5 % for infection.1 During World War II in the 

Mediterranean theater, amputations were due to the effects of trauma in 75 % of cases, infection 

9.5 % (a reverse of the previous rate) and vascular injuries in 14.5 %.4 Data on 484 patients 

received at Valley Forge Army General Hospital showed that indications for surgery were 

trauma in 89.5% of the cases, failed vascular repair for 8.4% and infection 1.9%. The wounds 

leading to amputation often are not discrete involving an isolated area. Explosive munitions 

often damage the entire limb, and there are often wounds to other anatomical regions, as well. 

LIMB SALVAGE ON THE BATTLEFIELD 

Several authors have analyzed amputations performed late after a patient was transported from 

Vietnam. Bagg, cited by Burkhalter, found that 13 of two hundred tibia fractures received at 

the 106th General Hospital in Japan from Vietnam required an amputation: (10 below knee and 

three above knee).13 

Schmitt and Armstrong found that open fractures with vascular injury was the cause for nearly 

half (48%) of the late amputations seen in his facility during the Vietnam War, followed by 

vascular injuries alone (25%), fractures only (17%), and soft tissue infection (10%).14 

Recent interest has focused on being able to determine which extremities will require amputation 

and which will fare best with limb salvage. Bosse et al., has reported on results of 556 limbs 

with “high energy” trauma of 539 patients enrolled in the multi-center Lower Extremity 

Assessment Project, prospectively evaluating published lower extremity injury severity scores 

with regards to sensitivity and specificity in predicting amputations. There were 63 immediate 

amputations and 86 delayed amputations. Threshold scores were found to have low sensitivity 

but relatively high specificity and could not be recommended by the authors as criteria to 

amputate a limb. Thus far, there is no scale that can reliably predict the outcome of a severely 

traumatized limb. 15 
12 Traumatic Amputation 

And Prosthetics 

It is not clear if new techniques developed since the Vietnam War will improve limb survival 

and function for patients injured on the battlefield. Vascular repair has been used since the 

Korean War. The open fracture with vascular injury can be treated by fracture stabilization and 

then repair of the vascular injury. Use of an external fixator is indicated to provide access to 

check the vascular status of the limb. 

Using local or free flaps for soft tissue coverage should never be attempted in a battlefield 

hospital. Flaps do poorly in the evacuation chain. Patients who will be evacuated out of theater 

should not have extensive surgery performed for soft tissue coverage before evacuation. 

Attempts at coverage should only be performed when a patient is in a stable environment and 

will not be moved. 

Figure 1 

TECHNIQUE 

The traditional technique for performing amputations on the battlefield has been the open 

circular technique (see Figure 1). 1-8 With a formal open circular technique, a circumferential 

incision is made at the lowest viable level of soft tissue through skin and subcutaneous fat. 

This level is allowed to retract and move proximally, and the muscle is incised. Named blood 

vessels are isolated and doubly ligated. Named nerves are isolated, stretched and have a single 

tie placed. The nerve is then divided and allowed to retract. The bone is then cut at the lowest 

level. A residual limb should have a concave appearance at the end of the formal open circular 

technique. 
13 Traumatic Amputation 

And Prosthetics 

The usual patient who needs an urgent amputation already has a partial or complete traumatic 

amputation, which requires only completion of the amputation. The amputation is completed 

at the lowest viable level of soft tissue. No consideration is given to final length of the limb or 

prosthetic fitting at the initial surgical procedure. All foreign material that is readily accessible, as well as dirt and debris, should be removed and the wound lavaged. Patients who have 

the open circular technique require special post-operative care not commonly taught in civilian 

residencies. At the conclusion of the case, the patient should be placed in skin traction (See 

Figure 2). This is done to prevent retraction of the skin and bone protrusion. The open circular 

technique must be used in conjunction with skin traction post-operatively throughout the 

evacuation chain. 

Figure 2 

Skin traction is applied by putting a tincture of benzoin or similar adhesive over the distal 

six inches or so of the residual limb. A dressing is applied to the wound and the stockinet is 

pulled forward. The amount of traction put on is only to overcome the elastic recoil of skin 

(about two-four pounds for a transtibial amputee). This technique is not skeletal traction, as 

one would use for the reduction of fractures. Just before evacuation out of theater the patient 

should be placed in a transportation cast. A transportation cast also should have a Cramer 

ladder splint as an outrigger and the stockinet should be connected to this (See Figure 3). 

Recent discussion by ICRC and Red Cross doctors about construction of flaps and performing 

delayed primary closure at a second sitting have not given as reliable results as the open 

circular technique. 11, 16 
14 Traumatic Amputation 

And Prosthetics 

The unique features of military surgery on 

the battlefield necessitate the use of the 

“open circular” techniques to prevent 

infection. A survey by LaNoue during the 

Vietnam War outlined the safety of the 

open technique. Of 230 patients who had 

transtibial amputations and were evacuated 

back to the United States, showed that 59 

% were left open and 41 % were closed in 

theater. Of those that were closed, 56 % 

failed due to gross infection, with some Figure 3 requiring urgent revision to a higher level. 

None of the limbs, which were left open, 

had this complication. LaNoue also evaluated patients who had a first stage Syme’s amputation performed. A Syme’s amputation is when an ankle disarticulation is performed and a heel 

pad is left for covering the residual limb. He found that there was an 88% failure of the Symes’ 

that were performed in theater, all of which required amputation to the next higher level 

(transtibial). Definitive procedures such as the Symes’ should not be performed in theater. 

Rather, if there is an injury to the forefoot that may necessitate a Symes’ amputation at a later 

date, simple forefoot wound excision would be the best treatment. LaNoue attributed the poor 

outcome of patients in both these groups to the “trauma of transportation” through the air 

evacuation system. The considerations of civilian physicians are not necessarily the same as 

those of military surgeons. In civilian practice, provided circulation is normal, one would 

expect a 5% or so failure rate in using delayed primary closure of skin flaps, not over half the 

residual limb wounds as in LaNoue’s data. 6 

Transportation casts should be applied to the patient in order to maintain skin traction throughout the evacuation chain. This also allows the patient to have limited ambulation. Skin traction 

to litters or beds while in the evacuation chain is difficult to maintain; therefore, a self-contained cast with an outrigger allows for this continuous traction to be maintained. Casts used 

with the major levels of amputation are as follows: for transtibial amputations, one should use 

a long leg cast with outrigger (See Figure 4); transfemoral amputations should have a low hip 

spica cast with an outrigger (See Figure 5). For upper extremity amputations, a transradial 

amputation should have a longarm cast and a transhumeral amputation needs a shoulder spica 

cast to maintain skin traction.6-8 
Figure 4 

15 Traumatic Amputation 

And Prosthetics 

Figure 5 

CARE AT A SITE OF DEFINITIVE CARE
 

Once a patient is received in the United States, the transportation cast should be removed at 

the amputation center and the wounds inspected. The patient is placed in skin traction in 

bed and as soon as possible, fitted with a plaster of Paris pylon for lower extremity amputee 

veterans, or for upper extremities, a provisional prosthesis that is made of casting material. 

After fitting with a pylon, lower extremity amputee veterans should be started on a program 

of early ambulation. Ambulation, even on an open residual limb, is beneficial to the patient. 

First, the patient redevelops a proprioceptive sense faster. Second, weight bearing on a hard 

plaster shell reduces the edema and swelling of the patient’s residual limb and finally, the 

patients’ mental status is improved by becoming upright as soon as possible. 

When not in the pylon, the patient is maintained in skin traction. As more time is spent with 

the pylon, there is correspondingly less time spent in skin traction. As the edema and swelling 

subside, the plaster socket is changed.6, 17 Planning should be made by the amputee team for 

treatment of the residual limb and eventual permanent prosthetic fitting as soon as the patient is 

admitted to a site of definitive care. Once the limb has become stable, closure with flaps, skin 

grafts or simple local wound care and granulation can be performed. Most patients will require a 

second procedure for wound closure. Additionally, if the limb is not an optimal length, steps can 

be taken to provide for the best length as well as optimal closure of the residual limb. A rigid 

protocol for timing of closure and perhaps limb lengthening or shortening cannot be made until 

both the treatment team and patient have an understanding of the options available. 
16 Traumatic Amputation 

And Prosthetics 

REFERENCES 

1.	 Brackett, E.G.: (editor). Amputation Service, A.E.F., Care of the Amputated in the 

United States. In The Medical Department of the U.S. Army in the World War. Volume XI, 

Surgery, edited by Merritte W. Ireland, pp. 687-712, 713-748. Washington DC, U.S. 

Government Printing Office, 1927. 

2.	 Peterson, L.T.: Chapter XXXIII Amputations of lower extremity, in Surgery in World 

War II Orthopaedic Surgery in the Zone of the Interior (edited by Mather Cleveland and 

Alfred Shands) Office of the Surgeon General and Center of Military History, Washington 

DC, pp. 965-1014, 1970. 

3.	 LaNoue, AM. Personal to the author, 1997. 

4.	 Hampton, O.: Chapter IX Amputations. In Surgery in World War II, Orthopaedic 

Surgery in the Mediterranean Theater of Operations (edited by Mather Cleveland) Office 

of the Surgeon General and Center for Military History, Washington DC, pp. 245-270, 

1957. 

5.	 Mayfield GW. Chapter 7-Vietnam War Amputee veterans in Surgery in Vietnam. 

Orthopedic Surgery. Editor-Burkhalter WE. Office of the Surgeon General and Center 

for Military History, U.S. Government Printing Office, Washington DC, pp. 131-153 

1994. 

6.	 LaNoue, A.M.: Care and Disposition of Amputee War Casualties. A Student Paper for 

the Communicative Arts Program, U.S. Army Command and General Staff College, Ft. 

Leavenworth, Kansas. April, 1971 

7.	 Commander-in-Chief-Pacific: Fifth Conference on War Surgery, pp. 40-47. Tokyo, 

Japan, 1971. 

8.	 Bowen TE and Bellamy RF. Emergency War Surgery. Chapter XXI, Amputations, 

2nd U.S. Revision of the Emergency War Surgery NATO Handbook. U.S. Government 

Printing Office, Washington DC, pp. 273-2791988. 

9.	 Oughterson AW, Hull HC, Sutherland FA, and Greiner AJ. Chapter V, Study on 

Wound Ballistics-Bougainville Campaign, in Wound Ballistics. Editor JC Beyer. Office of 

the Surgeon General, U.S. Government Printing Office, Washington, DC, pp 281-4361962. 

10.	 Bellamy, RF. Personal to the author, 1990. 
17 Traumatic Amputation 

And Prosthetics 

11.	 Simper LB. Below-knee amputation in war surgery: A Review of 111 amputations with 

delayed primary closure. Journal of Trauma, 34(1): 96-98, 1993. 

12.	 McKeever FM. A Discussion of Controversial Points in Amputation Surgery. Surgery, 

Gynecology and Obstetrics. 82 (5): 495-511, 1946. 

13.	 Burkhalter WE. Chapter 3-Penetrating Wounds of the Leg with Associated Fractures of 

the Tibia (WE Burkhalter, editor) Surgery in Vietnam. Orthopaedic Surgery. Office of the 

Surgeon General and Center of Military History, United States Army, U. S. Government 

Printing Office, Washington DC, pp.39-53, 1994. 

14.	 Schmitt HJ and Armstrong RG. Wounds Causing Loss of Limb. Surgery, Gynecology 

and Obstetrics. 130(4): 682-684, 1970. 

15.	 Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF et 

al., A Prospective Evaluation of the Clinical Utility of the Lower Extremity Injury 

Severity Scores. JBJS 83A(1) pp 3-14, 2001. 

16.	 Coupland RM. Chapter 4 “Amputations” in War Wounds of Limbs. Butterworth 

Heinemann Geneva, Switzerland, pp 61-65 1993. 

17.	 Brown PW. Chapter 9-Rehabilitation of the Combat-Wounded Amputee in Surgery 

in Vietnam. Orthopedic Surgery. Editor-Burkhalter WE. Office of the Surgeon General 

and Center for Military History, U.S. Government Printing Office, Washington DC, 

pp189-209, 1994. 
18 Traumatic Amputation 

And Prosthetics 

4. REHABILITATION FOLLOWING AMPUTATION
 

by Katherine M. Flood, M.D. and Sheila Saliman, Ph.D. 

REHABILITATION FOLLOWING AMPUTATION 

The large numbers of military personnel who sustain limb amputations during armed conflicts 

have been the driving force in the development of prosthetic devices and rehabilitation techniques. 

During World War II, military planners quickly realized that the Veterans Administration 

hospital system was not prepared to care for the large number of war-injured amputees. As 

a result, the Army was made responsible for both early care and definitive rehabilitation of 

amputees. To provide the necessary services, the United States military established five 

“amputation centers” at ports of debarkation. The U.S. Army Surgeon General directed that 

all amputees be transferred “as soon as possible” to designated amputation centers. Since 

these centers were responsible for the amputee’s full rehabilitation, as well as early care, 

longer military hospital stays were required. By 1944, two additional centers were established 

to handle the workload. 1 The Army health care system has continued to assume the responsibility 

for the surgical and rehabilitative care of the soldier sustaining a limb amputation. For simplicity, 

the following discussion will be directed toward the soldier with limb amputation alone, though 

multiple injures are more common and would affect all phases of the soldier’s care. In most 

cases, management techniques discussed will apply to both upper and lower limb amputations. 

Losing a limb in a combat situation and the subsequent medical and surgical care is very 

different from a traumatic amputation in a civilian setting. The combat-injured amputee was 

initially treated in the austere medical environment of a field hospital and may have passed 

through several care venues before arriving at a place where definitive care began. The goal 

of immediate military medical care is to preserve life through maximal early intervention and 

safe evacuation. Due to gross contamination, a circular amputation is usually performed and 

the wound left open with skin traction applied. Therefore, not only had the soldier sustained 

the sudden, unpredicted loss of a limb, he had to deal with a gaping wound and a skin traction 

device while being moved from site to site. As recently as the Persian Gulf War, which resulted 

in 15 soldiers with limb amputation who were treated at Walter Reed Army Medical Center2, 

it took approximately 19 days for casualties to arrive at medical centers in Europe and the 

United States. 1 

The principles developed at the WWII Army Amputation Centers continue to serve as a model 

for amputee care today. These centers assemble an interdisciplinary team that consists of the 

patient, treating physicians, physical and occupational therapists, nursing staff, psychologists/ 

psychiatrists, social workers, prosthetists, vocational counselors and other consultants, as 
19 Traumatic Amputation 

And Prosthetics 

required. The leadership of the team may change throughout the hospital course, beginning 

with the surgeon and progressing to leadership by a physiatrist or other rehabilitation specialist. 

The goals of surgical care of the soldier with limb amputation are preservation of maximal 

residual limb length, adequate soft tissue coverage and proper handling of nerve endings. In 

many cases, wounds are allowed to heal by secondary intention. This may require long periods 

of time and result in a less than optimal residual limb. Rehabilitation must begin even before 

the wound is definitely closed or fully healed. During “preprosthetic rehabilitation,” efforts 

are directed toward pain control, emotional support, prevention of joint contractures, skin 

breakdown and general deconditioning. 

PREPROSTHETIC MANAGEMENT 

Pain Control 

In addition to analgesic medications (including narcotics), control of residual limb edema is 

extremely important in decreasing pain and promoting healing. The best control of edema is 

achieved with a rigid dressing, such as post-operative casting. In cases where wound closure 

is incomplete or frequent inspection is required, a rigid dressing may not be possible. In these 

cases, elastic bandage wrapping or layering of tubular elastic material may be used. Wrapping 

with an elastic bandage is a skill that must be taught to health care personnel and the amputee. 

There is grave potential for inappropriate application of the wrap, resulting in increased rather 

than decreased edema and pain. With the previously described interventions, elevation of the 

residual limb should be encouraged, though care must be taken with joint positioning not to 

produce contractures. Protection of the residual limb from trauma, desensitization of the 

residual limb by sensory stimulation and proper positioning of the residual limb also are 

important in pain control. Other physical therapy modalities might be considered in resistant 

pain, such as transcutaneous nerve stimulation. The existence of other previously unidentified 

injuries, such as herniated lumbar or cervical disks with nerve root compression or occult 

fractures should be considered and appropriately investigated. Input from the rehabilitation 

team members, such as physical and occupational therapists and nursing staff, can be quite 

valuable in characterizing the pain and arriving at a treatment plan. 

Prevention of Secondary Complications 

To prevent contractures, joints must be moved through the full range of motion either actively 

or passively three times, at least twice a day. Static positioning in non-functional positions 

must be avoided. For example, the resting position of the knee should be extension, not flexion. 

To prevent decubitus ulcer formation, attention must be directed toward positioning, the fit and 
20 Traumatic Amputation 

And Prosthetics 

application of dressings or skin traction devices and the identification of patients at risk due to 

immobility, altered sensation (anesthetic skin areas) or decreased cognitive level. To prevent 

general deconditioning, the amputee must be out of bed as soon as possible and working toward 

independence in mobility and self-care activities as soon as medically and surgically stable. 

Even patients who cannot be out of bed should perform active range of motion exercises, 

resistive exercises using weights and other devices and isometric contractions of muscles in 

immobilized limbs. 

Emotional Support 

Individuals’ responses to amputation encompass a range of emotions and thoughts, from 

transitory shock and loss, to relief at the cessation of pain or disease, to long-term grief and 

severe depression. The physician can play a central role in facilitating a patient’s healthy 

adjustment to the loss of a limb. A physician who provides education, communicates a 

willingness to explore difficult issues such as sexuality and social stigma, and possesses an 

awareness of the indicators of severe emotional distress is in a position to impact significantly 

the patient’s recovery, both mentally and emotionally, as well as physically. 

The extent to which the patient is educated about amputation is an important factor in postsurgery adjustment and the success of rehabilitation. In civilian settings, and in cases where 

amputations are performed on veterans due to long-term complications from earlier combat 

injuries, there is usually time for patients to be educated before surgery. These patients benefit 

from hearing clear, concrete explanations of the actual surgical procedure, including a rationale 

for the level at which the amputation will be performed. Unless informed about the need for a 

residual limb to be short enough to comfortably accommodate a prosthesis, for example, the 

patient may assume that only the smallest possible amount of limb would be amputated. If 

there is uncertainty about the level of amputation because of issues such as an unknown extent 

of the spread of gangrene, the patient should be informed as to the extent of required surgical 

interventions and how the decision about where to amputate will be made. Certain religious 

traditions mandate that a person be buried with all body parts, so a physician should explain 

how the hospital normally disposes of the amputated limb, in case a patient wishes to make 

other arrangements. 

In situations where amputations occurred during combat or emergently following a severe 

injury, of course, no pre-amputation education is possible. However, it appears that veterans 

whose limbs were amputated emergently achieve greater adjustment when education is provided 

to them early in their rehabilitation. 3 In cases of surgical amputation, patients can be helped 

to construe the amputation as a necessary and ultimately positive process, which was lifesaving, allowed for relief from pain or arrested a progressive infection. It is important to 

remind the patient that a normal, active lifestyle after amputation is a reasonable goal. 
21 Traumatic Amputation 

And Prosthetics 

Reassurance that every effort was made to preserve the limb before the decision to amputate 

can be helpful in allowing the patient to accept the loss. 

For individuals whose limbs were amputated traumatically in a combat situation, the critical 

focus of education is post-surgery care and recovery. Patients should be made aware of the 

process of healing from the surgery, including the use of compression dressings to shrink the 

residual limb, the role of physical therapy in training them to transfer and ambulate singlelimbed, and the process of selecting, being casted for, and learning to use a prosthesis. 

Thorough knowledge about what to expect can allay fears, place a focus on rehabilitation and 

recovery of function, and encourage active participation in post-surgery care. 

Physicians can provide important education to their patients, but in most cases, the physician 

will not have undergone amputation personally. It can be invaluable for a patient to speak with 

someone who has lost a limb for a first-hand account of what to expect from rehabilitation. 

This person can provide empathy and support, as well as reassurance that successful recovery 

is possible. The Army Amputation Centers had the advantage of many amputees at various 

stages of recovery, allowing for peer support and teaching. Physicians should be aware of 

resources in their institutions and communities for peer support. 

Physicians who will be working with patients during the acute phase of rehabilitation can help 

facilitate successful recovery and return to normal functioning. Patients benefit from being 

encouraged to identify and articulate specific goals for their rehabilitation. Some patients may 

feel it is important to have a prosthesis that looks as natural as possible, while others may place 

more emphasis on sturdiness and durability. A patient may define successful rehabilitation 

as returning to work or a particular sporting activity, or may wish to perfect stair climbing to 

continue living in a non-accessible home. Working toward an individualized set of goals can 

enhance a patient’s motivation, persistence and satisfaction with rehabilitation. 

A physician can further facilitate successful rehabilitation by openly raising difficult and often 

embarrassing or upsetting topics that may be a reality after amputation. Once given permission 

to discuss their feelings, patients usually experience dramatic relief from talking about their 

fears of being socially stigmatized, feelings of unattractiveness and undesirability, and experiences of insensitivity or prejudice. A patient may have few people in his life who are willing 

to address these issues directly and with compassion, and a physician may need to offer no more 

than an empathic ear and reassurance that the patient’s responses are normal and understandable. 

