Amputation

AMPUTATION

Q. 1

TRUE/FALSE regarding the management of diabetic foot are:

1. Strict diabetic control
2. Venous system is commonly involved
3. Topical antibiotics are used
4. Early amputation should be done
5. Diabetic ulcers are trophic ulcer

 A

1,2,3 true & 4,5 false

 B

1,3,5 true & 2,4 false

 C

All are false

 D

All are true

Q. 1

TRUE/FALSE regarding the management of diabetic foot are:

1. Strict diabetic control
2. Venous system is commonly involved
3. Topical antibiotics are used
4. Early amputation should be done
5. Diabetic ulcers are trophic ulcer

 A

1,2,3 true & 4,5 false

 B

1,3,5 true & 2,4 false

 C

All are false

 D

All are true

Ans. B

Explanation:

About statement 5
Diabetic ulcers in diabetics commonly results from decreased protective sensations because of diabetic neuropathy (trophic ulcer is a neurogenic ulcer), peripheral arterial disease (macroangiopathy), abnormal foot biomechanics and poor wound healing.

About statements 1 & 3
Treatment of diabetic ulcers are focused on the strict diabetic control, preventing further damage to the area with devices such as custom-fitted orthopedic shoes to eliminate pressure over the metatarsal head (plantar surface of the metatarsal heads and heel are usual site for diabetic ulcers). Necrotic tissue must be debrided and and topical antibiotics may be needed to control local infection. And diabetic patients must be educated to examine their foot routinely which is very important to prevent recurrence of these ulcers.

About statement 2
It is the peripheral arterial occlusion in combination with neuropathy which results in ulcer diabetic peoples. Venous involvement is not mentioned as the pathophysiologic mechanism in causation of diabetic ulcers.

About statement 4
“With the advent of new therapeutic modalities and a multidisciplinary approach, the trend has shifted away from amputation to limb and function preservation”

Ref: Sabiston 18/e, Page 2148 ; L & B 25/e, Page 913 ; Textbook of surgery by S. Das 5/e, Page 129 ; Harrison 17/e, Page 2292


Q. 2

Myodesis is employed in amputations for all of the following indications, EXCEPT:

 A

Trauma

 B

Tumor

 C

Children

 D

Ischemia

Q. 2

Myodesis is employed in amputations for all of the following indications, EXCEPT:

 A

Trauma

 B

Tumor

 C

Children

 D

Ischemia

Ans. A

Explanation:

Myodesis is contraindicated in cases of severe dysvascularity in which blood supply to the muscle appears compromised.

Ref: Campbell’s Operative Orthopaedics, 10th Edition, Page 575; Physical Medicine and Rehabilitation Secrets, 2nd Edition, Page 556; Textbook of Orthopedics and Trauma By Kulkarni, 2nd Edition, Page 3909; Essentials of Orthopaedics for Physiotherapist By Ebnezar, 2003, Page 436


Q. 3

Tarso Metatarsal amputation is also known as?

 A

Chopart’s amputation

 B

Lisfranc amputation

 C

Pirogoff amputation

 D

Symes amputation

Q. 3

Tarso Metatarsal amputation is also known as?

 A

Chopart’s amputation

 B

Lisfranc amputation

 C

Pirogoff amputation

 D

Symes amputation

Ans. B

Explanation:

Tarsometatarsal joint is known as Lisfranc joint and amputation through this joint is known as Lisfranc amputation.

Amputation of foot
 
Mid foot amputation:
 
Type Level of amputation
Lisfranc Tarsometatarsal joint
Chopart Midtarsal joint
Pirogoff
Calcaneus is rotated forward to be fused to tibia after vertical section through the middle
 

Hind Foot Amputation:

Type Level of amputation
Syme Distal tibia fibula 0.6 cm proximal to the periphery of ankle joint passing through the dome of ankle
Sarmiento Distal tibia and fibula approximately 1.3 cm proximal to the ankle joint and excision of medial and lateral malleoli
Boyd talectomy, forward shift of the calcaneus and calcaneotibial arthrodesis

Ref: Campbell’s Operative Orthopedics 10/e, Page 557-70; Current Diagnosis & Treatment in Orthopedics 3/e, Page 654-57.


Q. 4

Amputation is often not required in:

 A

Gas gangrene

 B

Buerger’s disease

 C

Chronic osteomyelitis

 D

Diabetic gangrene

Q. 4

Amputation is often not required in:

 A

Gas gangrene

 B

Buerger’s disease

 C

Chronic osteomyelitis

 D

Diabetic gangrene

Ans. C

Explanation:

Chronic osteomyelitis is a relative indication of amputation so is the answer of choice here in this question.

Indications of Amputation
Absolute Indications:
  • Irreparable loss of blood supply of a diseased or injured limb
  • Fulminant infection (Gas gangrene)
  • Microvascular ischemia (Buerger’s disease)
  • Diabetic gangrene
Relative Indications:
  • Infections
  • Burns
  • Frostbite
  • Trauma
  • Tumors
  • Nerve injuries
  • Congenital anomalies (rare)
  • Chronic osteomyelitis (rare)
Ref: Campbell’s Operative Orthopedics 10/e, Page 537-43; Current Diagnosis & Treatment in Orthopedics 3/e, Page 641-43.