Little data exist about the combat veteran’s acute adjustment to amputation. This probably 

stems in part from the logistical difficulties of conducting research in the context of a war 

zone. The data that are available suggest that veterans’ early responses to amputation are 

similar to those of civilians; they can be expected to feel the full range of normal emotions 
22 Traumatic Amputation 

And Prosthetics 

such as loss, guilt, anger and dependency. 4 Veterans who have pre-existing maladaptive 

responses to stress are at greater risk for complications in their initial adjustment to the amputation. Furst and Humphrey5 reported on the perceptions and attitudes of younger, traumaassociated amputees, spouses of the amputees and the public regarding the degree of disability 

associated with amputation. They noted a great degree of individuality in coping styles, but 

rare evidence of persistent suffering or psychological disability in the amputees. Amputees 

were inclined to attribute family support as crucial to adjustment to amputation, while family 

members stressed the amputees’ own personality. Given a list of six common impairments 

(going blind, losing a leg, losing the preferred arm, becoming deaf, severe facial disfigurement 

and paralysis), amputees and their spouses rated their own amputation as the least severe 

handicap, while the general public group rated amputation second only to blindness. 

Amputees also tended to view themselves as slightly less “fortunate” after the amputation 

compared to before amputation, but even then, their ratings were above those of their spouses 

and the general public sample. 

Several factors appear to facilitate positive coping with the feelings and life changes precipitated 

by the amputation. Individuals who are able to re-define a sense of self-worth to include 

intrinsic qualities rather than physical or material achievements appear to adapt better to the 

loss of a limb. It also is helpful to be able to identify aspects of positive personal change that 

have emerged from the amputation, such as a renewed sense of priorities or a greater awareness of the preciousness of being alive. A strong social support network, a sense of faith or 

spiritual belief, and a willingness to allow one to fully grieve and then move on also facilitate 

positive adjustment. An excellent resource for physicians to recommend to their patients is 

Coping with limb loss: A guide to living with amputation for you and your family, by Ellen 

Winchell, Ph.D.6 Dr. Winchell is herself a person who experienced an amputation, and she 

provides a personal and professional perspective on adapting to the loss of a limb. 

While many veterans develop a healthy response to amputation, there are some issues unique 

to combat amputees that can negatively affect psychological adjustment. A study of 114 

Vietnam combat veterans found no significant differences between amputees and nonamputees on measures of PTSD, depression, hopelessness, psychiatric distress, guilt or societal 

adaptation. However, the study did find that a greater intensity of combat experiences predicted 

worsened psychological functioning in the form of PTSD, depression and psychological 

distress. The author of this study concludes, “The combat experience and the multiple events 

of which it is comprised are a more powerful determinant of psychological functioning and 

societal adaptation than the single event of being wounded.”7 Additionally, veterans with an 

amputation alone have been found to live relatively normal lives at long term follow-up, while 

those who experienced an amputation along with another major medical complication developed 

psychological symptoms and the need for care. 8 Thus, physicians working with individuals 

who lost limbs as a result of combat must be aware that their patients may indeed require 
23 Traumatic Amputation 

And Prosthetics 

psychological treatment to facilitate adjustment to the amputation; however, the psychological 

distress may arise less as a consequence of the limb loss itself than as a result of the experience 

of combat and all of its concomitant stresses. 9 

PROSTHETIC FITTING AND TRAINING 

Early prosthetic fitting, before the wound is completely healed, is common in the management 

of the traumatic amputee. For the upper limb amputee, it has been reported to increase the 

acceptance and use of the prosthetic device long term. 10 Early fitting and mobilization of the 

lower limb amputee has the advantage of decreasing the risk of deconditioning, muscle atrophy 

and joint contracture. In addition, some clinicians believe that early fitting and use of a prosthetic device provides sensory feedback that may reduce the risk of phantom pain syndromes. 

The early or temporary prosthesis may be applied in the operating room immediately following 

surgical closure. It generally consists of a plaster or fiber glass “socket” with a pylon and 

appropriate joints and terminal device applied and aligned by a prosthetist. Therapy staff will 

begin working on functional activities with the amputee as soon as the patient is medically 

stable. 

During the training period, the amputee not only learns how to use the prosthesis, but also 

learns how to care for the residual limb and maintain the prosthetic device. The amputee 

should learn to recognize problems with the fit of the prosthesis and how to make adjustments 

to compensate for usual changes in limb volume. The amputee also must learn to recognize 

situations that require the immediate attention of the prosthetist or other members of the health 

care team. During the initial months following prosthetic fitting, it is anticipated that residual 

limb volume and shape will change as underutilized muscles atrophy and residual edema 

resolves. Weight gain or loss also may significantly alter the fit of the prosthesis, so this 

will require modification or recasting of the prosthetic socket. To prevent complications, it 

is necessary for the amputee to recognize when to seek prosthetic modification. 

Vocational Rehabilitation 

Rehabilitation is complete when the amputee has achieved all functional goals and resumed 

the expected societal role, including productive work. Return to military duty after amputation 

appears to be rare; about 2.3%. Reports of vocational outcome of soldiers with amputations 

are generally limited to just a few years after the amputation and military discharge. It was 

reported in 1946 that 78% of WWII amputees were employed or full-time students. A 1982 

report indicated that the unemployment rate for soldiers sustaining limb amputation in the 

Vietnam conflict was twice that of non-injured Vietnam veterans. Amputees also earned less 
24 Traumatic Amputation 

And Prosthetics 

money, held more blue-collar jobs and obtained fewer college degrees. 1 In contrast, a retrospective analysis of functional outcome in 18 civilian traumatic upper limb amputees, for whom 

data were available showed that only four who were previously employed were unemployed. 

Of those employed, only eight were in the same job. 11 The type or severity of the limb injury 

was not found to be closely related to sub-optimal vocational outcomes, but rather motivation, 

availability of vocational retraining and a low unemployment rate in the general population 

were important factors. This supports the need for early, intensive vocational rehabilitation 

intervention. 1 

FUNCTIONAL STATUS FOLLOWING AMPUTATION 

In general, the longer the residual limb and the more joints preserved, the more functional the 

prosthesis. While the acceptance and daily use of lower limb prosthetic devices is generally 

high, abandonment of upper limb prosthetic devices is common. This is due to the function of 

the lower limb being gross motor, and support that is well substituted for by the prosthesis, 

while upper limb function is primarily fine motor activity, which is not well served by a 

prosthetic device. 

Upper Limb Loss 

In the civilian population, upper limb amputations comprise less than 25% of limb amputations 

performed, with trauma as the leading cause. 11 In contrast, upper limb amputations are reported 

to have comprised 68% of Civil War amputations (not including digit and partial hand 

amputations). 1 

While the terms “above and below elbow amputation” are still commonly heard, transition to 

the more descriptive, anatomically-based ISPO (International Society for Prosthetics and 

Orthotics) classification system is being encouraged. In this system, amputations are named 

based on anatomic and radiologic findings and classified as longitudinal, or transverse and 

complete or partial. Traumatic amputations are generally transverse and complete, with the 

exception of partial hand amputations. The partial hand amputations may include single or 

multiple digits, parts of digits or loss at any level between the digits and radio-ulnar-carpal 

joint. Amputations between the radio-ulnar-carpal joint and the ulnar-humeral joint (elbow) 

are transradial, and between the ulnar-humeral joint and the gleno-humeral joint are 

transhumeral amputations. These last two levels may be further described by the percentage of 

segment length loss compared to the intact side. Above the gleno-humeral joint, a forequarter 

amputation may be performed, which involves removal of the lateral portion of the clavicle 

and the scapula. 
25 Traumatic Amputation 

And Prosthetics 

All unilateral upper limb amputees are taught one-handed techniques for activities of daily 

living (ADL) and other necessary activities. If the dominant limb has been amputated, early 

therapy is aimed at increasing fine motor skills in the remaining non-dominant extremity and 

switching dominance. If the non-dominant extremity has been amputated, the amputee will use 

the remaining dominant extremity for most activities, relying very little on the prosthesis. 12 

Single digit amputations, with the exception of the thumb, are not amenable to functional 

prosthetic devices. There are, however, very realistic appearing cosmetic devices available. 

When the thumb has been lost, the hand loses all prehensile function. Functional prosthetic 

devices consist of a post that attaches to the hand to allow opposition. Indeed, prosthetic 

restoration of multiple digit or partial hand amputation is aimed at providing opposition 

and grasp. These devises are generally custom designed, taking into account the amputee’s 

intended activities and interests. 1 

When rehabilitation is complete, a unilateral transradial or transhumeral amputee is expected 

to be independent in all ADL, most household activities, driving and work. Restrictions 

regarding handling of delicate, heavy or voluminous objects are dependent on level of 

amputation and prosthetic design. The typical transradial amputee should be able to lift 20-30 

pounds. The typical transhumeral amputee should be able to lift 10-15 pounds. A bilateral 

transhumeral amputee is expected to be independent in ADL after assistance with donning the 

prostheses and being able to perform some household activities, drive with adaptive devices 

and perform some types of sedentary work. Bilateral transradial or transhumeral/transradial 

amputees will function at some level between the unilateral amputee and the bilateral 

transhumeral amputee. Bilateral amputees will be limited with respect to handling delicate 

objects or lifting objects greater than 15 pounds. 12 Side dominance will be assumed on the 

longer, more functional side for the bilateral upper limb amputee. 

Lower Limb Loss 

In the civilian population, vascular disease is by far the leading cause of lower limb amputation. 13 

The vascular amputee differs greatly from the combat-injured amputee with respect to age, 

general health and preamputation functional status. As in the civilian population, lower limb 

amputation is more common than upper limb amputation. Statistics from WWII indicate that 

71% of amputations were lower limb and of those, 9% were bilateral.1 

In the ISPO classification system, amputations between the knee and the hip joint are transfemoral, and those between the tibio-talar joint and knee are transtibial. Amputation proximal 

to the hip joint is a hemipelvectomy. Amputations in the foot may be named in the same way 

as partial hand amputations, but there also are some specialized techniques of which to be 
26 Traumatic Amputation 

And Prosthetics 

aware. Amputation at the metatarsal-tarsal joint is known as a Lisfranc amputation, and 

amputation at the mid tarsal level (anterior to the talus and calcaneus) is known as a Chopart 

amputation. Both of these levels present unique prosthetic problems. The Symes amputation 

completed electively at an amputation center is not uncommon in combat-injured amputees. 

The Symes amputation involves amputation through the talo-fibular-tibial joint with preservation 

and fixation of the heel pad to allow for end-bearing. 

Energy cost of ambulation is dependent on the path the center of mass of the body follows. 

Ideally, the only motion would be in the intended direction – a straight line. The design 

and mechanics of the human body make this efficiency impossible, but in return, allow for 

adjustment to uneven surfaces, climbing, etc. Change in the normal function, motion or loss 

of any part of the lower limb will result in deviation of the center mass and increased energy 

requirements per unit distance traveled. The first adaptation the amputee will make will be to 

walk slower in order to normalize the energy consumption per kilogram per minute. 14 

Soldiers with amputations at the transmetatarsal level or more distal will benefit from shoe 

fillers, custom inserts and/or modifications to rigidize the sole of the shoe. Amputation at this 

level generally has minimal impact on mobility in the otherwise healthy soldier. Symes level 

amputees will require a prosthetic device very similar to the transtibial prosthesis. Reports 

regarding impact of a Syme’s amputation on energy consumption are limited, but it appears to 

be similar to transtibial amputation. 15 Ambulation with a transtibial prosthesis (for traumatic 

amputees) has been reported to increase the energy cost of ambulation between 7-33%.16 

At the completion of rehabilitation, the transtibial or more distal amputee should be able to 

ambulate with the prosthesis on level ground, ramps and curbs without assistive devices, drive 

a motor vehicle with an automatic transmission (with minor modification for right lower 

extremity amputees), be independent in ADL and household activities, be able to stand or walk 

up to two hours, rise from the floor or kneeling independently, climb stairs with a reciprocal 

gait, return to most avocational interests (possibly with specialized prostheses or equipment) 

and return to most work.14 

The loss of the knee joint has profound effects on the efficiency of ambulation and function 

of the lower limb amputee. Ambulation with a traumatically-acquired transfemoral prosthesis 

has been reported to decrease comfortable walking speed 30-40% and increase energy expenditure per kilogram per unit distance 30-50%.15 The unilateral combat-injured transfemoral 

amputee should be able to ambulate on level ground, ramps and curbs with no more assistance 

than a straight cane, though distance will likely be limited due to energy expenditure. Like the 

transtibial amputee, the transfemoral amputee will be independent in ADL and most household 

activities, independent in donning and doffing the prosthesis and maintaining components. 

The transfemoral amputee will tolerate up to two hours of standing or walking, rise from 

the floor independently, climb stairs with the intact limb and drive a motor vehicle with an 
27 Traumatic Amputation 

And Prosthetics 

automatic transmission (right sided amputees require modification of the gas pedal). The 

transfemoral amputee will return to work, but may not be able to perform activities requiring 

heavy lifting or carrying of heavy objects, or that rely on good balance or mobility. The 

transfemoral amputee should return to most avocational activities, including sports activities, 

sometimes with appropriate modification of equipment, the prosthesis, or the way in which 

the activity is performed.15 

Functionally, amputation at a level leaving five cm. of residual femur or less results in the 

loss of hip joint as well as foot, ankle and knee joint function. The loss of multiple joints will 

increase energy requirements of ambulation 100% or more. Young, otherwise healthy hip 

disarticulation or amputees who are more proximal may ambulate with only a single cane, but 

distance will be limited by energy requirements. Like other unilateral amputees, these soldiers 

will be independent in ADL and household activities that do not require prolonged standing or 

walking. The hip disarticulation amputee can drive under the same circumstances as other 

unilateral lower limb amputees. This soldier will be employed in sedentary work and participate in avocational activities with specialized equipment and prosthetic devices. Even young, 

otherwise healthy persons with amputation at this level may find wheeled mobility to be more 

efficient than walking. In this case, care should be taken to provide the patient with the most 

appropriate and functional wheelchair or motorized conveyance. 

The impact of bilateral lower limb amputation on function and energy requirements of mobility 

are additive. Energy requirements for ambulation with bilateral transtibial prostheses are 

increased 60-100%.1 Standing and ambulation time is limited to one hour or less. The bilateral 

transtibial amputee may return to sedentary work with some restrictions and to avocational 

activities with specialized equipment or modifications of the activity. The amputee may require 

specialized prosthetic devices (“shower” legs) for ADL. Restrictions increase with combined 

transfemoral/transtibial and bilateral transfemoral amputations. Persons with amputations at 

these levels may require modifications to their wheel chairs to assure stability and safety. 

SUMMARY 

The combat-injured amputee will have received immediate and rehabilitative care at military 

health care facilities. An interdisciplinary team of surgical, medical and rehabilitation health 

care professionals provided this care. The emphasis of this care will have been control of pain, 

emotional support, prevention of secondary complications, early prosthetic fitting and training 

and reintegration into the civilian sector, including vocational activities. The functional and 

social outcome is dependent on the level of amputation and the presence, severity and permanence of associated injuries, but will be profoundly influenced by psychosocial factors, as well. 

References for this chapter are listed at the end of Chapter 5. 
28 Traumatic Amputation 

And Prosthetics 

5. LONG-TERM CARE OF THE AMPUTEE 


by Katherine M. Flood, M.D. and Shelia Saliman, Ph.D.
 

COMPLICATIONS EXPERIENCED BY PERSONS WITH LIMB AMPUTATION
 

The majority of combat-injured amputees seen at VHA facilities will be “graduates” of military 

rehabilitation programs. Often, these veterans will have an established relationship with a 

prosthetist and will take any problems related to the artificial limb to the prosthetist. If this 

relationship has been disrupted for some reason, or the prosthetist has been unable to resolve 

the issue, then the veteran may seek the assistance of the primary care provider. 

A 1983 survey of veterans who had sustained traumatic lower limb amputations identified 

problems with mechanical skin irritation, often associated with unaccommodated changes in 

the residual limb shape or volume, wear of inserts and liners or initial faulty construction of 

the prosthetic socket, as their primary amputation- related problem. In fact, more than 50% of 

respondents complained of “socket” problems. In addition, complaints of residual limb pain 

with prosthetic wearing, at rest or with use, or without the prosthesis, occurred in more than 

50% of amputees. Complaints of back, groin and intact limb pain also were common. On 

evaluation of the prosthesis, problems were found with socket fit, prosthetic suspension and 

alignment and function of components (knee joints and feet). 17 

LONG-TERM PSYCHOSOCIAL ADJUSTMENT 

Long-term emotional adjustment in veterans who experienced amputations because of combat 

appears generally comparable to the adjustment of civilians, and to the post-war adjustment 

of veterans who did not experience amputations.18, 19, 20 Successful rehabilitation and a return 

to independent functioning is a realistic goal. 21 As an individual heals from the surgery, learns 

to use a prosthesis and begins to resume activities of daily living, adaptation to altered life 

circumstances is influenced by several factors, including pre-amputation psychological adjustment, prior experience with loss or trauma, typical coping styles, and interpersonal factors 

such as experiences of stigma and victimization. 22 As with civilians, prior psychological 

functioning plays a strong role in their feelings and with the impact that the amputation has had 

on their lives may develop significantly lowered self-esteem, a negatively altered body-image, 

a crippling sense of vulnerability, substance abuse, clinical depression or suicidal thoughts. 

Physicians who observe these indicators of psychological distress can provide referrals for the 

patient to a peer support group or mental health professional. 
29 Traumatic Amputation 

And Prosthetics 

In addition to the wide range of initial emotional reactions, patients face a stunning array of 

challenges to everyday living, including the need to re-learn taken-for-granted physical activities, 

increased fatigue, changes in recreational activities, economic burdens of medical costs and 

loss of work and reaction of friends and family members. 

DISORDERS OF SKIN 

Excessive Moisture 

Skin functions to dissipate heat by the mechanism of perspiration. The increased energy needs 

of ambulation with a lower limb prosthesis results in increased heat production and the need to 

perspire. At the same time, the residual limb is covered with relatively impermeable materials. 

Blockage of eccrine glands by excessive sweating may result in superficial small blisters while 

deeper rupture results in a “prickly heat” rash. Still deeper rupture may result in the formation 

of papulas. Increased wetness of the residual limb in the socket may result in skin maceration 

and increased risk of infection and decreased tolerance for pressure or shear. The skin of 

most long term prosthetic wearers adapts to the lack of air circulation and heat of the socket. 

Recurrence of this problem may be related to changes in prosthetic materials, design or use 

of the prosthesis, changes in medical condition or changes in pharmacologic regimen. If the 

problem cannot be resolved by the prosthetist, the use of magnesium containing antiperspirants, 

iontopheresis with copper sulfate or formalin, or the use of cornstarch or unscented talc on the 

residual limb may be helpful. 23 

Mechanical Stress 

Maceration occurs because of rubbing over pressure points combined with moisture from 

perspiration. 24 The amputee should be questioned as to whether there has been significant 

weight loss, gain or edema of the residual or intact limb that might affect the socket fit. 

Information regarding other events, such as new or more intense activity, should be sought. 

Information regarding actions taken by the amputee or the prosthetist to correct the problem 

should be elicited, as well. Excessive moisture may be managed as described above. Friction 

may be reduced by the use of a nylon sheath next to the skin under the prosthetic socks or use 

of a transparent dressing, such as Tegaderm or Opsite. If occlusive dressings are used to allow 

prosthetic wear, care must be taken to allow the areas regular exposure to air. Bulky or thick 

wound dressing should be avoided, since this will only increase pressure on the area inside the 

socket. If the break in skin integrity is severe or progresses to ulceration, prosthetic wearing 

should be suspended until the lesion has healed. 
30 Traumatic Amputation 

And Prosthetics 

Ulcerations result from excessive mechanical forces or pressure. Risk factors include 

ischemia, edema, adherent scars, impaired sensation and systemic disorders, such as diabetes.3 

The amputee should be questioned as to whether there has been significant weight loss or gain, 

edema of the residual or intact limb that might impact the socket fit or the development of new 

medical disorders. Prosthetic socks and liners should be examined for wear or compression 

that may alter fit of the socket. The occurrence of ulceration requires suspension of prosthetic 

wearing and use. Treatment of the ulceration includes removal of devitalized tissue, cleansing 

and providing an optimal environment for healing. Skin areas adherent to bone should be 

mobilized by gentle massage. Ulceration over bone spurs is best treated with accommodation 

in the prosthetic socket. Surgical revision of the periosteum is reserved for when non-surgical 

interventions have failed. Prosthetic wear should not be resumed until the ulceration is healed 

and socket fit and prosthetic alignment have been evaluated and corrected by the prosthetist. 

Blisters are the result of the combination of friction and pressure and may result from either 

a socket that is either too loose or too tight.3 Again, the amputee should be questioned as to 

whether there has been significant weight loss or gain or edema of the residual or intact limb 

that might impact the socket fit. Prosthetic socks and liners should be examined for wear or 

compression that may alter fit of the socket. Generally, the occurrence of a blister requires a 

break in prosthetic wear. Intact blisters should be protected and left to heal. Open blisters 

should be treated like ulcerations with cleansing and a protective dressing until healed. 

Sebaceous glands are seldom problematic since the increased pressure within the gland due 

to blockage arrests the production of sebum. Epidermoid cysts may form in the adductor 

region of the thigh at the upper edge of the transfemoral prosthesis. If the cyst becomes 

infected, it is painful and will prevent wearing of the prosthesis. The infecting organism is 

usually staphylococci. Prevention is by meticulous skin hygiene and treatment is the usual 

treatment for superficial staph infections. Apocrine glands are important only in the groin 

and axilla. The brim of the transfemoral prosthesis may irritate the groin. Chronic irritation 

in the groin crease may result in hidradenitis suppurativa that is marked by foul discharge 

from painful cysts. 2 

Allergic reactions of skin are common in the amputee. Allergens may be components of the 

socket, liner or prosthetic socks. Information regarding changes in the prosthesis or socks, 

cleansing agents or lotions being used on the skin or changes in laundry detergent should be 

sought. The interaction of perspiration with the socket materials may result in chemical breakdown and production of irritating substances. Due to the moisture and heat within the socket, 

fungal infections of the skin are not uncommon. These should be treated with topical powders 

during prosthetic wearing and lotions, when the prosthesis is not worn. 2 
31 Traumatic Amputation 

And Prosthetics 

Ingrown or infected hair follicles often result from pistoning in the prosthetic socket. They 

are most simply treated by plucking the offending hair. If the infection is severe, incision and 

drainage and/or antibiotic treatment may be required. Recurrent problems may require chemical 

or electrolytic epilation. 2 

While the above skin problems are generally related to excessive pressure, verrucose hyperplasia 

is the result of lack of distal contact. If there is lack of firm containment of the distal residual 

limb in the socket, chronic edema will form distally. The skin will undergo changes that are 

very similar to stasis dermatitis. With time, the skin will assume a warty condition and be 

prone to breakdown and bacterial and fungal infection. The treatment is to restore distal 

contact in the socket. 3 

PAIN 

Patients also require information about pain and phantom limb experiences following amputation. 

Most patients have phantom limb sensations, in which the person has a distinct sense that the 

limb is intact, to the extent that he may attempt to stand or walk on the missing limb. The 

sense of presence, itching or tingling from the amputated limb is not necessarily upsetting or 

particularly uncomfortable. This phenomenon is most marked in the immediate post-amputation 

period and gradually diminishes with time, but may persist in some form throughout life. 

The phantom limb may undergo a process known as telescoping. With time, the sensation is 

confined to the terminal digits of the phantom, which seem to be attached to the end of the 

residual limb. 25 

In contrast, phantom limb pain can be quite intrusive. Phantom pain is reportedly present in 

75% of amputees at some time, but appears to be a persistent, chronic problem in only about 

5%.4 This pain varies in its intensity, duration and specific quality, ranging from mild feelings 

of electrical shock or tingling, to debilitating sensations of shooting, throbbing or burning. 

Patients can be reassured that phantom limb pain abates over time in most cases. However, 

there is evidence that significantly more veterans than civilians experience long-term phantom 

limb pain, and veterans’ pain is less amenable to treatment. 26 The pathophysiology of phantom 

limb pain is unknown and theories involving peripheral, spinal cord, supraspinal and neuromatrix 

loci have been proposed.3 It also has been proposed that the reason for treatment failure may 

be that phantom pain is not a single disorder with a single locus and etiology, but may have 

many underlying pathophysiological processes and represent a collection of disorders. Each 

of these disorders may require a unique treatment approach.27 Sherman, et al.,6 reported that 

only 1% of veteran amputees who were treated for phantom pain indicated that the treatments 

were effective. On the other hand, treating practitioners surveyed believed their management 

was effective. Surveys of care providers have identified as many as 50 different treatment 
32 Traumatic Amputation 

And Prosthetics 

methods for phantom pain syndrome. 3 These findings would seem to bear out the opinion 

of Anton Chekhov, “When a lot of remedies are suggested for a disease, that means it cannot 

be cured.” 

The complexity of the problem being understood, the first step in managing phantom pain is to 

differentiate it from phantom sensation and other forms of residual limb pain or referred pain 

syndromes.3 A careful history regarding the onset and characteristics of the pain, exacerbating 

and remitting factors may help identify intrinsic residual limb factors or causes extrinsic to 

the residual limb. Ischemia may present as intermittent claudication – pain recurring at a set 

ambulation distance. Examination of the residual limb may show pallor or soft tissue breakdown. Evaluation may include arterial Doppler studies, TcPO2 or xenon 133 vascular studies. 

Treatment is focused on skin healing, protection and optimizing arterial flow by prosthetic 

socket modification. Development of ectopic bone spurs may result in localized pain that may 

increase with prosthetic use. Diagnosis is made by correlating the locus of pain with x-ray 

findings. The first line of treatment is modification of the prosthetic socket to relieve pressure 

over the spur. Surgical resection is usually the last option. Excess fibular length may result 

in pain with weight bearing. Examination may show soft tissue breakdown at the end of the 

fibula and a prominent fibular end. X-rays will confirm the diagnosis. Management includes 

socket modifications and possibly, surgical revision. Inadequate tibial beveling may result in 

excessive pressure and pain at the tibial end. Examination may reveal a prominent tibial end, 

bursa formation and/or skin breakdown over the tibial end. Like other bony problems, the first 

line of treatment is socket modification, followed by surgical intervention. A hypermobile 

fibula may result from traumatic disruption of the tibial-fibular interosseous membrane resulting 

in pressure on the peroneal, tibial or sural nerve remnants. Treatment involves surgical fusion 

of the tibial-fibular joint. 3 

A neuroma occurs whenever a nerve is cut, but not all neuromas are symptomatic. Neuroma 

pain is described as sharp, shooting pain brought on or worsened by prosthetic wear, weight 

bearing or mechanical pressure. Examination may reveal a Tinnel’s sign over the site of the 

neuroma and reproduction of symptoms with palpation of the neuroma. A neuroma may 

become symptomatic spontaneously, when it becomes entrapped in scar tissue, or when 

exposed to pressure due to soft tissue atrophy or changes in socket fit or prosthetic alignment. 

Neuromas may be visualized on MRI but, since they are expected, MRI findings must be 

correlated with symptoms and physical findings. The best treatment of neuroma pain is prevention by proper handling of nerve endings at the time of surgery. Once a neuroma becomes 

symptomatic, initial management consists of socket modification. Trancutaneous nerve stimulation (TNS) may be useful in symptom control. Pharmacologic agents used in the treatment 

of other neuropathic pain syndromes, such as anticonvulsants, low dose tricyclic antidepressants 

and non-narcotic analgesics may be tried. Use of opioids for chronic pain syndromes is 

controversial. If injection of the neuroma with short-acting local anesthetic relieves the 
33 Traumatic Amputation 

And Prosthetics 

symptoms, CT-guided neurolysis with phenol or other substance may be tried. If conservative 

measures fail, surgical resection of the neuroma may have benefit. 3 A surgeon with experience 

in handling nerve tissue should be consulted. 

Amputees may suffer from medical conditions such as degenerative joint disease of the residual 

limb joints that cause pain, especially with weight bearing. Residual limb pain may be 

referred from other areas. Symptoms of radiculopathy, spinal stenosis, facet syndrome, 

pyriformis syndrome and myofascial pain syndrome should be elicited and investigated.3 

Once the diagnosis of phantom pain syndrome has been confirmed by ruling out other etiology, 

attempts at treatment may include medical/pharmacologic, surgical, psychologic or use of 

physical modalities. For most amputees, a number of interventions have been found to be 

effective in phantom pain relief. Pharmacological treatment may start with analgesics such as 

NSAIDs. These may be effective in phantom pain worsened by weather changes. As in other 

pain syndromes, anticonvulsants and low dose tricyclic antidepressants may be helpful. 

Neuroleptics, such as butyrophenone, phenothiazines and benzamides have been used to alter 

central mechanisms of pain. Sympathetic beta-blockers may act centrally by seratonergic 

mechanism and be effective for burning or throbbing pain. Mexiletine, a sodium channel 

blocker, has been utilized, as well, with some success, as has intravenous calcitonin.3 The role 

of opioid agents in the management of chronic pain is controversial. In the past, it has been 

discouraged due to fears of addiction and dependence, but recommendations that are more 

recent may require reconsideration of the treatment role of narcotics. 

Surgical procedures for the management of phantom limb pain include dorsal root entry zone 

(DREZ) lesioning and implantation of electrical dorsal column and deep brain stimulators. 

Long-term outcomes from these procedures have been less than optimal and ablative procedures are not recommended for the treatment of this syndrome.3 

In addition to the traditional approach of pain relievers or short-term use of anti-depressant 

medications, varieties of ancillary approaches are useful in addressing phantom limb pain. 

These include relaxation techniques and acupuncture; adjusting the prosthetic fit, desensitizing 

the limb, applying heat or massage, including ultrasound; electronic stimulation, such as 

TENS units and pulse magnetic resonators; and referral to a pain clinic. 28 Individuals who 

lost limbs because of combat may require long-term assistance with identifying effective 

methods to control phantom limb pain. Biofeedback may be useful for cramping types of pain 

associated with increased muscle tension. Hypnosis also has been used, but without definitive 

evidence of benefit. Phantom pain is not believed to be a psychologic disorder, so psychotherapy 

has a place only in the treatment of pre-existing psychologic disorders3 and in assisting the 

veteran to develop effective coping methods to mitigate the “suffering” aspect of pain experience. 
34 Traumatic Amputation 

And Prosthetics 

Physical modalities such as range of motion exercises, massage, heat or cold modalities, 

acupuncture, TNS, vibration, percussion and desensitization techniques have been reported to 

provide short-term relief. They may be useful as an adjunct to other treatments and to control 

episodic exacerbation of pain.3 

Sherman, et al.,5 point out that many of the reports claiming success in the treatment of 

phantom limb pain conducted time-limited follow-up. Due to this, while the treatment may 

produce initial, short-term relief, pain may recur and be even more resistant to treatment long 

term. Reports of successful treatment must be carefully evaluated, with respect to the length 

of follow-up. 

AGING WITH LIMB AMPUTATION 

Amputees are not exempt from the development disorders associated with aging, which may 

impair physical function. However, amputees are less able to adapt to these new impairments, 

so what may be a minor problem in an otherwise intact person has profound impact on the 

function of the amputee. Burger, et al.,29 reported that one-third of persons who were young 

at the time of traumatic lower limb amputation faced limitations of mobility later in life. 

Musculoskeletal Impairments 

It is reasonable to predict that there would be an increased incidence of degenerative joint 

disease in the remaining joints of the residual limb, the intact limb and possibly the spine 

due to over use and altered body mechanics and stress on musculoskeletal structures. A study 

of British war veterans with major lower limb amputations showed a 61% incidence of hip 

osteoarthritis (OA) on the amputated side and a 23% rate on the intact side, compared to an 

11% rate in the population. There was a three-fold increase in hip OA for transfemoral 

amputees compared to transtibial amputees. 30 A significant decrease in bone mass density 

(BMD) of the femoral neck of the amputated side compared to the intact side also was reported. 

As with OA, decreased BMD was more prominent in transfemoral amputees compared to 

transtibial amputees. In a study of Canadian war amputees, a significantly increased incidence 

of OA of the intact side knee was reported. Gait analysis showed larger forces across the 

intact side knee joint, as well. 31 

The strain of ambulation with a lower limb prosthetic device is not limited to the lower 

extremity joints. Fifty-two percent of amputees who were at least six months post amputation 

reported persistent, bothersome back pain. Fifty-three percent of the amputations had resulted 

from trauma, including war injuries. During the three months preceding the survey, 22% 

reported that back pain had severely interfered with activities of daily living (ADL), 23% that 
35 Traumatic Amputation 

And Prosthetics 

recreational, social and family activities had been severely disrupted and 28% that work, 

including school and housework, had been severely limited. No relationship of back pain to 

level of amputation was identified. The majority of amputees reported the intensity of back 

pain as mild, but one-third reported severe pain. Seventy-two percent characterized the pain as 

intermittent and 22% as constant, but with variation in intensity, and 4% as constant with little 

variation in intensity. 32 Clearly, back pain is common in lower extremity amputees, and in a 

significant number of these individuals, disabling. 

Similar complications have been reported in upper limb amputees. Jones and Davidson33 

surveyed upper limb amputees regarding prosthetic use, intact limb problems and employment. Of 46 responses, 50% of amputees reported pain in the intact limb. There did not 

appear to be a relationship between employment and pain, or wearing a prosthesis and pain. 

Diagnoses related to the pain included epicondylitis, shoulder impingement, tenosynovitis, 

osteoarthritis, reflex sympathetic dystrophy-like syndrome, carpal tunnel syndrome and 

trigger finger. 

Musculoskeletal complaints in amputees should be evaluated and treated in the same manner 

as such complaints in non-amputees. Usually, the first line of treatment is NSAID, joint 

protection and rest and physical therapy treatment (modalities and specific exercise programs). 

It must be kept in mind, though, that the functional impact of even minor impairment of the 

intact limb may be profound. The upper limb amputee with shoulder impingement no longer 

may be able to comb his/her hair or don a shirt. The lower limb amputee with OA of the intact 

limb knee no longer may be able to climb the stairs, get out of bed and go to the bathroom, or 

to complete necessary household activities. Therefore, while pursuing treatment to alleviate 

the musculoskeletal problem, the new, functional disabilities must be addressed by training in 

new techniques to accomplish common tasks or provision of adaptive equipment. The physical 

and/or occupational therapist can be of great service in this area. 

Cardiovascular Disease and Other Systemic Disease 

Hrubec and Ryder34 described a statistically significant relationship between combat- related 

limb amputation and cardiovascular disorders, though the reason for this association was not 

clear. They postulated a possible association between amputation leading to sedentary life 

style and cardiovascular disease. Whatever the reason for the association, the onset of heart 

disease and its attendant exercise tolerance limitations may have profound impact on the function 

of the lower limb amputee. There have been many studies reporting the impact of amputation 

on the energy cost of ambulation.35, 36, 37, 38 All studies have shown significant increases in 

energy cost per body weight per unit distance for persons with lower limb amputation due to 

trauma or vascular disease. The increase in energy cost is greater for vascular amputees. 

Cardiovascular disease that results in decreased exercise tolerance may make ambulation nonfunctional. The same is true for pulmonary dysfunction that limits aerobic capacity. 
 

36 Traumatic Amputation 

And Prosthetics 

Amputees who are experiencing decline in aerobic capacity may present with complaints 

about the weight of the prosthesis. If the prosthesis is of older design or materials, it may be 

possible to decrease prosthetic weight enough to decrease the energy cost of walking. The 

amputee must be warned, however, that it will take time and possibly training to adapt to the 

new prosthesis and caution should be used in making multiple prosthetic changes simultaneously. Consideration also should be given to assistive devices, such as manual or motorized 

wheel chairs. 

The onset of functional decline can be even more difficult for the amputee than for the 

previously healthy individual. The amputee may need support and time to accept the new 

impairment and proceed with adaptation. 

REFERENCES 

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In Chief. Text Book of Military Medicine, Part IV, Surgical Combat Casualty Care, 

Rehabilitation of the Injured Combatant, Volume 1. Published by the Office of the 

Surgeon General, Department of the Army, United States of America: 1998. 

2.	 Dillingham TR and Belandres PV. Physiatry, Physical Medicine, and Rehabilitation: 

Historical Development and Military Roles. In: Zajtchuk GR, ed. In Chief. Text Book 

of Military Medicine, Part IV, Surgical Combat Casualty Care, Rehabilitation of the 

Injured Combatant, Volume 1. Published by the Office of the Surgeon General, 

Department of the Army, United States of America: 1998. 

3.	 Gerhards F. Florin I and Knapp T. The Impact of Medical, Re-educational, and 

Psychological Variables on Rehabilitation in Amputees. International Journal of 

Rehabilitation Research. 1984, 7: 379-388. 

4.	 Frank JL. The Amputee War Casualty in a Military Hospital: Observation on 

Psychological Management. International Journal of Psychiatry in Medicine. 1973, 

83:383-389. 

5.	 Furst L and Humphrey M. Coping with the Loss of a Leg. Prosthetics and Orthotics 

International. 1983, 7: 152-156. 

6.	 Winchell E. Coping with Limb Loss. Avery Publishing Group, publisher, Garden City 

Park, NY, 1995. 
 

 

37 Traumatic Amputation 

And Prosthetics 

7.	 Schwartz LS. Wounded Vietnam Combat Veterans: Effects of Type and Severity of 

Injury on Psychological Function and Societal Adaptation. Adelphi University, Institute 

of Advanced Psychological Studies, Doctoral Dissertation, 1993. 

8.	 Dougherty PJ. Transtibial Amputees from the Vietnam War. Twenty-eight-year 

Follow-up. Journal of Bone and Joint Surgery. 2001, American Volume 83: 383-389. 

9.	 Sivik T, Delimar D, Korenjak P, Delimar N and Schoenfeld R. Certain Psychological 

Characteristics of Soldiers Injured in the 1991-1993 War in Croatia. Stress Medicine, 

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10.	 Pinzur MS, Angelats J, Light TR, Izuierdo R and Pluth T. Functional Outcome Following 

Traumatic Upper Limb Amputation and Prosthetic Limb Fitting. The Journal of Hand 

Surgery, 1994, 19A(5): 836-839. 

11.	 Cummings V, Alexander J and Gans SO. Management of the Amputee. In: Ruskin AP, 

editor. Current Therapy in Physiatry. W.B. Saunders Company, publishers, Philadelphia, 

PA. 

12.	 Esquenazi A. Upper Limb Amputee Rehabilitation and Prosthetic Restoration. In: 

Braddom RL, editor. Physical Medicine & Rehabilitation. W.B. Saunders Company, 

publisher, Philadelphia, PA, 1996. 

13.	 Leonard JA and Meier RH. Upper and Lower extremity Prosthetics. In: DeLisa JA, 

editor-in-chief. Rehabilitation Medicine Principles and Practice, Third Edition. 

Lippincott-Raven Publishers, Philadelphia, 1998. 

14.	 Inman VT, Ralston HJ and Todd F. Human Walking. Williams & Wilkins, publisher, 

Baltimore, 1981. 

15.	 Fisher SV and Gullickson G. Energy Cost of Ambulation in Health and Disability: A 

Literature Review. Archives of Physical Medicine & Rehabilitation, 1978, 59: 124-133. 

16.	 McAnelly RD, and Faulkner VW. Lower Limb Prostheses. In: Braddom RL, editor. 

Physical Medicine & Rehabilitation. W.B. Saunders Company, publisher, Philadelphia, 

PA,1996. 

17.	 Hoaglund FT, Jergesen HE, Wilson L, Lamoreux LW and Robert R. Evaluation of 

Problems and Needs of Veteran Lower-Limb Amputees in the San Francisco Bay Area 

during the Period 1997-1980. Journal of Rehabilitation R&D, 1983, 20(1): 57-71. 

18.	 Doughtery PJ. Long-Term Follow-up Study of Bilateral Above-the-knee Amputees: 

Injuries and Rehabilitative Needs. Military Medicine, 1994, 159: 635-639. 
38 Traumatic Amputation 

And Prosthetics 

19.	 Delimar d, Korenjak P, Sivik T and Delimar N. The Effect of Different Traumatic 

Experiences on the Development of Post-Traumatic Stress Disorder. Military Medicine, 

1995, 160: 635-639. 

20.	 Curley MD, Wlash JM and Triplett RG. Some Adjustment Indices of Oral-Maxillofacial 

War Casualties, Limb Amputees and Noninjured Veterans. Military Medicine, 1982, 147: 

572-574. 

21.	 Dillingham TR, Braverman SE and Belanders PV. Persian Gulf War Amputees: Injuries 

and Rehabilitative Needs. Military Medicine, 1994, 159: 635-639. 

22.	 Rybarczyk B, Szymanski L and Nicholas JJ. Limb Amputation. In: RG Frank and TR 

Elliott, Eds. Handbook of Rehabilitation Psychology. American Psychological 

Association, publishers, Washington, DC, 2000. 

23.	 Friedmann LW. Rehabilitation of the Lower Extremity Amputee. In: Kottke FJ and 

Lehmann JF, editors. Krusen’s handbook of Physical Medicine and Rehabilitation, 4th 

edition”. W.B. Saunders, publisher, Philadelphia, PA, 1990. 

24.	 Huston C, Dillingham TR and Esquenazi A. Rehabilitation of the Lower Limb Amputee. 

In: Zajtchuk GR, ed. In Chief. Text Book of Military Medicine, Part IV, Surgical 

Combat Casualty Care, Rehabilitation of the Injured Combatant, Volume 1. Published by 

the Office of the Surgeon General, Department of the Army, United States of America; 

1998. 

25.	 Leonard JA and Meier RH. Upper and Lower extremity Prosthetics. In: DeLisa JA, 

editor-in-chief. Rehabilitation Medicine Principles and Practice, Third Edition. 

Lippincott-Raven Publishers, Philadelphia, PA, 1998. 

26.	 Sherman RA and Sherman CJ. Prevalence and Characteristics of Chronic Phantom Limb 

Pain Among American Veterans. Results of a Trial Survey. American Journal of Physical 

Medicine, 1983, 62: 227-238. 

27.	 Sherman RA, Sherman CJ and Parker L. Chronic Phantom and Stump Pain among 

American Veterans: Results of a Survey. Pain, 1984, 18: 83-95. 

28.	 Winchell E. Coping with Limb Loss. Avery Publishing Group, publisher, Garden City 

Park, New York, 1995. 

29.	 Burger H, Marincek C and Isakov E. Mobility of Persons after Traumatic Lower Limb 

Amputation. Disability and Rehabilitation, 1997, 19(7): 272-277. 
 

39 Traumatic Amputation 

And Prosthetics 

30.	 Kulkarni J, Adams J, Thomas E and Silman A. Association between Amputation, 

Arthritis and Osteopenia in British Male War Veterans with Major Lower Limb 

Amputations. Clinical Rehabilitation, 1998, 12: 348-353. 

31.	 Lemaire ED and Fisher FR. Osteoarthritis and Elderly Amputee Gait. Archives of 

Physical Medicine & Rehabilitation, 1994, 75(10): 1094-1099. 

32.	 Ehde, DM, Smith DG, Czerniecki JM, Campbell KM, Malchow DM and Robinson, LR. 

Back Pain as a Secondary Disability in Persons with Lower Limb Amputations. Archives 

of Physical Medicine & Rehabilitation, 2001, 82(6): 731-742. 

33.	 Jones LE and Davidson JH. Save that Arm: a Study of Problems in the Remaining Arm 

of Unilateral Upper Limb Amputees. Prosthetics and Orthotics International, 1999, 23: 

55-58. 

34.	 Hrubec Z and Ryder RA. Report to the Veterans’Administration Department of 

Medicine and Surgery on Service-Connected Traumatic Limb Amputations and 

Subsequent Mortality From Cardiovascular Disease and other Causes of Death. Bulletin 

of Prosthetics Research, 1979, Fall, pp.29-53. 

35.	 Fisher SV and Gullickson G. Energy Cost of Ambulation I Health and Disability: A 

Literature Review. Archives of Physical Medicine & Rehabilitation, 1978, 59: 124-133. 

36.	 Skinner HB and Effeney DJ. Gait Analysis in Amputees. American Journal of Physical 

Medicine, 1985, 64(2): 82-89. 

37.	 Huang CT, Jackson JR, Moore NB, Fine PR, Kuhlemeier KV, Traugh GH and Saunders 

PT. Amputation: Energy Cost of Ambulation. Archive of Physical Medicine & 

Rehabilitation, 1979, 60: 18-24. 

38.	 Hoffman MD, Sheldahl LM, Buley KJ and Sandford PR. Physiological Comparison of 

Walking among Bilateral Above-Knee Amputee and Able-Bodied Subjects, and a Model 

to Account for the Differences in Metabolic Cost. 1997, 78(4): 385-392. 
40 Traumatic Amputation 

And Prosthetics 

6. PROSTHETICS CLINICAL ISSUES 


by John Milani 

CAUSES AND LEVELS OF AMPUTATION 

Amputations are performed because of severe trauma to limbs, congenital anomalies and 

disease processes, such as peripheral vascular disease (PVD) or cancer. Amputation is 

categorized into those of the lower limb and those of the upper limb. Lower limb amputation 

includes: (1) transtibial (below knee); (2) knee disarticulation, (3) transfemoral (above knee), 

(4) hip disarticulation, (5) trans-pelvic (hemipelvectomy); and (6) partial foot. Partial foot 

amputation encompasses: transmetatarsal amputation; Lisfranc, in which all tarsal bones 

remain; Chopart, in which the talus and calcaneus remain; and Syme, or ankle disarticulation. 

Upper limb amputation includes: 1) partial hand, which takes in digit amputation; (2) wrist 

disarticulation; (3) transradial (below elbow); (4) elbow disarticulation; (5) transhumeral 

(above elbow); (6) shoulder disarticulation; and (7) forequarter amputation, in which the 

clavicle and scapula also are removed. 

Functional Levels – Lower Limb 

In general, functional levels are dependent upon several factors, among them the overall physical 

condition of the amputee. This includes the level of amputation, other orthopaedic conditions, 

cardiovascular conditions, respiratory conditions, vascular problems (particularly PVD), 

visual problems, CVA, and neuromuscular conditions all play a role in determining the level 

of functionality the amputee will have following surgery. In addition, the patient’s emotional 

and mental state have an impact, particularly the amputee’s understanding of his situation and 

cognitive ability. Other factors that directly affect the level of function include the patient’s 

activity level, degree of motivation, vocation, age and the presence, or lack thereof, of a support 

system made up of family and friends. 

To determine an amputee’s ability to function with a prosthesis, the amputee is evaluated in 

clinic and a functional level is derived. There are five functional levels (K0-K4) that are used 

to establish a functional level for the amputee. These levels go from the least function to the 

greatest function. At the K0 functional level, the amputee does not have the ability or potential 

to ambulate or transfer safely without assistance and a prosthesis does not enhance their quality 

of life or mobility. At the K4 functional level, the amputee has the ability or potential for 

prosthetic ambulation that exceeds the basic ambulation skills, exhibiting high impact, stress 

or energy levels, typical of the demands of active adults, or athlete.6 The traumatic war 

amputee would be expected to function at the highest levels, K3 and K4. 
 

41 Traumatic Amputation 

And Prosthetics 

Prescription Formulation 

The Prosthetic Clinic Team evaluates the patient and then formulates a prosthetic prescription 

based on functional level, patient’s age, date of amputation, condition of the residual limb, 

amputation level, activity level, vocation, sports participation, weight, motivation, cosmetic 

concerns and any other physical or cognitive conditions. Additionally, the Clinic Team must 

determine whether the patient understands and has the ability to don/doff the prosthesis and 

the ability to care for and maintain the prosthesis. 

Lower Limb Prosthetic Socket Designs 

In general, lower limb prostheses are fitted to provide weight bearing, balance, ambulation, 

function and cosmesis. 

Partial foot amputations have several levels that include the transmetatarsal, Lisfranc (all tarsal 

bones remain), Pirogoff, Boyd and Chopart (calcaneus and tarsus are present). There are 

limited components available for these levels of amputations. Prostheses for a transmetatarsal 

amputation may require only shoe modifications such as a toe filler, long steel spring and 

rocker bar. Additionally a high top shoe can provide additional support. At the Chopart level, 

an ankle-foot-orthosis can be used with toe filler and shoe modifications. 

A Syme amputation (ankle disarticulation) with full weight bearing capacity distally at the 

heel pad offers a very good functional level that also is comfortable. Traumatic amputees can 

benefit from the full weight-bearing feature and long lever arm for function. Additionally, this 

design offers anatomical suspension by intimate contours just proximal to the malleoli. The 

Syme prosthesis can be constructed with an opening (window) usually placed medially to 

allow donning and doffing of the prosthesis. Another method of fabrication is to make the 

Syme prosthesis without a window. The prosthesis is fabricated with a soft insert with wedges 

that incorporate the bulbous end. This creates a cylindrical shape to the insert. The insert then 

is donned onto the residum, and the residum with insert then is inserted into the socket. The 

prosthesis easily self-suspends, due to the intimate fit and addition of materials in the undercut 

areas. The major disadvantage of the Syme prosthesis is the bulbous end, which detracts from 

the cosmesis. This can be minimized by surgically shaving down the malleoli at the time of 

surgery. Another concern at one time was the limited number of prosthetic feet that could be 

used. Today there is a large variety of prosthetic feet that include energy storing capacity. 

The transtibial level of amputation has traditionally been the most common level of amputation performed due to trauma and disease such as diabetes (PVD) or other circulatory diseases. 

The three most popular designs of prosthetic sockets include the patellar tendon bearing 

(PTB), total surface bearing (TSB) and plug fit. 
42 Traumatic Amputation 

And Prosthetics 

Since the late 1950’s, the PTB has been the design of choice for most traumatic transtibial 

amputees. The socket design of the PTB provides for selective weight bearing, usually at the 

medial tibial flare and at the patellar tendon. Other areas of the residual limb that can take 

weight and pressure that can be tolerated for support are at the anterio-medial and anteriolateral areas of the socket and at the posterior musculature of the calf. The PTB design also 

provides distal socket contact, which prevents edema and improves proprioception. This socket 

design also provides relief (built in pockets) for bony prominences, tendons or sensitive tissue 

to sit in, so as not to overload these tissues with excessive pressure. 

The TSB socket design was developed in the mid 1980’s and provides for complete contact of 

the prosthetic socket to the residual limb with no built-in pockets for relief of bones and other 

sensitive tissue. By allowing total surface contact, all tissue of the residual limb is in contact 

with the prosthetic socket, thus reducing the loading on the medial tibial flare and patellar 

tendon. When using this type of design it is usually necessary to use a roll-on type of liner 

made of silicone, mineral gel or similar material. The thickness of these liners is usually 

three, six or nine millimeters. This design is fast becoming the socket design of choice for 

traumatic amputees. 

The plug fit prosthesis was very popular from WWI to mid 1950’s, but is seldom used today. 

This socket design provided weight bearing at the patellar tendon and was used in conjunction 

with a thigh lacer for suspension. Additionally by tightening the thigh lacer additional weight 

bearing was achieved on the thigh. The prosthesis was usually fabricated of wood and the 

distal end of the prosthesis usually was left open with no contact. 

The knee disarticulation level is similar to the Syme level in that the residual limb is long, can 

usually bear full weight on the end and is fairly comfortable. A door or window is generally 

needed as with the Syme to allow the bulbous end to get past the narrower area of the limb 

just proximal to the femoral condyles. The major disadvantages of 

this design is the cosmesis and limited prosthetic knees that can be 

used to keep the knee center at the same height as the sound limb. 

The three types of design utilized for transfemoral level prostheses 

are the quadrilaterial (quad), ischial containment and plug fit. The 

quad design provides a socket that is rectangular in shape with a 

large medio-lateral and narrow anterio-posterior opening. (Figure 1) 

The quad socket is designed so that the ischial tuberosity sits on the 

top of the posterior wall of the prosthesis and parallels the gluteal 

fold. To keep the ischial tuberosity in place, the anterior wall of the 

prosthesis is approximately 1" to 2 1/

2 Figure 1 " higher than the posterior wall 
43 Traumatic Amputation 

And Prosthetics 

(depending on length of the residual limb). The anterior wall exerts a posteriorly directed 

force, which keeps the ischial tuberosity from slipping forward into the socket. The height of 

the medial wall is the same as that of the posterior wall. The function of the medial wall is to 

contain the medial thigh tissue. Sometimes it is necessary to dip this wall slightly near the 

pubic ramus to avoid pressure on the pubis. The lateral wall is approximately 2" to 3" higher 

than the medial wall and usually is at or slightly distal to the greater trochanter. The lateral 

wall of the socket stabilizes the femur from abducting in stance phase. Additionally, reliefs 

(channels) are placed proximally in the socket to avoid excessive pressure on the adductor 

longus, quadriceps, rectus femoris and hamstring tendons. Distally, the socket provides total 

contact to prevent edema and has a relief at the distal lateral wall to prevent excessive pressure 

on the distal lateral femur. 

There are several designs that fit into the ischial containment classification. The most popular 

include the Normal Shape Normal Alignment (NSNA), the Contoured Adducted TrochantericControlled Alignment Method (CAT-CAM) and the Icelandic Scandinavian New York (ISNY). 

(Figure 2) 

These designs along with others, provide for larger anteriorposterior openings and narrower medial-lateral openings. 

The rationale for this flip-flop from the Quad socket is that 

the anterior-posterior muscles are the ones that are used 

more extensively during ambulation, standing and stairway 

ascend/descend. The Ischial Containment designs also differ 

in that their proximal trim lines are considerably higher than 

traditional Quad sockets for containment of the ischial tuberosity 

and greater trochanter. This provides for greater stabilization 

and control of the femur than the Quad socket and increases 

the surface area of support for weight bearing. The lateral 

wall extends proximally to the iliac crest to encase the greater 

trochanter inside the socket. The posterior wall slopes up laterally from the posterior-medial corner, encapsulating the ischial 

tuberosity. The distal socket provides contact to prevent edema.4 

This design due to the greater containment of the residual limb and control is very suitable for 

use by the traumatic amputee who is very active or athletic. 

The plug fit design provides for a conical shape in which the residual limb slips into the socket 

and then is supported along the proximal brim (hanging up effect). This design was popular 

from post-WWI to the mid-1950’s, but is seldom ever prescribed today. To use this design and 

provide suspension and control, it was necessary to use a pelvic hip joint, band, and belt. The 

Figure 2 
44 Traumatic Amputation 

And Prosthetics 

sockets were usually made of wood and were open-ended distally without socket contact. 

This design did not differentiate between pressure-tolerant or pressure-sensitive tissue. 

Additionally, the prosthesis had a tendency to piston (up and down telescoping action during 

swing phase). 

The hip disarticulation and transpelvic levels of amputation usually require specialized socket 

designs due to the loss of most bony, weight-bearing structure. In the case of the hip disarticulation, the ischial tuberosity is intact and weight can be taken on this bony element. In the 

case of the transpelvic amputee, there are no bony structures to allow for weight bearing. 

The socket is designed to fully contain the soft tissues to allow hydrostatic support of the 

body weight. Sockets of this design may extend proximally to the torso (lower rib margin). 

Lower Limb – Suspension Systems 

Prosthetic designs for lower limbs include differential pressure suspension systems, anatomical 

suspension systems, strap suspension (PTB), thigh corset with mechanical hinges, Silesian 

Belt and pelvic joint with belt. 

Transtibial (Below Knee) 

At the transtibial level, differential pressure suspension systems use an atmospheric pressure 

(vacuum) or suction to maintain the prosthesis onto the residuum. These designs tend to provide 

the amputee with enhanced function, greatest range of motion, added sense of security, greater 

control of prosthesis and no piston action when fitted properly. Of all suspension modes, these 

designs tend to be the most desirable because of the enhanced retention of the prosthesis to the 

residua created by the atmospheric pressure (vacuum).5 

One design incorporates an overall snug fit with a valve placed 

distally into the prosthetic socket. The skin is in direct contact 

with the socket interface. To don the prosthesis, a skin lotion is 

used to push the residua into the socket. The air is then expelled 

through the distal valve causing a vacuum to occur. In order to use 

this type of suspension, the residua have to be stable with no fluctuations in volume and generally need to be free of scars that could 

prevent vacuum from being achieved.5 

Other atmospheric systems include the use of elastomer sleeves 

made of silicone, urethane or mineral gel. (Figure 3) These sleeves 

are rolled onto the residua and have a distal pin attachment (plunger) 

Figure 3 that anchors distally into the socket securing (locking) the prosthesis 
45 Traumatic Amputation 

And Prosthetics 

in place. These systems allow for moderate volume changes by placing socks of varying plies 

on the outside of the sleeve to achieve a snug fit and for residua’s that may have some scarring 

or grafts.5 Variants to these methods include the “hypobaric” design, which has a valve distally 

in the socket to expel air and a silicone rubber band (gasket) molded into standard textile 

stump socks at the proximal socket. This gasket is positioned so that it is at a level slightly 

distal to the proximal posterior socket edge, which creates a seal and maintains vacuum or 

suction. This silicone band is molded into prosthetic sheaths and stump socks of varying plies 

to accommodate volume changes. To enhance the seal, a skin lotion is used for a wet fit.5 

Another design allows a mineral gel sleeve to be rolled onto the 

residual limb, with a fabric backing and no distal pin. (Figure 4) 

Once the sleeve has been placed onto the residua, the residua is 

placed into the socket, where a distal valve expels the air. With 

all the air expelled, a second sleeve is placed over the inner 

mineral gel sleeve and outer socket, sealing any air from entering 

the socket, thus creating a suction or vacuum. This design can 

accommodate some volume changes by use of a thicker sleeve. 

The sleeves usually come in thicknesses of 3mm, 6mm and 9mm. 

Additionally, the socket can be padded with leather to re-establish 

the fit and vacuum required for suspension. 

The simplest design of achieving suction suspension could be to 

use a rubberized sleeve over the outer socket surface and onto the 

mid-thigh, thus preventing air from entering into the socket. This 

design allows for stump socks and/or soft insert to be used. 

Anatomical suspension designs are the second most desirable option for suspension of the 

prosthesis. Suspension is achieved by careful contouring of the proximal socket walls over and 

proximal to the femoral epicondyles to lock the condyles in place. This method of suspension 

is known as supracondylar (SC) and can be very effective in suspending the prosthesis and in 

providing enhanced mediolateral stability in individuals with a shorter residual limb. A variant 

to this design allows for molding of the socket anteriorly above the patella for added suspension 

and to control hyperextension in the shorter residual limb. This design is known as supracondylar/supra-patella (SC/SP) or (PTS). The advantages of these designs are increased ML 

stability with the SC and increased AP stability with the SP feature. Disadvantages include 

localized pressure over condyles and restriction of full flexion.5 

When it is not feasible to use differential pressure or anatomical modes of suspension, a strap 

can be used to suspend the prosthesis. A popular strap, called a PTB cuff, is attached to the 

medial and lateral walls of the prosthesis at their posterior-proximal juncture and is then 

Figure 4 
46 Traumatic Amputation 

And Prosthetics 

angled proximally over the patella. The lower border of the cuff touches the superior border of 

the patella to achieve suspension. In addition to the cuff, a waist belt with extension assist can 

be attached to the proximal border of the cuff to increase suspension and to assist the individual 

in extending the prosthesis. This design can accommodate changes in volume and is relatively 

simple to adjust. Disadvantages include slight pistoning and belt irritation.5 

The thigh corset with mechanical hinges was the design of choice up until the late 1950’s or 

early 1960’s and still has its place when the residual limb and or knee are severely damaged. 

Advantages in using the thigh lacer with joints include the reduction of weight bearing on the 

residual limb and can greatly increase the ML stability. Disadvantages include pistoning, 

added weight and bulk, difficulties in donning and excessive wear and tear on clothing. 

Transfemoral (Above Knee) 

The same differential pressure systems are used for the transfemoral level as in the transtibial 

level. The goal is to evacuate air from the prosthesis and to keep air from re-entering the 

prosthesis. This is accomplished by direct skin contact of the residual limb with the inner 

interface of the socket with a pull-sock method or wet method application. Once the residual 

limb is positioned in the socket, a distal valve is used to keep air from entering the prosthesis.5 

As in the transtibial method, a roll-on sleeve made of silicone, urethane or mineral gel can be 

used. Attached to the distal end of the sleeve is a pin, which attaches to a locking mechanism 

located in the distal end of the socket.5 

The knee disarticulation presents the problem of a bulbous end that cannot be readily fitted 

with a differential pressure system. It is, therefore, necessary to fabricate an insert with 

condylar wedges to allow the bulbous end of the residual limb to pass through the narrow 

opening. An option to this anatomical suspension method would be to place an anterior door 

into the distal socket to allow the residual limb to be donned, with the door positioned over the 

opening and held secure with Velcro straps. 

The Silesian Belt is a belt that can be used in a quadrilateral socket with partial suction to 

help suspend the prosthesis. This belt can be used in conjunction with a TES belt, which is 

a neoprene rubber sleeve that fits over the outside of the socket and which goes around the 

individual’s waist and is secured with Velcro closure. The Silesian Belt also can control 

prosthesis rotation, especially when the residual limb is flabby. Additionally, this belt can be 

used to accommodate volume changes of the residual limb. 
47 Traumatic Amputation 

And Prosthetics 

To provide suspension and maximum ML stability to the individual with a short, weak or 

flabby residual femoral limb, a metal or plastic pelvic joint with band and leather belt can be 

used. The pelvic joint usually is attached to a quad socket or plug fit socket at the proximal 

lateral wall so that the center of the joint is approximately 1/2” anterior and 1/2” proximal to the 

greater trochanter. This positioning is used to approximate the anatomical hip joint. This 

suspension system also can provide some rotational stability of the prosthesis. Disadvantages 

would include pistoning, added weight and bulk, wear and tear on clothing and more time to 

don and doff. 

LOWER LIMB PROSTHETIC COMPONENTS 

Figure 5 

Socket Liners 

Socket liners (Figure 5) are used to cushion and protect fragile 

limbs and to accommodate volume changes. They can be used to 

suspend prostheses by rolling them onto a residual limb to provide suction suspension or they can have wedges built into them to 

provide supracondylar suspension. They can be made of silicone, 

urethane, and mineral gel, rubbers and expanded polyethylene 

foam. Liners fit inside prosthetic sockets.5 

Ankle/Foot Components 

The following ankle/foot components are described by function 

and design. Not all name brands are included. 

Solid Ankle Cushion Heel (SACH) feet were developed in the 1950’s and remain the simplest 

designs, the least expensive, relatively lightweight and most reliable foot components that are 

clinically accepted. Up until the mid-1980’s, the SACH design had been the foot of choice. 

There are no moving parts, which makes this design very durable and ideal for children and 

for individuals whose ambulation is limited to walking. Many manufacturer designs also 

include sculptured toes and heel rise to allow women the ability to wear high-heel shoes. 

The SACH foot designs allow compression of the foam heel at heel-strike to simulate planterflexion. A wooden internal keel provides stability in mid-stance and allows for a relatively 

easy rollover in late stance.5 

Single-Axis feet pre-date the American Civil War and still are used today on a limited basis. 

The main advantage is that the foot will allow for a quick foot-flat, which increases knee 

stability in an above-knee prosthetic wearer or in a below-knee prosthetic wearer who uses a 
48 Traumatic Amputation 

And Prosthetics 

thigh corset with knee joints in early stance. This feature is important in the individual who 

has knee instability. Disadvantages include weight, maintenance, abrupt dorsiflexion stop, 

noise and cost.5 

The multiaxial foot adds inversion-eversion and transverse rotation capabilities to the function 

of the single-axis foot and is often recommended to accommodate uneven terrain. Its weight 

and maintenance requirements are similar to that of the single-axis foot. Hikers, fisherman, 

golfers and others who find it necessary to walk on uneven terrain can use the multiaxial foot 

with much success.5 

Stationary Ankle Flexible Endoskeletal (SAFE) feet became available in the 1980’s. This 

design had an elastic keel, which enabled a smoother and easier rollover, which was more 

preferable than the rigid keel of the SACH foot. Some disadvantages include limited push-off, 

increased cost and added weight.5 

Dynamic Response (formerly Energy Storing) feet have a plastic spring keel that provide a 

dynamic responsiveness during stance. There are numerous dynamic response feet available, 

such as the Carbon Copy, Seattle, Flex-foot, Springlite, etc. The more aggressive ambulator 

can use these designs, including runners and those participating in recreational or competitive 

sports who can load the forefoot for these activities. Disadvantages include increased fabrication 

time and increased cost for some designs. 

Hybrid Design feet are available that combine multiaxial ankle mechanism with dynamic 

response, such as the College Park foot/ankle and the Phoenix foot. These designs can be used 

for recreational and competitive sports, as well as for uneven terrain. Disadvantages would 

include maintenance and cost. 

Knee Components 

As with the ankle/foot components, knee components are listed by function and design, rather 

than by manufacturer. 

Single-Axis knees offer the simplest function and are the least expensive and most reliable for 

individuals who will be walking at a single speed. These knees have one center of rotation and 

act like a simple hinge. They are specially suited for use in remote areas where durability is a 

major concern. The knee also can be used for young children because of durability and cost. 

An adjustable friction control is usually incorporated to allow for swing dampening to limit 

heel rise and terminal impact. The amputee must use voluntary muscle control to keep the 

knee stable during ambulation.5 
49 Traumatic Amputation 

And Prosthetics 

Stance Control (Formerly called Safety Knee) knees provide enhanced stance stability to that 

of the single axis knee by incorporating a weight-activated brake, which adds friction to the 

knee axis and prevents it from bending under weight bearing. This knee also has one axis of 

rotation. This knee is useful to train new amputees and those who have instability problems. 

Disadvantages include delayed swing phase, unloading fully to flex and sit and lack of use 

in bilateral situations. The knee cannot be flexed under weight-bearing conditions and this 

makes descending stairways step over step impossible. Additionally, over time the brake 

wears and loses its effectiveness.5 

Polycentric knees have multiple centers of rotation. Many polycentric knees are designed to 

offer enhanced knee stability early in stance phase, combined with the ability to flex under 

weight bearing just prior to swing phase. Besides stability, polycentric knees allow shortening 

of the prosthesis below the knee, which allows for clearance during swing phase. This feature 

also makes sitting more cosmetic for the longer transfemoral amputee. Polycentric knees can 

be used on bilateral amputees due to the stabilizing features.5 

Manual Locking knees are the least desirable when looking for a smooth, energy- efficient 

gait. The stiff-legged gait that results from having a locked knee disrupts swing phase and 

forces the amputee to “pole vault” over the prosthesis. It is best to use lock knees for temporary 

periods of time, such as when hiking on uneven terrain or when a newer, less experienced 

amputee needs to stand in place for a considerable amount of time.5 

Fluid Controlled knees have chambers in which either air (pneumatic) or oils, such as silicone 

(hydraulic), permit variable speed in swing phase. Pneumatic control units are more suited for 

moderate cadences and hydraulics for moderate to high cadences. The most advanced designs, 

such as the SNS, provide stance and swing control.5 

Computer knees have onboard microprocessors, which control swing phase. These knees 

usually have pneumatic chambers. One knee, the C-Leg, has a hydraulic chamber and is 

capable of controlling swing and stance phase. 

Hybrid knees combine functions of two or more of these generic groups. One design combines 

the stability of a polycentric knee with a pneumatic chamber to allow for variable swing to occur.5 

Special Components 

The Torque Absorber allows the leg to rotate with reference to the socket during stance phase, 

automatically returning the leg to the normal position during swing phase. The torque 

absorber is excellent in activities where rotation is important: golfing, dancing, bowling, baseball, standing and working at a bench for considerable periods of time. Generally, the shorter 
50 Traumatic Amputation 

And Prosthetics 

the residual limb, the greater the loss of natural torsional capabilities. A torsion absorber 

would restore the loss of torsion.5 

A Locking Transverse Rotation Unit is usually placed above the prosthetic knee. When the 

amputee is seated, the locking transverse unit can be unlocked, allowing the entire knee-shin 

foot assembly to rotate 90 degrees (crossing the leg) to allow getting into tight places such as 

an automobile, a booth in a restaurant, etc. This component can be used by almost all aboveknee amputees.5 

Shock absorbing pylons allow for telescoping of the pylon to absorb shock to the residual limb 

that occurs in jumping and running activities, as well as aggressive walking. 

Gait Deviations 

Gait deviations are abnormalities that occur during gait due to prosthetic misalignment or fit, 

amputation level, length of residual limb, patient weakness or lack of therapy. Gait deviations 

that are due to prosthetic misalignment usually can be corrected or reduced significantly by 

realigning the prosthesis. When the gait deviation is due to an ill-fitting socket, the socket can 

be modified to establish a proper fit, or the socket can be replaced. 

Upper Limb Prosthetic Socket Designs 

In general, upper limb prostheses are fitted to provide prehension, cosmesis, movement 

and balance. 

At the partial hand level, most prostheses are fabricated for cosmetic purposes (passive 

prehension) and can include silicone finger prostheses, which are life like in appearance. 

When the thumb has been amputated, the main goal of the prosthetist is to provide a prosthesis 

that will allow for opposition to enable prehension. This can be done with a post (passive 

prehension). In some instances, a hook could be mounted onto the palm section of a hand 

wrist orthosis to permit prehension via body movement, using a harness and cable system 

(active prehension). 

At the wrist disarticulation level, the radius and ulna are present and usually allow normal 

range of motion in supination and pronation. Prosthetic designs usually include a low-profile 

wrist unit attached to a double wall socket. The proximal trim lines of the socket usually are 

well below the cuboidal fold to allow for full flexion/extension and full supination/pronation 

of the prosthesis. The terminal device can be a hand or hook, which can be actively controlled 

by a cable and harness system. Additionally, the trim lines of the socket could be left higher, 

such as in a Northwestern University design for suspension; electrodes could be used for myoelectric control of the terminal device. This allows for complete freedom from all harnessing. 
 

51 Traumatic Amputation 

And Prosthetics 

Figure 6 

The transradial prosthesis is designed with a double 

wall socket and wrist unit. The terminal device 

can be either a hook or hand (passive or active). 

Suspension can be provided by harness or anatomically. Positioning of the terminal device is accomplished through positioning the anatomical elbow. 

To operate the terminal device by body movement, 

it is necessary to use a harness and cable system. 

Body movements to operate the terminal device 

include humeral flexion on the involved side and 

scapula abduction. Myoelectric or switch control 

also can be used to operate the terminal device. 

Socket designs can incorporate anatomical suspension, such as the Northwestern University 

socket (Figure 6), and Muenster socket. Optional suspension can be achieved through 

differential pressure systems (suction). 

The elbow disarticulation prosthesis poses special problems with regards to cosmesis and 

matching the mechanical elbow joints to the anatomical elbow joint to match the anatomical 

joint, it is necessary to use external joints. There are a limited amount of joints available and 

they all tend to increase the width of the prosthesis at the elbow. This especially is a cosmetic 

problem, since the elbow disarticulation as in the Syme amputation has a natural bulbous end 

due to the condylar flares. The prosthesis is suspended by harness and controlled by a dual 

cable system. 

The transhumeral prosthesis has a socket with elbow and forearm component. The prosthesis 

is suspended by a harness system; the terminal device and elbow are operated through a dual 

cable control system. Suspension also can be achieved by differential atmospheric pressure 

(suction). 

The shoulder disarticulation and forequarter amputee represent the most difficult levels to fit 

with prosthesis. Due to the high level of amputation, it is usually recommended to use external 

power to operate the elbow and terminal device. Even with external power, patient compliance 

is a problem due to the weight of the prosthesis and the inability of the prosthesis to provide 

high levels of function. 

Myoelectric Control Systems 

In many instances, prostheses incorporating myoelectric control of the terminal device can be 

used for the wrist disarticulation, transradial, elbow disarticulation and transhumeral level. 

There are several types of electrodes that can be used with either single or dual functions. 
52 Traumatic Amputation 

And Prosthetics 

In the most basic prosthesis, a transradial, two electrodes can be used to pick up signals from 

the wrist extensors and wrist flexors. The electrodes are generally positioned over the muscle 

bellies of these two groups of antagonistic muscles. In the transhumeral prosthesis, these 

electrodes would be located at the muscle bellies of the triceps and biceps. The electrodes are 

placed on the skin and will pick up muscle signal and then amplify this signal, sending it to a 

motor in the terminal device for the desired operation, closing or opening. 

When the upper limb amputation is a high, very short transhumeral, shoulder disarticulation 

or interscapular thoracic, it is not feasible to use a myoelectric system. This is due to difficulty 

in containing electrodes within a socket and the inability to pick up clear signals. In addition, 

these levels of amputation also make it difficult to get adequate body movement to operate 

standard harness and cable systems. At these levels, an externally-powered prosthesis using 

micro switches to operate the elbow and or terminal device is recommended. These switches 

are usually simple in design and can be referred to as pull switches. They usually provide a 

dual function and can be mounted onto a harness or onto the outer surface of the prosthesis. 

One short pull on the switch (1/16") can flex an elbow or open a terminal device, while a long 

pull (1/8") can extend an elbow or close a terminal device. 

Upper Limb – Suspension Systems 

Suspension systems may be utilized for the upper limbs. Harnessing can provide suspension 

and to operate body-powered components. The figure of 8 is the most popular and can be used 

for the transradial, elbow disarticulation and transhumeral levels. The figure of 9 and shoulder 

saddle are two additional types of harness. For shoulder disarticulations and interscapular 

Thoracic (Forequarter) levels, a chest strap is used for suspension. 

To self-suspend (anatomical suspension) a transradial prosthesis, the socket must contain 

within it the olecranon and/or humeral condyles. The Northwestern University socket design 

allows for self-suspension of wrist disarticulation and long transradial prostheses. For the 

shorter transradial prosthesis, a Muenster socket design can be used. This design has trim 

lines, which are considerably higher than the cuboidal fold. Since this limits elbow flexion, 

the forearm is pre-flexed to enable the terminal device to reach the mouth. 

As with the lower limb, differential pressure systems can be used on upper limb prostheses to 

create an atmospheric pressure (suction or vacuum) to maintain the prosthesis on the residual 

limb. Specific atmospheric designs are outlined in the Lower Limb-Suspension System section. 
53 Traumatic Amputation 

And Prosthetics 

UPPER LIMB COMPONENTS 

Terminal Devices 

The most important function for the upper limb amputee is prehension, movement and cosmesis. 

The terminal device can be a hand or hook and either can be passive or active. A passive 

device does not move and can be made to be very aesthetic and life-like in appearance. Active 

devices move and provide function, such as grasp. To operate the active device, body power 

can be used through a harness system at the shoulder or electricity can be used to operate an 

externally powered system. Batteries are used to supply the electricity required to operate an 

externally powered system. 

Active devices include hooks and hands and 

either can be voluntary opening (VO) or voluntary 

closing (VC). To operate a voluntary opening 

device, the amputee exerts force on the harness 

system, which pulls on the control cable to open 

the device. Once this force is relaxed, rubber 

tension bands or springs will close the device 

for grasp. To operate a voluntary closing device, 

an initial pull on the harness is used to open the 

fingers of the device. Once the fingers are open, 

the amputee relaxes the pull on the harness. A 

second pull then is used to allow the fingers of 

the device to close onto an object for grasp. In 

this instance, the amputee is controlling the force 

being exerted on an object. Hooks are usually 

more functional and durable for manual types of 

functions. Hooks also provide “visual cue,” 

which is the ability of the amputee to see as they 

are attempting to pick up smaller objects. 

(Figure 7) 

Hands with cosmetic gloves are very aesthetic 

and are very functional when grasping larger or 

spherical types of objects. (Figure 8) 

Figure 7 

Figure 8 
54 Traumatic Amputation 

And Prosthetics 

Wrist Components 

Wrist components are located at the distal end of the prosthesis and they allow for the attachment 

of the terminal device and for the pronation and supination of the terminal device. Many wrist 

components provide other features, such as quick-disconnect, wrist flexion, rotation and the 

ability to lock/unlock the terminal device in place. 

Elbow Components 

For the transradial amputee, flexible hinges or rigid hinges can be used to suspend the prosthesis 

and to provide support. The flexible design hinges, usually made from leather or plastic, 

allow for active pronation and supination. The rigid hinges made of metal provide maximum 

strength to the prosthesis and can protect the elbow. Rigid hinges can be single pivot or polycentric. For very short transradial amputations, metal set-up hinges can be used to provide 

additional forearm flexion. For the transhumeral amputee, there are a variety of body-powered 

and electrically-operated prosthetic elbows. These elbows can be locked and unlocked and 

usually can be manually rotated at the distal humeral section to provide internal or external 

placement of the elbow and forearm. 

Shoulder Components 

For the shoulder disarticulation, there are very few components available. The components 

available can provide no movement such as in a monolith construction to those that provide 

flexion or flexion with abduction by use of metal joints. These movements are usually all 

accomplished through body movement (patient leaning) or with the assist of the sound extremity. 

Harnessing 

Harnessing provides suspension, elbow flexion and terminal device function. Harnesses usually 

are designed in the figure of 8, figure of 9, or shoulder saddle. The materials used to fabricate 

a harness usually are made of textiles, such as webbing and leather. 
55 Traumatic Amputation 

And Prosthetics 

GLOSSARY 

Alignment – Alignment is the relationship of the socket to the prosthetic foot. 

CAD/CAM – This is a method by which prostheses can be designed and manufactured by 

computer. There are currently four or five computer programs available for designing and 

fabricating prosthetic sockets. 

Certified Orthotist – A Certified Orthotist is a practitioner who provides care to patients with 

disabling conditions of the limbs and spine by evaluating, designing, fabricating, fitting and 

aligning those devices known as orthoses.1 

Certified Prosthetist – A Certified Prosthetist is a practitioner who provides care to patients 

with partial or total absence of a limb by evaluating, designing, fabricating, fitting and aligning 

those devices known as prostheses.1 

Endoskeletal – A soft outer finish with an interior support.4 Internal components are used to 

provide structural support and then foam is shaped to resemble the uninvolved side. Cosmetic 

hose or a “skin” is applied to provide color.3 

Energy Storing Foot – A prosthetic foot, that stores energy during stance phase and then due 

to the design, releases this energy at push-off to enable activities such as running and jumping. 

Exoskeletal – A hard outer support and finish.4 Wood or plastic is used to provide structural 

support and is then shaped to resemble the uninvolved extremity. A laminate is applied to the 

exterior of the shaped part to provide color and additional strength.3 

Externally-Powered Prosthesis – An artificial limb that has switches usually mounted on a 

harness, which operates an electric elbow or terminal device. 

Lamination – A process by which a plastic socket is fabricated, using a liquid resin 

(thermoset plastic) to impregnate materials such as nylon, carbon, fiberglass, Spectra or 

Kevlar. A catalyst is added to the resin, which causes the resin to gel and set over a controlled 

period of time, usually 20-30 minutes. 

Myoelectric Prosthesis – An artificial limb with electrodes that contact the skin to pick up 

muscular activity (signals) which is then amplified and sent to the terminal device which has a 

motor for opening and closing. 
56 Traumatic Amputation 

And Prosthetics 

Orthosis – An orthopedic appliance used to support, align, prevent or correct deformities, or 

to improve function of movable parts of the body.2 

Orthotics – The field of knowledge relating to orthoses and their use.2 

Patellar Tendon-Bearing (PTB) – This socket design allows pressure to be placed onto tolerant 

tissue (patellar tendon, medial tibial flare and muscles) while providing relief (minimal to 

no contact) for sensitive tissues (bones, tendons, scars, etc.) to allow for weight bearing and 

socket control. 

Permanent Prosthesis – An artificial limb used by amputees whose residual limb has matured 

and the amputee has satisfactorily completed the temporary limb phase. The socket and 

components are manufactured to provide lasting durability and proper cosmetic appearance.3 

Preparatory Prosthesis – This is the first limb a new amputee will wear. It consists of a 

plaster/fiberglass cast (applied during or shortly after surgery) and basic components which 

easily are removed. It controls swelling and protects the residual limb, while allowing minimal (standing, touchdown weight bearing) ambulation.3 

Proprioception – This the ability of the amputee to know where the prosthesis is in relationship 

to the body when standing and/or during ambulation, while not visually looking at the prosthesis. 

Prosthesis – An artificial substitute for a missing body part, such as an arm, leg eye, or tooth 

used for functional and cosmetic reasons, or both.2 

Prosthetics – The field of knowledge relating to prostheses, their design, use, etc.2 

Quick foot-flat – The prosthetic foot-at-heel contact moves rapidly to a foot-flat. One cause 

could be a prosthetic heel that is too soft. 

Recreational Prosthesis – An artificial limb that is specifically designed to permit the 

amputee to participate in a particular activity, e.g., swimming, skiing, running, etc., when a 

conventional prosthesis is not suitable. These prostheses are constructed in such a manner as 

to resist environmental conditions and/or external forces, which adversely effect conventional 

prosthetic designs.3 

Residual Limb – The remaining limb after amputation.4 

Supracondylar – This is an area just proximal to the femoral condyles which can have significant pressure applied for suspension of the transtibial (below-knee) prosthesis. 
57 Traumatic Amputation 

And Prosthetics 

Supracondylar/Suprapatellar (SC/SP) or PTS – In addition to the suspension of a transtibial 

prosthesis proximal to the condyles, the area proximal to the patella also can be compressed to 

provide additional suspension and to provide control to prevent hyperextension. 

Temporary Prosthesis – An artificial limb designed for the evaluation and training of a new 

amputee. It consists of a plastic socket attached to modular components that have alignable 

features. Temporary limbs are worn the first few months following amputation, until the residual 

has matured. Components can be adjusted or changed, until optimal function is achieved.3 

Terminal Device – Artificial hands or hooks designed for use with upper limb prostheses.2 

Total Contact – The total contact prosthetic socket is designed to provide minimal distal end 

contact to prevent edema. 

Total Surface Bearing (TSB) – This design allows for the entire residual limb to be in 

contact with the prosthetic socket. The loading on tolerant tissue is greater than the loading 

on sensitive tissue. 

Trim line – This is the proximal edge of a prosthesis. This can vary according to the type of 

socket design used. 

Visual Cue – This is the ability of the upper limb amputee to see the object they are attempting to pick up with the terminal device. 

REFERENCES 

1.	 Practitioner Book of Rules, American Board of Certification in Orthotics and Prosthetics 

Inc., March 16, 1988 pg. 2. 

2.	 Dorland’s Illustrated Medical Dictionary, 27th Edition, Philadelphia, PA: W. B. Saunders 

Company, 1988. 

3.	 VHA Directives 1173 Handbook, Amputee Clinic Teams and Artificial Limbs, November 

1, 2000 pp 4-5. 

4.	 A Manual for Below-Knee Amputee, 3rd Edition, American Academy of Orthotists and 

Prosthetists, Alvin C. Muilenberg, CPO and A. Bennett Wilson, Jr. 1991. 

5.	 Orthopaedics, A Study Guide, McGraw-Hill, Chapter 143, Amputations, John W. 

Michael, 1999 pp 833-850. 

6.	 2002 HCPCS Level II Expert, 13th Edition, St. Anthony Publishing, Appendix 1: 

Modifiers pg. 160. 
58 Traumatic Amputation 

And Prosthetics 

7. PROSTHETICS – ADMINISTRATIVE ISSUES 


AMPUTEE CLINIC TEAMS AND ARTIFICIAL LIMBS by Fred Downs 

Introduction 

Artificial limbs are custom-made medical devices which require a prescription before they can 

be provided to a veteran. Since they are not available “off the shelf,” this process does not 

involve simply writing a product name, dimensions and instructions on a slip of paper to take 

to the pharmacy or other provider. In the Department of Veterans Affairs, artificial limbs are 

provided to amputees through the prescription process established by an Amputee Clinic 

Team. The entire process is described in the VHA Handbook Chapter 3, titled “Amputee 

Clinic Teams and Artificial Limbs,” which is included as Appendix 9C. 

Amputee Clinic Teams 

The Handbook establishes uniform and consistent, system-wide procedures in conducting 

amputee clinics and providing artificial limbs to amputee veterans. The administrative 

processes described in the Handbook cover the basic functions of the clinic. It is important to 

realize that the clinic is much more than the place where the prescriptions are written and the 

artificial limbs are fitted. All Amputee Clinic Team members are acutely aware of the importance of the personal perceptions of the amputee as the patient proceeds through the Amputee 

Clinic Team procedures. The Amputee Clinic Team is one of the crucial elements in helping 

the amputee through another difficult stage of adapting to life as an amputee. The team can be 

the key to the successful fitting of an artificial limb to an amputee. 

The Amputee Clinic Team should be flexible in membership and be adjusted to meet local 

needs. A physician who is knowledgeable about artificial limbs always should chair the team. 

A prosthetist, physical therapist and others may make up the rest of the team. The chairman 

always should introduce the members of the team and their role. If there are students attending 

the session, they, too, should be introduced. 

Amputation Clinic Team Functions 

The Amputation Clinic Team provides evaluation, education and support during the entire 

process. The first time an amputee goes before the Amputation Clinic Team, the patient needs 

to be made to feel comfortable with the team. The patient should receive an explanation of 

what is going on, why the process is important and what the patient needs to do to help the 

team write a good prescription. The team should ask the patient questions about him/herself, 

activities and expectations. The patient’s loved ones should be invited to the clinic so they can 

listen, learn and ask questions. 
 

 

59 Traumatic Amputation 

And Prosthetics 

It often is said that the patient is an important member of the team. However, it also must be 

remembered that the patient is the only member of the team who has not been trained in the 

patient’s role as team member. The patient is not there by choice and the patient probably is 

apprehensive about everything concerning an artificial limb. In all probability, the patient has 

never seen an artificial limb. The patient certainly will not understand how it functions. The 

artificial limb will seem very alien to him/her. The patient’s thoughts will be in turmoil as the 

patient contemplates the fact that the patient will have to wear a mechanical device, a cold 

“thing” made of metal and plastic. Something ugly will be part of the patient’s body for the 

rest of the patient’s life. The patient’s instincts will be to reject wearing a limb. The leg 

amputee, of necessity, usually quickly accepts the fact the they must have a limb if they are to 

become mobile. A bilateral arm amputee also recognizes the necessity of having artificial 

limbs if they are to be independent. However, if the unilateral arm amputee is not quickly 

fitted within a “Golden Period,” 60 to 90 days after amputation, the patient will learn to be 

independent with one arm and the chances of successfully fitting the patient with an arm 

diminishes rapidly after the Golden Period. 

Some amputations are very difficult to fit with limbs that are useful. Hip or shoulder 

disarticulations are two examples where the bodies’ tolerance for pressure or gadgetry is 

low and expenditure of body energy to move the limbs becomes a burden for the amputee. 

However, in all cases, the amputee should be the one to make that decision. The Amputee 

Clinic Team should write the best prescription they can, and be prepared to be creative in 

designing the most appropriate limb for the amputee. 

The new amputee feels very vulnerable. He/she does not want to be treated like “a piece of 

meat.” The patient needs to be treated with dignity and respect. The physiological trauma 

of losing a limb is similar to what one experiences when diagnosed with a fatal disease. The 

amputee goes through the stages written about by Dr. Kubler-Ross in her book on the stages 

of dying. First there is denial, blame, anger, sorrow and finally acceptance. Each stage takes 

time. Some people pass quickly through the stages, while others may take days, weeks or 

perhaps months to reach acceptance. Of course, there are a few who never reach acceptance. 

The Amputee Clinic Team should be aware of these stages, so they are better able to assess 

the amputee. 

After the prescription is written, the limb will be fabricated in a VA Prosthetic Shop or by a 

contract vender. The amputee is fitted and adjustments made over the course of one or two visits 

in most cases. The Amputee Clinic Team will check to ensure the prostheses was fabricated to 

their prescription and it is appropriate for the patient. The first limb for an amputee is considered 

a temporary limb that the amputee will wear while learning to use the limb and to allow time 

for the residual limb to stabilize, which may take months. Depending upon the condition of 

the stump and the health of the patient, the amputee can be up and learning to walk within a 
60 Traumatic Amputation 

And Prosthetics 

month or so after amputation. The temporary socket will be replaced by the prosthetist as the 

stump shrinks. When the stump has stabilized, the final socket is fabricated and the amputee 

again will come before the Team for a final check. If the amputee likes the limb’s fit and is 

satisfied, the team will sign off on it and the vender is paid. If the amputee is not satisfied, the 

prosthesis must be sent back to the prosthetist to redo until the amputee is satisfied. 

Melding the artificial limb to the human body is an art and it takes an artist to do it well. 

The Amputee Clinic Team is the judge of the artist’s work. 
61 Traumatic Amputation 

And Prosthetics 

8. PRIMARY CARE ISSUES RELATED TO VETERANS WITH TRAUMATIC AMPUTATIONS 


by Vic M. Malabonga, M.D. 

The primary care practice of VHA clinicians may include the care of veterans who have suffered 

traumatic amputations from explosive munitions. The accepted standards of medical care 

for the general population apply equally to traumatic amputee veterans, including the VHA 

Prevention Index and clinical practice guidelines.1 There is evidence in the medical literature 

that victims of explosive war injuries that lead to lower limb amputation are predisposed 

towards certain medical conditions. In this chapter, we shall review the studies that have 

brought this to light. 

In 1979, Hrubec and Ryder presented a report to Congress on a National Academy of Sciences 

study of more that 12,000 American combat veterans with traumatic war injuries.2 They found 

a greater number of deaths from ischemic heart disease (IHD) among the proximal lower limb 

amputee veterans, compared to distal amputee veterans and veterans with disfiguring scars 

as a result of their injuries. The greatest frequency of IHD-related deaths was found among 

bilateral above-knee amputee veterans (BAKA), where the incidence was 3.5 times that of 

non-amputated veterans with disfiguring scars. In a study of 4,738 Finnish World War II 

amputee veterans, Bakalim did not find any difference in mortality rates, compared to the 

general population.3 However, there was a 63.1% greater death rate from cardiac and vascular 

diseases among the amputee veterans. Vollmar et al., looked at 329 German World War II 

traumatic lower limb amputee veterans and found an increased incidence of abdominal aortic 

aneurysms (5.8%) among the amputee veterans, compared to veterans without amputations 

(1.1%).4 This study did not find a higher incidence of coronary artery disease (CAD) or 

peripheral vascular disease in the amputee population. 

A number of studies were conducted subsequent to the report of Hrubec and Ryder in an 

attempt to identify factors contributing to the increased incidence of IHD among traumatic 

amputee veterans (TA). Yekutiel et al., studied Israeli veterans of the Middle East Wars with 

spinal cord injuries and traumatic lower limb amputations.5 They found an excess incidence 

of IHD and diabetes mellitus among the TA, but no difference in the incidence of hypertension 

(HTN). Rose et al., studied 31 Vietnam War veterans with TA and found a higher incidence of 

HTN among veterans with BAKA (47.4%) compared to those with unilateral below-elbow 

amputations (8.3%).6 Moreover, the BAKA with HTN in this study were noted to be significantly more overweight and markedly hyperinsulinemic, with reduced glucose tolerance. 

A related study of the same cohort by Rose et al., found that there was a strong correlation of 

the percentage body fat of the study population with the systolic and diastolic blood pressure.7 

They found the blood pressure elevation to have a strong and independent relation to body fat 

and insulin levels. Modan et al., looked at 201 Israeli veterans of the Middle East Wars with 
62 Traumatic Amputation 

And Prosthetics 

traumatic lower limb amputations.8 These veterans also were found to be hyperinsulinemic 

with increased blood coagulability. In contrast to the findings by Rose et al.,6 Modan and her 

group did not find a higher incidence of HTN or obesity among the TA in their study. They 

ascribed this discrepancy to the difference in numbers of BAKA between the two study 

cohorts. Studies by Loos 9 and Solonen et al.,10 also failed to show any higher incidence of 

HTN among traumatic amputee veterans. 

An interesting finding of the study by Hrubec and Ryder was the early increase in mortality 

among veterans in the 31 - 44 year age group, where the early deaths were noted 11 - 20 years 

after the injury. This suggests that the pathologic process that led to accelerated atherosclerosis 

was probably triggered not long after the injury was sustained. Rose et al., mentioned an 

unpublished survey by their group of 119 Vietnam War veterans with BAKA which showed 

that 25% of them became obese and hypertensive within one to two years of discharge from 

the military hospital.7 A study by Kurbidaylo found a significant correlation of obesity with 

the level of amputation.11 Obesity is an independent risk factor for the development of cardiovascular disease (CVD).12 In the final report of the Pooling Project, the authors reported that 

the risk attributed to obesity in relation to CVD is greatest in the 40 - 49 year age group.13 

It is possible that the early accumulation of excess body fat shortly after the war injury is one 

of the factors leading to an accelerated atherosclerotic process among traumatic lower limb 

amputee veterans. 

Several studies noted the sedentary lifestyle of amputee veterans.5,7,11 Independent of a predisposition to obesity, reduced physical fitness has been implicated as a risk factor for CVD 

and primary cardiac arrest.14,15,16 Yekutiel postulated that the stress of the war injury, as well 

as the drastic changes in lifestyle could have led to the increased incidence of IHD among 

amputee veterans.5 Hrubec and Ryder also implicated sedentary lifestyle and increased 

emotional stress as factors of importance in the increased risk of CVD among traumatic lower 

limb amputee (TLLA) veterans in their study.2 Kurbidaylo reported in his study that a regular 

exercise program among amputee veterans was needed in order to promote increased physical 

activity.11 It is likely that both obesity and reduced physical fitness are significant contributors 

to the predisposition of TLLA to ischemic heart disease. 

Some studies have reported a biochemical predisposition of TLLA to cardiovascular disease. 

Hyperinsulinemia is a known predictor for development of IHD.17,18 The study by Rose et 

al.,6 and Modan et al.,8 were able to demonstrate the presence of hyper-insulinemia among 

TLLA. In addition, Modan documented an increased mortality of traumatic amputee veterans 

from CVD in association with increased insulin levels and increased blood coagulability. 

Various hemostatic factors have been implicated in the pathogenesis of IHD.19 It is possible 

that these biochemical alterations contribute to the increased incidence of IHD among traumatic 

lower limb amputee veterans. Interestingly, alterations in the lipid profile have not been found 

to be different between TLLA and control groups.6, 8 
63 Traumatic Amputation 

And Prosthetics 

Summary 

Veterans with traumatic lower limb amputations have a higher incidence of ischemic heart 

disease, especially among bilateral above-knee amputee veterans. In addition, they also 

have a predisposition to being overweight with reduced physical fitness. Hyperinsulinemia 

and increased blood coagulability appear to be more common among those with TLLA, 

which could contribute to the increased risk of IHD in this population. Traumatic lower limb 

amputee veterans, especially BAKA, have been reported to be at increased risk for abdominal 

aortic aneurysms. There is no conclusive evidence that traumatic amputee veterans are more 

prone to develop hypertension or diabetes mellitus. For the primary care providers, it will be 

important address the cardiovascular risk factors that are present in their individual traumatic 

amputee patients and to determine if the patient can benefit from a regular exercise program. 

Vigilant application of the VHA Prevention Index measures and clinical practice guidelines is 

an essential intervention in this patient population. 

REFERENCES 

1.	 FY 2001 VHA Performance Measurement System Technical Manual. Office of Quality 

and Performance, Department of Veterans Affairs. Washington, DC: December 2000. 

2.	 Hrubec Z, Ryder RA. Traumatic lower limb amputations and subsequent mortality from 

cardiovascular disease and other causes. J Chronic Dis 1980; 33: 239-250. 

3.	 Bakalim G. Causes of death in a series of 4,738 Finnish war amputee veterans. Artif 

Limbs 1969; 13: 27-36. 

4.	 Vollmar JF, Pauschinger P, Paes E, Henze E, Friesch A. Aortic aneurysm as late sequelae 

of above-knee amputation. Lancet 1989; 2: 834-835. 

5.	 Yekutiel M, Brooks ME, Ohry A, Yarom J, Carel R. The prevalence of hypertension, 

ischemic heart disease and diabetes in traumatic spinal cord injured patients and amputee 

veterans. Paraplegia 1989; 27: 58-62. 

6.	 Rose HG, Schweitzer P, Charoenkul V, Schwartz E. Cardiovascular disease risk factors in 

combat veterans after traumatic leg amputation. Arch Phys Med Rehabil 1987; 68:20-23. 

7.	 Rose HG, Yalow RS, Schweitzer P, Schwartz E. Insulin as a potential factor influencing 

blood pressure in amputee veterans. Hypertension 1986; 8: 793-800. 

8.	 Modan M, Peles E, Halkin H, Nitzan H, Azaria M, Gitel S, Dolfin D, Modan B. 

Increased cardiovascular disease mortality rates in traumatic lower limb amputations. 

Am J Cardiol 1998; 82: 1242-1247. 
64 Traumatic Amputation 

And Prosthetics 

9.	 Loos HM. Clinical and statistical results of blood pressure behavior in amputee veterans. 

Die Med 1957; 29-30:1 059-1065. 

10.	 Solonen KA, Rinne HJ, Viikeri M, Karvinen E. Late sequelae of amputation: the health 

of Finnish war veterans. Ann Chir Gynaecol Fenniae 1965; 54 (Supp. 138):5-47. 

11.	 Hurbidaylo SF. Obesity and metabolic disorders in adults with lower limb amputations. 

J Rehabil Res and Develop 1996; 33: 387-394. 

12.	 Hubert HB, Feinleib M, McNamara PM, Castelli WP. Obesity as an independent risk 

factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham 

heart study. Circulation 1983; 67: 968-977. 

13.	 Relationship of blood pressure, serum cholesterol, smoking habit, relative weight, and 

ECG abnormalities to incidence of major coronary events: final report of the pooling 

project. J Chronic Dis 1978; 31: 201-306. 

14.	 Morris JN, Pollard R, Everitt MG, Chave SPW, Semmence AM. Vigorous exercise in 

leisure time: protection against coronary heart disease. Lancet 1980; 2: 1207-1210. 

15.	 Rabkin SW, Mathewson FAL, Ping-Hwa H. Relation of body weight to development of 

ischemic heart disease in a cohort of young North American men after a 26-year observation period: the Manitoba study. Am J Cardiol 1977; 39: 452-458. 

16.	 Siscovick DS, Weiss NS, Hallstrom AP, Inui TS, Peterson DR. Physical activity and 

primary cardiac arrest. JAMA 1982; 248: 3113-3117. 

17.	 Pyorala K. Relationship of glucose tolerance and plasma insulin to the incidence of 

coronary heart disease: results of two population studies in Finland. Diabetes Care 1979; 

2: 131-141. 

18.	 Spallarossa K, Cordera R, Andraghetti G, Bertero G, Brunelli C, Caponnetto S. 

Association between plasma insulin and angiographically documented significant 

coronary artery disease. Am J Cardiol 1994; 74: 177-179. 

19.	 Folsom AR, Wu KK, Shahar E, Davis CE. Association of hemostatic variables with 

prevalent cardiovascular disease and asymptomatic carotid artery atherosclerosis: the 

Atherosclerosis Risk in Communities (ARIC) Study Investigators. Arterioscler Thromb 

1993; 13: 1829-1836. 
65 Traumatic Amputation 

And Prosthetics 

9. APPENDICES
 

APPENDIX 9A. 

ENERGY COST OF AMBULATION IN HEALTH AND DISABILITY: 

A LITERATURE REVIEW 

Summary prepared by: Michael Howe, M.S.L.S. 

Reference: Archives of Physical and Medical Rehabilitation. 1978 Mar; 59: 124-133. 

Authors: Steven V. Fisher, M.D. and Glenn Gullickson, Jr., M.D. 

This paper attempts to summarize the current knowledge of the measurement of the energy 

expenditure (E ) of ambulation by normal subjects and for different disabilities. Ambulation e

essentially involves a translation of the body’s center of gravity through space along a pathway 

requiring the least E . In this paper, E is spoken of in terms of kcal/min and/or kcal/m. e e 

Normal Ambulation 

A review of the literature noted that the gross E /unit distance walked at speeds of 60-80 e

m/min varied little, but was least at speeds of about 80 m/min. No significant correlation 

was found between age or height and E , but weight, sex and speed of walking were e

important factors 

Lower-Extremity Amputations 

These amputations are probably the most studied disability in terms of energy requirements of 

ambulation, but the published data on energy cost of walking at different levels of amputation, 

or even at the same level of amputation, are difficult to compare and summarize because 

of the small numbers of subjects, varied speeds of walking and variations in experimental 

procedures. 
66 Traumatic Amputation 

And Prosthetics 

Symes Amputee Veterans 

When 13 Symes vascular-problem amputee veterans were studied, the investigator found that 

their average speed of walking was 34% less than that of normal controls and that they 

expended 31% more kcal/m/kg at the slower speed. 

Below-Knee (BK) Amputee Veterans 

Reitemeyer reported that two young adults with unilateral BK amputations walked 14% slower 

than normal persons and used 28% more E /unit distance when they walked at that speed. e

In Ralston’s study of the energy cost of locomotion at various speeds of two BK amputee 

veterans, the E (kcal/unit distance) was within the range for normal subjects, although in one e 

it was at the upper limit. The author concluded that the E /step is substantially higher in the e

amputee; however, when the amputee is allowed to choose his rate, the E /min is similar in the e

amputee and a normal subject. 

In reporting a treadmill study at speeds of from 50-90 m/min in BK amputee veterans, all but a 

few of whom were disabled because of trauma, Molen stated that at all speeds, they expended 

an average of 20% more kcal/min than normal subjects walking at the same speeds. 

Burnin and Passmore reported that BK amputee veterans have a 10% increase in E (kcal/min) e 

over normals when both walk at speeds of 70-83.3 m/min. 

Gonzalez and associates studied nine BK amputee veterans and the average comfortable walking speed was 64.4 m/min, or 22% slower than the normal controls, but the E /min was the e

same for BK amputee veterans and normal subjects, although the amputee walked slower than 

the normal subject. 

In Waters’ 1973 study of 13 vascular and 14 traumatic BK amputee veterans, while the E /min e

for these amputee veterans and normals was the same, the vascular amputee’s speed of walking was 41% less than the normal’s and the amputee expended 55% more kcal/m/kg at that 

speed. The traumatic amputee veterans’ speed of walking was 13% less than normal and they 

expended 25% more kcal/m/kg at that speed. 

Above-Knee (AK) Amputee Veterans 

Muller and Hettinger measured the E in three subjects fitted with 11 types of prosthetic knees e 

and found that the AK amputee used 38% more E /unit distance than a normal person walking at e

the same speed. A decade later, Inman and associates reported that an AK amputee optimally 
67 Traumatic Amputation 

And Prosthetics 

walked 20% slower and used 30% more E /unit distance than a normal subject who walks at e

his own natural, comfortable walking speed. 

The results of another study showed that at speeds of 60, 67, and 80 m/min, the E /unit distance e

for AK amputee veterans when compared to normal subjects walking at the same speeds was 

increased by 37, 40, and 51%, respectively. 

Seventeen AK amputee veterans over 50 years of age had an average walking speed of 28.2 

m/min (62% less than the natural walking speed for normal adults), and their E was stated to e 

be 55% greater than that of normals. 

Ganguli’s group described six AK amputee veterans aged 21 to 34 years in comparison with 

16 normal adult males, finding that both groups walked 1 km at the previously established 

speed of 50 m/min. Both groups walked the same distance at the same speed and a 100% 

increase in E occurred both in terms of kcal/unit distance and kcal/unit time of AK amputee e 

veterans, compared to normals walking at the same speed. 

Traugh studied nine AK amputee veterans and found that their average walking speed was 

53% slower than the comfortable walking speed of normal adults. The AK amputee veterans 

used 65% more E /unit distance at that speed than normal subjects walking at their own e

comfortable walking speed. 

In James’ report, 37 AK amputee veterans walked 30% slower than normals. At this, their 

most efficient speed, the E /unit distance of these amputee veterans was on average 40% more e

than a normal subject at his normal walking speed. Their E /unit time, however, was the same e

as that of the normal controls. 

In a study of 13 vascular and 15 traumatic AK amputee veterans, vascular amputee veterans 

walked 66% slower than normal controls and expended on the average 120% more kcal/m/kg 

at that speed. The traumatic AK amputee walked 37% slower than the normal control speed 

and expended 53% more kcal/m/kg. Unlike the BK amputee, the vascular AK amputee could 

not slow down enough to lower his kcal/min E to the level normal persons expended at their e 

most efficient speed. 

Assistive Devices 

In Inman’s group study of forearm crutches, the amputee’s natural or optimal speed of walking 

with forearm crutches was 40% slower and required 70% more kcal/unit distance than walking 

by a normal person. The forearm crutch user walked about 33% slower than did a prosthetic 

user and utilized approximately 40% more kcal/unit distance. 
68 Traumatic Amputation 

And Prosthetics 

In contrast, Erdman and co-workers compared underarm crutch walking of AK amputee veterans 

with prosthetic walking of these amputee veterans and concluded that no significant difference 

in E was demonstrated between the two methods of ambulating. e 

Trough’s group found that axillary crutch ambulation required 6% less E /min overall when e

compared to the prosthetic AK amputee’s ambulation. Waters found that the E /min was less e

in all groups of amputee veterans when using a prosthesis than when using crutches, with the 

exception of the vascular AK amputee. 

Ganguli compared normal ambulants and the E in 10 AK amputee veterans using axillary e 

crutches. The axillary crutch ambulation of the amputee required 46.5% more kcal/min than 

normal ambulation at the same speed. In another report, he studied the AK amputee using a 

prosthesis. A combination of his two studies indicated that walking at 50 m/min with a prosthesis requires 35% more E /unit time than axillary crutch ambulation at the same speed. e

McBeath and associates, however, comparing the effects of forearm and axillary crutches on 

the energy requirements of ambulation using normal adults, found that both types of crutches 

required about the same amount of E /min for a swing-through gait. Both were most efficient e

at approximately 70 m/min. 

Hemiplegics 

In a study with three hemiplegics, Bard and Ralston reported that one had considerable return 

of function and her E /unit distance was less than that of normals up to a speed of 73 m/min; a e

second, requiring a brace and cane, could walk only at 28 m/min; however, his E /unit distance e

fell within normal limits; a third patient, who also required a cane, walked at 49 m/min and 

utilized 25% more E /unit distance than normal persons. e

In a later study, Bard found that severely spastic patients required more E /unit distance than e

normal persons, the moderately spastic required the same amount of energy as normals, and 

the minimally spastic required less energy than normals. 

Corcoran and associates studied 15 hemiparetic patients without an orthosis and with both 

plastic and metal drop-foot, short-leg orthosis. The average comfortable speed without bracing 

was 41 m/min, or 46% slower than the 83 m/min comfortable walking speed for normals. The 

hemiparetic used 64% more E /unit time at this speed than did the normals at the same speed. e

With either metal or plastic bracing, the speed of walking improved 17% to 49 m/min and the 

E /unit time also was significantly reduced from 10% to 13%. e
69 Traumatic Amputation 

And Prosthetics 

Gersten and Orr measured external mechanical work, using accelerometric records of 15 

hemiplegic patients, noting a 100% increase in E /unit distance in hemiplegics as compared e

to normals. 

Paraplegics 

More of the determinants of gait are lost in paraplegics than in amputee veterans or 

hemiplegics and one would, therefore, expect their energy cost of ambulation to be higher and 

this is the case. It has been shown that the proper prescription of braces in paraplegia reduces 

energy consumption. The use of anterior ankle stops, as well as trunk support for high paraplegics has been emphasized. However, no matter how well prescribed and fitted the braces, 

a severe loss of function will still exist and, therefore, the E of ambulation is very large. e 

Wheelchair Locomotion 

Wheelchair locomotion offers an alternative to ambulation and a linear relationship exists 

between speed of wheelchair locomotion and E .e

Glaser and colleagues studied nine able-bodied males, both walking and propelling a wheelchair at 53, 70 and 83.3 m/min. The E propelling the wheelchair at each of these speeds was e 

not significantly different from that of walking. Traugh found the wheelchair locomotion 

required 9% more kcal/min than normal ambulation. Therefore, wheelchair locomotion seems 

not only to be safe, but also to require approximately the same energy as normal ambulation. 

Conclusions 

Since the disabled person, like the normal subject, tends to choose his most efficient speed of 

ambulation, it seems appropriate to let the subject pick his own speed, instead of imposing an 

unnatural speed of walking for the researcher’s convenience. Some general conclusions can be 

drawn from the averaging of the results of studies in which the subjects did choose their own 

speed. However, the results given should be taken as approximations and generalizations. 

1.	 The normal person walks 83 m/min and expends 0.063 kcal/min/kg and 0.000764 

kcal/m/kg. 

2.	 The average BK amputee walks 43% slower, and expends five% less kcal/min and 89% 

more kcal/m than the normal person. 
70 Traumatic Amputation 

And Prosthetics 

3.	 The hemiplegic walks 46% slower and expends 16% less kcal/min and 63% more kcal/m 

than normals. 

4.	 Normal and disabled persons naturally attempt to walk at a speed which is most efficient in 

terms of E /kcal/min. e

5.	 Disabled persons decrease their speed of walking, so that their E /kcal/min decreases e

toward the normal range. 

6.	 The more disabled a person, the more determinants of gait are lost; therefore, the more 

E /unit distance is used in ambulating and the less efficient is the gait. e
71 Traumatic Amputation 

And Prosthetics 

APPENDIX 9B. 

LONG-TERM FOLLOW-UP STUDY OF BILATERAL 

ABOVE-THE-KNEE AMPUTEES FROM THE VIETNAM WAR 

Summary prepared by: Michael Howe, M.S.L.S. 

Reference: The Journal of Bone and Joint Surgery. 1999 Oct; 81-A(10): 1384-1390. 

Author: Lieutenant Colonel Paul J. Dougherty, United States Army Medical Corps 

Background 

Amputation for battle casualties is carried out in two stages: (1) the goal of the first stage is to 

prepare the patient for safe transportation by removing dead tissue, allowing for wide drainage 

of the residual limb and preserving length, and (2) the goal of the second stage is to prepare 

the residual limb for a prosthesis of the appropriate length and shape. This study is the first 

to document the long-term outcome for patients who sustained a bilateral above-the-knee 

amputation during battle and were managed for this unusual injury at an Army General 

Hospital that provided specialty care for amputee veterans. It also is the largest series of 

bilateral above-the-knee amputations that has been documented. 

Materials and Methods 

A review of the records of 484 battle amputee veterans who were patients at Valley Forge 

General Hospital during the Vietnam War identified 30 patients (six %) who had sustained a 

bilateral above-the-knee amputation. After informed consent had been obtained, a survey 

consisting of a questionnaire (specifically designed for this study) and the Short Form-36 

(SF-36) Health Survey were administered. The responses of the patients on the SF-36 were 

compared with those of a group (145 individuals) of age and gender-matched controls who 

had completed the SF-36 as part of the National Survey of Functional Health Status in 1990. 

Results 

Twenty-six patients (87 %) had been injured by an unconventional land mine or booby trap; 

three (10 %) by artillery or mortar fire; and one (three %), by multiple bullets that had been 

fired from a machine gun. Fifty-three (88 %) of the sixty lower extremities had a partial or 

complete traumatic amputation that was treated with debridement and completion of the 
72 Traumatic Amputation 

And Prosthetics 

stump as the initial operative procedure. The other seven lower extremities (12 %) 

were amputated secondarily because of infection. Although it is recommended that skin 

traction be applied at the time of the initial operative treatment and continued throughout the 

evacuation chain, this protocol was used for only 26 (43 %) of the 60 residual limbs. All of 

the residual limbs were placed in skin traction once the patients reached the Valley Forge 

General Hospital. The patients were fitted for pylons or stubbies as soon as possible, so that 

they could begin gait-training. The 23 patients (77 %) for whom such data were available 

were fitted for these devices at an average of 8.3 weeks (range, three to 20 weeks) after the 

injury. Staff encouraged patients to bear increasing weight on the extremities. After the 

wounds had closed and edema had subsided, the patients were fitted for permanent prostheses. 

The 17 patients (57 %) for whom such data were available were fitted for permanent prostheses 

at an average of 6.4 months (range, six weeks to 14 months) after the injury. 

More than one-third of the 23 respondents in the present study reported that they continued to 

use prostheses with some regularity, and 10 respondents (43 %) reported that they had used 

prostheses for walking for an average of 12.9 years after they had been fitted. Walking with 

use of prostheses may have become more difficult as the patients gained weight or sustained 

injuries of the shoulder. Seventy percent of the respondents were or had been employed outside their homes. The physical functioning seen on the SF-36 questionnaire was significantly 

lower then the comparison group, but no statistically significant differences could be detected 

with respect to physical role functioning, body pain, general health, vitality, social functioning, 

emotional role functioning, or mental health. 

Discussion 

Previous military conflicts demonstrated that amputee centers were needed in order to consolidate the skills of surgeons, prosthetists, nurses and therapists. During the Vietnam War, the 

Wound Data and Munitions Effectiveness Team studied approximately 5,000 casualties and 

found that 14 of 19 patients who had sustained a bilateral above-the-knee amputation died 

before hospitalization, despite prompt medical care and timely evacuation. 

Most bilateral above-the-knee amputations noted in the study summarized here were caused 

by unconventional land mines and booby traps or by weapons fabricated from locally available 

materials or from another piece of ordnance, such as a cannon shell. A psychiatrist assigned to 

the Valley Forge General Hospital described three phases of treatment: (1) stabilization and 

wound-healing, during which patients were taught and encouraged to change their own dressings, 

(2) walking with use of prostheses, and (3) transition to outpatient status. 
73 Traumatic Amputation 

And Prosthetics 

Because of lack of practice, it is unlikely that the reality of rehabilitation at Valley Forge 

General Hospital could be equaled at a military facility today. Caring for patients who have 

sustained an amputation during battle is a discontinuous practice in the military. Documenting 

the stages in the rehabilitation process is essential for facilitating the inevitable relearning 

process that is forced on each generation of orthopaedic surgeons who must care for such 

patients. The fact that graduate medical education programs in orthopaedic surgery have 

de-emphasized amputee care further increases the need for learning. 

Two courses of action could help to minimize the learning curve in future conflicts. The first 

component is the assignment of military medical personnel to Department of Veterans Affairs 

hospitals so that they can gain experience in working with amputee veterans. The second 

component is the rotation of military medical personnel to hospitals in regions where large 

numbers of patients are injured by residual land mines, such as Asia, Africa and the Balkans, 

so that military surgeons can gain experience in the treatment of amputations. 

Future research should be directed toward preventing death on the battlefield by improving 

local resuscitative measures that can be applied immediately after soldiers are wounded. 

Efforts should be made in other areas as well. For example, because most patients who have 

sustained a bilateral above-the-knee amputation use a wheelchair for moving about, prosthetics 

research should be directed toward providing a more energy-efficient means of locomotion 

that duplicates normal gait as much as possible. 

This study has several limitations. First, a comparison of the responses of the patients in the 

study group with those individuals who were managed for a bilateral above-the-knee amputation 

at other military hospitals during the Vietnam War would have provided an excellent basis for 

conclusions. The second limitation is related to the image of heroism associated with the type 

of injury in the military setting. The third limitation of this study concerns the question of 

whether the SF-36 is appropriate for the assessment of amputee veterans. 

Wartime amputations remain an important clinical problem for the United States Army 

Medical Department. Veterans who have sustained a bilateral above-the-knee amputation have 

one of the most challenging types of injuries not often seen in civilian practice, but this study 

provides evidence that those who have sustained a bilateral above-the-knee amputation on the 

battlefield are not automatically condemned to live with severe physical and emotional difficulties. The patients in this long-term, follow-up study have led relatively normal, productive 

lives within the context of their physical limitations. 
74 Traumatic Amputation 

And Prosthetics 

APPENDIX 9C.
 

Department of Veterans Affairs VHA HANDBOOK 1173.3 

Veterans Health Administration Transmittal Sheet 

Washington, D.C. 20420 November 2, 2000 

AMPUTEE CLINIC TEAMS AND ARTIFICIAL LIMBS 

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) Handbook updates 

the previous procedures for the Department of Veterans Affairs (VA) in administering amputee 

clinic teams and providing artificial limbs to veteran beneficiaries. 

2. SUMMARY OF CHANGES: This Handbook updates current policies and procedures. 

3. RELATED ISSUES: VHA Directive 1173, and VHA Handbooks 1173.1 through 

1173.15. 

4. RESPONSIBLE OFFICE: The Chief Consultant, Prosthetic and Sensory Aids Service 

Strategic Healthcare Group (113), is responsible for the contents of this VHA Handbook. 

Questions may be referred to 202-273-8515. 

5. RESCISSIONS: VHA Manual M-2, Part IX, Chapter 2 and Chapter 6 are rescinded. 

6. RECERTIFICATION: This document is scheduled for recertification on or before the 

last working day of July 2005. 

Thomas L. Garthwaite, M.D. 

Under Secretary for Health 

Distribution: RPC: 0005 

FD 

Printing Date: /00 
75 Traumatic Amputation 

And Prosthetics 

CONTENTS
 

AMPUTEE CLINIC TEAMS AND ARTIFICAL LIMBS
 

PARAGRAPH PAGE
 

1. Purpose ................................................................................................................................76 


2. Amputee Clinic Teams ....................................................................................................... 76 
 

3. Definitions .......................................................................................................................... 79
 

4. Artificial Limbs .................................................................................................................. 81
 

5. VA Source ............................................................................................................................82 


6. Residual Limb Sock ........................................................................................................... 83
 

7. Commercial Sources ............................................................................................................83
 

8. Replacements........................................................................................................................85 


9. Spare Artificial Limbs .........................................................................................................86 


10. Repairs .............................................................................................................................. 86
 
 

76 Traumatic Amputation 

And Prosthetics 

AMPUTEE CLINIC TEAMS AND ARTIFICIAL LIMBS
 

1. PURPOSE 

This Veterans Health Administration (VHA) Handbook establishes uniform and 

consistent system-wide procedures in conducting amputee clinics and providing artificial 

limbs to amputee veterans. 

2. AMPUTEE CLINIC TEAMS 

a. Purpose 

(1) Amputee Clinic Teams provide treatment for amputee veterans. These clinics 

perform the following; they: 

(a) Examine VA beneficiaries requesting or requiring major prosthetic appliances. 

(b) Determine that an appliance is no longer serviceable and should be replaced. 

(c) Conduct closely controlled clinical evaluations on new techniques or componentry 

under policies and procedures announced by the Chief Consultant, Prosthetic and Sensory 

Aids Service Strategic Healthcare Group (SHG). 

(d) Inspect and evaluate new prostheses. 

(e) Conduct follow-up examination and treatment of beneficiaries who have received 

prescriptions through the clinic team. 

(2) Amputee Clinic Teams are established in selected field facilities under the supervision of a physician who is knowledgeable about prosthetics and physical disabilities. 

b. Responsibility 

(1) The Chairman, Amputee Clinic Team, will be charged with the direct responsibility for the treatment of all patients referred to the team. The Chairman will normally serve on 

an attending or consultant basis and will be appointed by the Chief of Staff. 

(2) The Chief, Prosthetic and Sensory Aids Service, at a facility in which an Amputee 

Clinic Team is located, will be responsible for the overall administrative management of the 
77 Traumatic Amputation 

And Prosthetics 

team. The prosthetic manager serves as coordinator, technical advisor, and designee to inspect 

and evaluate all appliances prescribed by the Clinic. 

(3) The organization of the Amputee Clinic Team will remain flexible and be adjusted 

to meet local needs. Members may include physicians from Orthopedics, Vascular, Physical 

Medicine and Rehabilitation Services, a podiatrist, physical therapist, the Preservation 

Amputation Care and Treatment (PACT) coordinator, a Department of Veterans Affairs (VA) 

and/or a commercial prosthetist, and other medical specialists as required. No more than one 

qualified prosthetist from each local commercial provider with a limb contract will be invited 

to participate in the clinic meetings. NOTE: Every effort will be made to limit the size of the 

clinic team to a maximum of eight people. 

(4) All assignments of VA personnel to Amputee Clinic Teams will be in addition to 

other duties. 

(5) The Amputee Clinic Team will orient and train medical residents who have an 

interest in prosthetics. 

c. Procedures 

(1) Beneficiaries requiring artificial limbs will be referred to the nearest Amputee 

Clinic Team when: 

(a) Residing within the Prosthetic Primary Service Area (PSA) of the facility in which 

the clinic team is located. 

(b) Residing within the PSA of another VA facility which does not have an Amputee 

Clinic Team or has been unable to resolve the patient’s prosthetic problem. 

(c) Determined to be a good candidate for a special or experimental type appliance 

which may only be prescribed by the team. 

(2) Hospitalized or domiciled beneficiaries may be referred to Amputee Clinic Teams 

at other facilities after appropriate arrangements have been made with the prosthetic representative of the facility in which the team is located. In such cases, a brief review of the beneficiary’s problem, the local medical recommendation, and the objective expected to be 

accomplished will be provided. 
 

78 Traumatic Amputation 

And Prosthetics 

d. Scheduling of Appointments and Preparation of Records 

(1) The Prosthetic Representative of each Amputee Clinic Team will arrange appointments for veterans to appear before the Clinic team. A Veterans Health Information Systems 

and Technology Architecture (VISTA) appointment management entry will be established for 

each patient scheduled with the Amputee Clinic. 

(2) Field facilities referring patients to the Clinic team will request appointments by 

use of consult (Standard Form 513, Medical Record – Consultation Sheet) or VA Form 10-2529-3, 

Request and/or Receipt for Prosthetic Appliances or Services. 

e. Conduct of Clinic Team Meetings 

(1) The patient will be treated with courtesy, respect, and empathy. The patient’s 

personal preferences will be solicited and considered before a final decision is made. 

(2) Before each patient is called for examination, a brief verbal summary of the case 

for the benefit of the members of the team and any medical residents who may be attending as 

observers will be presented. This summary will consist of: 

(a) The patient’s name; 

(b) The patient’s age; 

(c) The patient’s disability and current occupation; 

(d) The type, age and condition of prosthesis being worn; 

(e) Previous major difficulties experienced with prostheses; 

(f) Reason for present examination, and 

(g) Recommendations when indicated. 

(3) Each beneficiary will be carefully examined in a private room by the entire clinic 

team to assess the patient’s needs. If a new or replacement prosthesis is indicated, the advantages of new technology will be fully explained to the patient. However, if a patient has worn 

or used a particular type of appliance for several years without difficulty, and wishes on an 

identical replacement, the patient’s wishes will be honored unless there are definite medical 

contraindications. 
79 Traumatic Amputation 

And Prosthetics 

(4) In amputee evaluations, the medical findings and recommendations of the clinic 

team, with a specific component prescription for an artificial limb or major repair, will be 

included in the patient’s Consolidated Health Record (CHR). If additional treatment is indicated 

prior to prescription of the prosthesis, the provision of the limb will be deferred pending treatment outcome. 

f. Action Following Meeting of Clinic Team. When the meeting of the clinic team is 

adjourned, the prosthetic representative will be responsible for the following actions: 

(1) Upon receipt of the prescription and contractor selection, the veteran will be provided 

specific instructions regarding travel, delivery, training and follow-up. When pricing for the 

prescribed limb is not determined in the clinic, VA Form Letter (FL)10-90 (ADP), Request for 

Firm to Submit Estimated Cost of Prosthetic Appliance, or contractor’s letterhead quote will 

be necessary before procurement can be completed. 

(2) In the event that a beneficiary fails to appear for a scheduled appointment without 

contacting the clinic coordinator, the referring facility will be advised that the appointment was 

not kept and that a future appointment must be scheduled as though it were an original request. 

(3) In the case of beneficiaries referred from other field facilities and examined by the 

clinic team, a Standard Form (SF) 509 Medical Record – Progress Note, will be prepared, in 

duplicate, and the original will be immediately forwarded to the facility from which the beneficiary was referred. The remaining copy will be retained for the clinic team file. 

(4) Appliances or repairs prescribed by the clinic team will be obtained, inspected, 

evaluated and delivered in accordance with procedures outlined in this manual. 

3. DEFINITIONS 

AFMA Host Facility. A Prosthetic Referral Center equipped with AFMA technology and 

designated as a central fabrication center to fabricate sockets for other VA Orthotic Labs. 

Artificial Limb Contract. A competitively bid contract locally awarded to preferred 

providers and used by VA personnel for the purchase of artificial limbs. 

Automated Fabrication of Mobility Aids (AFMA). A process of fabricating and fitting 

artificial limbs using computer aided design and manufacturing. 
80 Traumatic Amputation 

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Endoskeletal Prosthesis. Artificial limbs whose cosmetic and structural components are 

separate. Internal components are used to provide structural support and then foam is shaped 

to resemble the uninvolved side. Cosmetic hose or a “skin” is applied to provide color. 

Exoskeletal Prosthesis. Artificial limbs whose cosmetic and structural components are 

combined. Wood or plastic is used to provide structural support and is then shaped to resemble 

the uninvolved side. A laminate is applied to the exterior of the shaped part to provide color 

and additional strength. 

Non-contract Artificial Limb. A commercially available artificial limb, which is not on the 

current Artificial Limb Contract. 

Permanent Prosthesis. An artificial limb used by amputee veterans whose residual limb has 

matured and the amputee has satisfactorily completed the temporary limb phase. The socket and 

components are manufactured to provide lasting durability and a proper cosmetic appearance. 

Preparatory Prosthesis. This is the first limb a new amputee will wear. It consists of a plaster/ 

fiberglass cast (applied during or shortly after surgery) and basic components which are easily 

removed. It controls swelling and protects the residual limb while allowing minimal (standing, 

touchdown weight-bearing) ambulation. 

Prosthetic Sheath. A sock-like item made of synthetic materials manufactured in one thickness, 

which is worn over the residual limb to reduce abrasion. 

Prosthetic Sock. A soft fabric that is applied directly to the residual limb and acts as an 

interface between the residual limb and the prosthetic socket. Socks are used to provide comfort, 

absorb perspiration, reduce irritation and re-establish proper fit of the socket. Prosthetic socks 

come in varying thicknesses called ply (usually from one to eight ply) and in varying materials 

(usually wool, cotton, nylon, or a blend of man-made materials). In addition, they are available 

with varying thickness of silicone gel impregnated into the fabric. 

Prosthetist and/or Orthotist. An individual trained in mechanics and biomechanics to 

manufacture and fit custom or non-custom devices and assist physicians in prescribing these 

devices. 

Recreational Prosthesis. An artificial limb that is specifically designed to permit the amputee 

to participate in a particular activity, e.g., swimming, skiing, running, etc., when a conventional 

prosthesis is not suitable. These prostheses are constructed in such a manner as to resist 

environmental conditions and/or external forces, which would adversely effect conventional 

prosthetic designs. 
 

81 Traumatic Amputation 

And Prosthetics 

Temporary Prosthesis. An artificial limb designed for the evaluation and training of a 

new amputee. It consists of a plastic socket attached to modular (alignable) components. 

Temporary limbs are worn the first few months following amputation until the residual limb 

has matured. Components will be adjusted or changed until optimal function is achieved. 

Terminal Devices. Artificial hands or hooks designed for use with upper extremity prostheses. 

VA Orthotic Lab. A VA facility employing at least one orthotist and or prosthetist equipped 

to provide custom mobility aids such as artificial limbs, orthotic devices, power or manual 

wheelchairs and non-custom items like cervical collars, elastic hose or crutches. 

4. ARTIFICIAL LIMBS 

a. Artificial limbs, components, parts and repairs will be procured, fabricated and 

issued to eligible beneficiaries upon prescription from a designated physician/podiatrist of the 

Amputee Clinic Team or the Prosthetic Representative in accordance with the policies and 

procedures outlined herein and in VHA Handbook 1173.1 and VHA Handbook 1173.2. 

b. These appliances should be from commercial vendors where adequate facilities are 

available, the time required obtained for delivery is not excessive for patients, and the prices 

charged for such appliances are reasonable. VA Orthotic Laboratories with a prosthetist may also 

be used as a source in the fabrication of preparatory, temporary and permanent artificial limbs. 

c. Eligible veterans, as identified in VHA Handbook 1173.1, who have previously 

received artificial limbs from commercial sources, will continue to have their choice of vendors 

on contract with VA or their non-contract prosthetist, providing the prosthetist will accept the 

VA preferred provider rate for the geographic area. VA facilities with Orthotic Laboratories, 

or facilities with access to a VA Laboratory, will provide new amputee veterans with the 

preparatory or temporary prosthesis and permanent limbs. When the patient has achieved 

appropriate shrinkage and is ready for a permanent prosthesis, the preparatory or temporary 

prosthesis will be replaced. 

d. Terminal devices, i.e., hooks, hands, will be provided with replacement artificial 

arms. When a terminal device is prescribed, the selection of a particular type of hook and/or 

hand will be based upon a patient’s lifestyle or vocational needs. 

e. Recreational Artificial Limbs, which allow an amputee to participate in a specific 

recreational or athletic activity, may be provided. The following general guidelines should be 

followed whenever the issue of a recreational prosthetic appliance is contemplated: 
 

82 Traumatic Amputation 

And Prosthetics 

(1) The physician or podiatrist of the Amputee Clinic Team must prescribe the prosthesis. 

(2) The prescription must indicate the therapeutic, rehabilitative or psychological 

benefit to be expected or achieved through participation in this specialized activity. 

(3) The prescription must indicate that a conventional prosthesis which is worn daily 

is unsuitable for use in the recreational activity either because of environmental factors which 

would affect the prosthesis or because a specialized function not available in the conventional 

limb is required in the activity. 

(4) Frequently required prosthetic components (within the limitation of the storage 

area provided to the Prosthetic and Sensory Aids Department and the Orthotic Laboratories) 

will be stocked to expedite patient care. 

5. VA SOURCE 

a. The VA Artificial Limb Contract will be used as a primary source in custom fabrication for artificial limbs purchased for VA beneficiaries. However, fabrication may be from VA 

Orthotic Laboratories where adequate facilities are conveniently available and qualified staff is 

available to patients and prescribing physicians, the time required for delivery is not excessive 

or will not result in prolonged hospital stay for patients, and the prices charged for such 

appliances are reasonable. 

b. Work for Other Stations 

(1) Facilities with the AFMA remote system requiring the services of a VA Orthotic 

Laboratory AFMA host system must determine whether the desired appliance can be fabricated 

utilizing the AFMA system or if the beneficiary will be required to travel to the receiving 

station. The referring facility will confirm an appointment prior to sending a beneficiary to 

the laboratory in order to avoid delays and backlogs in the laboratory’s production schedule. 

Orders will be processed on a first in/first out basis, regardless of origin. 

(2) AFMA host facilities which fabricate sockets for distant facilities, where the 

patient will not be seen and is not in their VISTA system, will receive a VA Form 10-2529-3 

from the referring station utilizing the remote order section of the electronic – 3 package. 

Reimbursement costs will be negotiated between the facilities and/or VISNs involved. 
 

83 Traumatic Amputation 

And Prosthetics 

6. RESIDUAL LIMB SOCK 

a. Residual limb socks, sheaths, and other socket interface products will be furnished 

to eligible amputee veterans, VA Orthotic Laboratories and VA medical centers by the Denver 

Distribution Center (DDC), Denver, CO. 

b. Veterans residing in the United States (U.S.), U.S. possessions, or Puerto Rico will 

be furnished residual limb socks directly by initiating a request into the Remote Order Entry 

System (ROES) to the DDC, Denver, Colorado. 

c. Veterans whose eligibility is based upon enrollment will be monitored biennially, 

and the DDC will be informed of any change. The ROES electronic order will be generated 

by the facility which has the responsibility of maintaining the veteran’s VA Form 10-2319, 

Record of Prosthetic Service. The ROES order will be transmitted to the DDC on all initial 

cases and the VA Form 10-2319 annotated appropriately. 

d. Veterans residing in a foreign country will receive direct mail orders through the 

local consular office of the U.S. State Department. VA Form 10-2345, Veterans Request for 

Residual limb Socks, will be provided with all issues for the purpose of ordering future supplies. 

Veterans should be advised that the VA Form 2345 must be mailed in an envelope with the 

necessary foreign postage when mailed through their postal service. Repairs to artificial limbs 

should be directed to the Health Administration Center, Denver, CO. 

(1) Allied veterans residing in the U.S. or Puerto Rico. Issues will be made as indicated 

in preceding subparagraph 6a. The original or certified copy of the letter of authorization from 

the allied government must be on file at the DDC to indicate eligibility for continuing services. 

(2) Residual limb socks may be stocked at VA facilities for issuance to eligible beneficiaries where there is an active amputee rehabilitation program requiring immediate access for 

post- operative and temporary limb fitting. 

7. COMMERCIAL SOURCES 

The local Artificial Limb contract will be used as the primary source for commercial 

procurement of limbs purchased for VA beneficiaries. Prosthetics representatives are responsible 

for compliance with the terms and conditions of this contract. They will perform inspections 

of contractor facilities. Any changes in qualified personnel, i.e., regarding certified prosthetists 

or VA qualified prosthetists, which occur during the contract year, will be reported to the 

contracting officer at the local facility. 
 

 

84 Traumatic Amputation 

And Prosthetics 

a. Eligible veterans will be permitted to obtain authorized artificial limbs and/or terminal 

devices from any commercial artificial limb dealer who is under a current local contract to the 

VA or the veteran’s preferred prosthetist who agrees to accept the preferred provider rate. 

Such procurements are subject to the following restrictions and limitations: 

(1) The artificial limb and/or components provided to a veteran will be limited to the 

type recommended by the prescribing physician. The physician’s prescription will be specific 

as to the type of limb recommended and will include specific instructions as to the components 

to be used; e.g., type of knee joints, type of foot, etc. Any changes to the prescription, deemed 

necessary by the prosthetist, will be presented to the prescribing physician for approval. 

(2) The veteran’s choice of an approved contractor will normally be limited to those in 

the immediate geographical area. 

(a) If the prescribed limb is not available from any of the local contractors, but is 

available under contract in a more distant city, the facility will take appropriate action in favor 

of the veteran and VA. 

(b) If a veteran selects an approved contractor other than a contractor in the local 

geographical area, any travel costs incurred will be at the veteran’s own expense. Exceptions 

will only be made in those instances when it is clearly indicated that it is in the best interest of 

both the veteran and VA. 

b. All eligible veterans authorized permanent artificial limbs using a commercial contractor will be provided a current list of approved contractors in the immediate geographical 

area to assist them in their selection of a contractor. Included in this list will be the VA 

Prosthetic-Orthotic Laboratory when applicable. VA personnel will not direct, guide or prompt 

a veteran to go to a specific contractor except in those rare instances where a physician determines 

it to be necessary for the proper medical treatment of the veteran. A rotating contractor 

schedule will not be used as a method of selecting a contractor for the fabrication of a limb. 

(1) The list of VA contractors (in alphabetical order) will be developed locally and 

include all contractors having a current VA contract which are located in the facility’s area of 

prosthetic jurisdiction. 

(2) Each list will contain the following statement in bold face type: 

YOU HAVE THE RIGHT TO SELECT THE ARTIFICIAL LIMB CONTRACTOR OF 

YOUR CHOICE FROM ANY OF THE BELOW LISTED VA APPROVED CONTRACTORS. 

ANY ATTEMPT TO INFLUENCE YOUR DECISION, OR TO DIRECT YOU TO ANY PARTICULAR CONTRACTOR, SHOULD BE REPORTED TO THE DIRECTOR OF THIS FACILITY. 
 

85 Traumatic Amputation 

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c. When the designated physician of the Amputee Clinic Team prescribes a limb not 

currently covered by a VA contract or if a veteran requests a qualified contractor not under a 

current contract, the limb may be approved locally, provided charges do not exceed the average 

discount price of preferred vendors. Appropriate non-contract components (which are commercially available) may be added to a contract limb and approved locally, provided the cost 

of the component does not exceed the dollar limitation stated in the current Health Care 

Financing Administration (HCFA) schedule plus the discount. 

d. Veterans residing in Alaska, Hawaii, and San Juan may have a choice of contractors 

located within their respective states. Selection of a contractor located in the continental 

United States will be permitted only when the prescribed limb is not available from a contractor 

in the state where the veteran resides. The contractor selected will be located nearest to the 

principal point of entry within the 48 States. Veterans who (as a matter of personal preference) 

desire to select a contractor located at points more distant than those indicated above, may do 

so provided the dealer is under contract for the limb prescribed and the veteran agrees to any 

additional travel beyond the point of entry at no expense to the Government. 

8. REPLACEMENTS 

a. An artificial limb or prosthetic component (issued to an eligible beneficiary by VA) 

will be replaced after it is determined that the limb or component is no longer serviceable (due 

to fair wear and tear) or that physical changes of the beneficiary’s residual limb renders the 

appliance unsuitable for further use. Appliances in serviceable condition will be used for as 

long as it is feasibly possible. Useful life through repair will always be investigated before a 

new appliance is authorized. 

b. The determination of need for the replacement of a prosthetic appliance will be 

made and documented in the veteran’s consolidated health record by the Chief, Prosthetic and 

Sensory Aids Service, based upon physical examination of the appliance for which a replacement is requested. The progress note will document that the appliance has been examined and 

is unsatisfactory for future use due to fair wear and tear, or that a replacement is necessary due 

to physical changes in the beneficiary’s condition. 

c. If a beneficiary claims that a prosthesis is lost or destroyed, or if it is determined by 

examination that the appliance has been damaged through other than fair wear and tear, the 

Chief, Prosthetic and Sensory Aids Service, may cause an inquiry to be made into the facts of 

the case. If findings indicate the appliance has been willfully damaged or destroyed, such 

appliance will not be replaced until the beneficiary receives adequate counseling. 
 

86 Traumatic Amputation 

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9. SPARE ARTIFICIAL LIMBS 

Spare artificial limbs and terminal devices may be furnished to eligible veterans 

after clinical determination of need in each case. Such determination will be based upon the 

environmental factors, where the veteran lives or works, the availability of repair facilities and 

the particular needs of the beneficiary concerned. It is not intended that the second prosthesis 

be in such a condition that it is suitable for constant use, but only that it be in sufficiently good 

condition for temporary use whenever the regular limb requires repairs. 

10. REPAIRS 

a. Commercial 

(1) The procedures outlined in Handbook 1173.2 are applicable to the furnishing of repairs 

to artificial limbs and limb components. 

(2) Repairs may be obtained through commercial sources with the authority of VA 

Form 10-2501, the Prosthetic Service Card, (PSC), not to exceed $300, or VA Form 10-2421, 

ADP Prosthetic Authorization for Items or Services, when authorized by the Chief, Prosthetic 

and Sensory Aids Service, or designee. 

(3) Prosthetic and/or orthotic appliances may be repaired if the cost of the repair is 

less than one-half the cost of replacement. The Chief, Prosthetic and Sensory Aids Service, 

or designee, will determine whether it is more practical, from an economic point of view, to 

repair or replace the appliance. 

(4) A veteran wearing an artificial limb will be encouraged to have repairs and/or adjustments made to the appliance by the contractor or vendor who fabricated the item. If eligible for a 

PSC, the veteran should be encouraged to use the card whenever possible and practical. 

(5) Whenever repairs or adjustments to an artificial limb or terminal device are 

required within 1 year after delivery of the item, care should be exercised to determine 

whether the repairs or adjustments are necessitated because of defective materials and/or 

workmanship. If so determined, the guarantee provisions of the contract or warranty period 

under which the item was procured will be enforced. 

b. VA. VA Orthotic Laboratories may be utilized to furnish repairs to artificial limbs if 

adequate parts and qualified manpower are available. Procedures outlined in VHA Handbook 

1173.2 and VHA Handbook 1173.6 will be followed. 
87 Traumatic Amputation 

And Prosthetics 

Traumatic Amputation And Prosthetics
 

Independent Study Test Questions for CME Credit 

Using the Independent Study Participant Registration/Answer Sheet, please circle the 

letter corresponding with the correct answer. 

1.	 What is the purpose of the Amputee Clinic Team? 

a) To evaluate the amputee patient for economic status 

b) To evaluate the amputee patient for prosthetic prescription 

c) To evaluate the amputee patient’s social life 

d) To evaluate handicap parking at Rehabilitation Center 

e) None of the above 

2.	 Which of the following statements is/are TRUE? 

a)	 Veterans with traumatic lower limb amputations have a higher incidence of ischemic 

heart disease. 

b)	 Traumatic lower limb amputee veterans have a predisposition to obesity. 

c) Traumatic lower limb amputee veterans tend to have sedentary lifestyles. 

d) All of the above. 

e) None of the above. 

3.	 The type of traumatic amputation with the greatest reported risk for ischemic heart 

disease and abdominal aortic aneurysms is/are: 

a) Unilateral lower limb amputation.
 

b) Distal upper extremity amputation.
 

c) Bilateral above-knee amputation.
 

d) All of the above.
 

e) None of the above.
 
88 Traumatic Amputation 

And Prosthetics 

4. 	 Which of the following statements about traumatic lower limb amputee veterans 

is/are TRUE: 

a) Traumatic lower limb amputee veterans tend to have reduced insulin levels. 

b) Traumatic lower limb amputee veterans have been reported to have decreased blood 

coagulability. 

c) There is no conclusive evidence that traumatic amputee veterans are more prone to 

develop hypertension.
 

d) All of the above.
 

e) None of the above.
 

5.	 Cardiovascular disease risk factors that traumatic amputee veterans could be 

exposed to include which of the following: 

a) Obesity.
 

b) Reduced physical fitness.
 

c) Hyperinsulinism.
 

d) All of the above.
 

e) None of the above.
 

6. 	 Which of the following statements regarding post-operative residual limb care 

is TRUE? 

a) Narcotic medications are never required for pain control.
 

b) Knee and hip joints should be maintained in a flexed position.
 

c) Casts or rigid dressing are never used.
 

d) Activity and physical therapy is not started until the wound is completely healed.
 

e) Control of residual limb edema results in decreased pain and enhances wound healing.
 

7. 	 During the prosthetic fitting and training period, the soldier with an amputation: 

a) Should not be allowed to interact with other amputee veterans.
 

b) Learns to recognize prosthetic fit problems and when to seek professional evaluation.
 

c) Will receive his definitive prosthetic device. 


d) Is told that changes in body weight will not affect prosthetic fit and function.
 

e) Does not need vocational counseling, since the patient will be totally and 


permanently disabled. 
89 Traumatic Amputation 

And Prosthetics 

8. A soldier who has sustained a transhumeral amputation of the dominant limb will: 

a) Learn to write with the prosthesis.
 

b) Most likely return to active duty.
 

c) Switch hand dominance.
 

d) Be dependent on others for self-care activities, such as hygiene and dressing.
 

e) Cannot drive a car.
 

9. Single digit amputations: 

a) Have no functional significance, regardless of which digit is lost.
 

b) Do not require a prosthetic device, regardless of which digit is lost.
 

c) Result in complete loss of prehension, regardless of which digit is lost.
 

d) Are amenable to cosmetic restoration.
 

e) Require switching of hand dominance regardless of which digit is lost.
 

10. The energy cost of ambulation is: 

a) Generally reported as energy expenditure per kilogram per minute.
 

b) Dependent on the path taken by the center of mass of the body.
 

c) Increases as the level of amputation moves more proximally.
 

d) Increased for lower limb amputee veterans and compensated for by slowing 


walking speed.
 

e) All of the above.
 

11. A 78-year-old veteran who sustained a transfemoral amputation in WWII presents to 

your primary care clinic for initial evaluation c/o difficulty walking. He gets short of 

breath and must stop to rest about every 200 feet. He feels that his previously satisfactory prosthesis is suddenly too heavy and too long. On initial examination you 

note that he has 3+ pitting edema of his remaining foot. Management should initially 

begin with: 

a) Referral to prosthetics service for a newer, lighter and shorter prosthesis.
 

b) Tell the veteran he is just getting older and to adjust.
 

c) Request an electric scooter for the veteran.
 

d) Evaluate and treat causes of fluid retention.
 
90 Traumatic Amputation 

And Prosthetics 

12. A 55-year-old veteran with traumatic transtibial amputation presents to the primary 

care clinic three days after receiving a new prosthesis. He complains of ulceration 

over the end of his residual tibia. The veteran should: 

a) Have cleansing and debridement of the wound, as needed.
 

b) Discontinue prosthetic use until the wound is healed.
 

c) After the wound is healed, return to the prosthetist for modification of the new 


prosthesis.
 

d) All of the above.
 

13. A 65-year-old sustained traumatic transfemoral amputation 40 years ago. 	He has 

had persistent but not bothersome phantom sensation since that time. Three weeks 

ago, he fell and had immediate onset of low back pain radiating to his phantom great 

toe. Pain is made worse by movement, coughing and sneezing. The best initial 

evaluation/management would involve: 

a) Prescribe dilantin for central pain syndrome.
 

b) Refer to pain clinic.
 

c) Refer to psychiatry.
 

d) Investigate possible non-amputation related etiologies of pain, such as lumbosacral
 

radiculopathy. 

e) Treat acute pain and investigate possible non-amputation related etiologies of pain, 

such as lumbosacral radiculopathy. 

14. A 75-year-old transfemoral amputee has been ambulatory with a prosthesis since his 

injury in 1946. He was admitted with myocardial infarction, complicated by severe 

congestive heart failure and respiratory failure requiring ventilator support for 

several days. He has an ejection fraction of 25% and gets short of breath with stand 

pivot transfers. If his cardiac status does not improve, this patient: 

a) Has the same potential for ambulation as some one without an amputation.
 

b) Will be able to walk as before, but will need a new, lighter prosthesis.
 

c) Will be bed-bound.
 

d) May be a candidate for a motorized wheel chair.
 
91 Traumatic Amputation 

And Prosthetics 

15. Select the statement that is FALSE. Neuromas: 

a) Occur every time a nerve is cut.
 

b) Are always painful.
 

c) Are best managed by prosthetic socket modification.
 

d) May exhibit a Tinnel’s sign.
 

e) Symptoms may be treated pharmacologically with antidepressants, anticonvulsants and
 

non-narcotic analgesics. 

16. What were the principal causes of traumatic amputations during the Vietnam War? 

a) Aerial bombing and artillery.
 

b) Rockets and mortars.
 

c) Land mines and booby traps.
 

d) Answers (a) and (b), but not (c).
 

17. What is the preferred surgical approach for performing amputations on the 

battlefield? 

a) Open circular
 

b) Closed circular
 

c) Convex triangular
 

d) Immediate prosthetic implantation
 

18. Which of the following is/are important treatment practices, following battlefield 

amputations? 

a) Skin traction during evacuation
 

b) Transportation casts
 

c) Intravenous prophylactic heparin
 

d) (a) and (b), but not (c)
 
92 Traumatic Amputation 

And Prosthetics 

19. Which of the following is/are benefits of early weight bearing, following a traumatic 

lower limb amputation and fitting with a hard plaster shell and pylon? 

a) Faster redevelopment of a proprioceptive sense
 

b) Reduction of edema and swelling
 

c) Improved mental status
 

d) All of the above
 

20. Useful approaches to emotional support of the amputee may include: 

a) Provide education about amputation to the patient.
 

b) Encourage patients to identify specific goals for their rehabilitation.
 

c) Obtain information from others who have experienced amputations.
 

d) All of the above.
 

21. Which of the following may be useful initial drug(s) for treating “phantom pain” 

following amputation? 

a) Anticonvulsants
 

b) Low-dose tricyclic antidepressants
 

c) Intravenous morphine
 

d) Answers (a) and (b), but not (c)
 

22. How do amputees tend to view the severity of their problems, compared to rating by 

their spouses and the general public? 

a) Worse
 

b) Better
 

c) About the same
 

d) Answers (a) and (b), but not (c)
 
93 Traumatic Amputation 

And Prosthetics 

23. How do lower limb amputees frequently adjust for increased energy expenditure 

associated with ambulation? 

a) Walk slower
 

b) Use a wheelchair
 

c) Walk faster
 

d) Answers (a) and (b), but not (c)
 

24. How does the aging process often affect amputees? 

a) Frequently improves their impairment
 

b) Frequently worsens their impairment
 

c) Usually has no effect on their impairment
 

d) Answers (a) and (b), but not (c)
 

25. The functional level of an amputee may depend upon: 

a) General physical condition.
 

b) Presence or absence of cardiac, respiratory, vascular and visual problems.
 

c) Motivation and support system.
 

d) All of the above.
 

26. Lower limb prostheses may provide: 

a) Weight bearing.
 

b) Balance and ambulation.
 

c) Cosmesis.
 

d) All of the above
 

27. Upper limb prostheses may provide: 

a) Prehension.
 

b) Cosmesis.
 

c) Movement and balance.
 

d) All of the above.
 
94 Traumatic Amputation 

And Prosthetics 

28. Where are electrodes for myoelectric control devices generally positioned? 

a) In the brain
 

b) In the spinal cord
 

c) Over muscle bellies
 

d) Answers (a) and (b), but not (c)
 

29. Types of suspension systems for prosthetics include: 

a) Differential pressure, such as vacuum and suction.
 

b) Anatomical, such as by careful contouring.
 

c) Straps, corsets, harnesses and belts.
 

d) All of the above.
 

30. Which of the following is/are types of upper limb terminal devices for prosthetics: 

a) Voluntary opening.
 

b) Voluntary closing.
 

c) Secure locking.
 

d) Answers (a) and (b), but not (c).
 

31. Which of the following disciplines usually is/are represented on VA’s Amputee 

Clinic Team 

a) Physician
 

b) Prosthetist
 

c) Physical therapist
 

d) All of the above