Q. 5

In flap method of amputation, which structure is kept shorter than the level of amputation?

 A

Bone

 B

Muscles

 C

Nerves

 D

Vessels

Q. 5

In flap method of amputation, which structure is kept shorter than the level of amputation?

 A

Bone

 B

Muscles

 C

Nerves

 D

Vessels

Ans. A

Explanation:

Bone is kept shorter than soft tissue in flap method of amputation to facilitate closure of amputation stump.

 

Also know:

 

In guillotine amputation, limb is transected at one level through skin, muscle and bone.

 

 

 

Ref: Campbell’s operative Orthopaedics 10/e, page 544.

 


Q. 6

Ring sequestrum is seen in?

 A

Typhoid osteomyelitis

 B

Chronic osteomyelitis

 C

Amputation stump

 D

Tuberculosis osteomyelitis

Q. 6

Ring sequestrum is seen in?

 A

Typhoid osteomyelitis

 B

Chronic osteomyelitis

 C

Amputation stump

 D

Tuberculosis osteomyelitis

Ans. C

Explanation:

Excessive periosteal stripping is contraindicated as it may result in formation of ring sequestrum in amputation stump.

Type of sequestrum Found In
Ring sequestrum
Amputation stump
Around pin tracts ( external fixator)
Tubular sequestrum
Hematogenous osteomyelitis
Segmental fractures ( middle segment)
Rice grain sequestrum Tuberculosis

Ref: Campbell’s operative Orthopaedics 10/e, page 544.


Q. 7

Which of the following score evaluates chances of amputation in a traumatized limb:

 A

Revised trauma score

 B

Injury severity score

 C

Abbreviated injury score

 D

MES score

Q. 7

Which of the following score evaluates chances of amputation in a traumatized limb:

 A

Revised trauma score

 B

Injury severity score

 C

Abbreviated injury score

 D

MES score

Ans. D

Explanation:

D i.e. MES score.

 

Mangled Extremity Severity Score (MESS)

  • used to predict necessity of amputation after lower extremity trauma

Variables

  • skeletal and soft tissue injury (graded 1-4)
  • limb ischemia (graded 1-3)
  • shock (graded 0-2)
  • age (graded 0-2)

Calculation

  • score determined by adding scores of components in four categories

Interpretation

  • score of 7 or more is highly predictive of amputation

Q. 8

All of the following factors evaluate the chances of amputation in a limb, except

 A

Age

 B

B.P

 C

Velocity of trauma

 D

Presence of infection

Q. 8

All of the following factors evaluate the chances of amputation in a limb, except

 A

Age

 B

B.P

 C

Velocity of trauma

 D

Presence of infection

Ans. D

Explanation:

D i.e. Presence of infection

Mangled Extremity Severity Score (MESS) can be used as predictor of eventual amputation versus limb salvageQ. Higher the score lower the chances of salvage i.e. higher score has higher chances of amputation. However recent studies have shown it to be inaccurate in predicting the functional outcome for mangled limb patient
• Factors in evaluation of MESS are : Mn- ” Shocked SIA”


Q. 9

Tarsometatarsal amputation is also known as

 A

Chopart’s amputation

 B

Lisfranc amputation

 C

Pirogoff amputation

 D

Symes amputation

Q. 9

Tarsometatarsal amputation is also known as

 A

Chopart’s amputation

 B

Lisfranc amputation

 C

Pirogoff amputation

 D

Symes amputation

Ans. B

Explanation:

B i.e. Lisfranc amputation

Tarsometatarsal joint is known as Lisfranc joint and amputation through this joint is k/a Lisfranc amputationQ.


Q. 10

Amputation is often not required in:

 A

Gas gangrene

 B

Buerger’s

 C

Chronic osteomyelitis

 D

Diabetic gangrene

Q. 10

Amputation is often not required in:

 A

Gas gangrene

 B

Buerger’s

 C

Chronic osteomyelitis

 D

Diabetic gangrene

Ans. C

Explanation:

C i.e. Chronic Osteomy

Indications of amputation

Absolute

– Irreparable loss of blood supply of a diseased or injured limb
– Fulminant infection (eg. gas gangrene)Q
– Micro vascular ischemia (Burgers gangrene) Q
– Diabetic gangrene Q

Relative

– Infections
– Burn
– Frostbite
– Trauma
– Tumors
– Nerve injuries
– Congenital anomalies
– Chronic osteomyelitis



Q. 11

In below elbow amputation the length of stump should be

 A

10-15 cm

 B

15-20 cm

 C

20-25 cm

 D

5-10 cm

Q. 11

In below elbow amputation the length of stump should be

 A

10-15 cm

 B

15-20 cm

 C

20-25 cm

 D

5-10 cm

Ans. B

Explanation:

B i.e. 15 – 20 cm


Q. 12

Distance from Olecranon in amputation should be

 A

5-10 cm

 B

10-25 cm

 C

15-20 cm

 D

20-30 cm

Q. 12

Distance from Olecranon in amputation should be

 A

5-10 cm

 B

10-25 cm

 C

15-20 cm

 D

20-30 cm

Ans. C

Explanation:

C i.e. 15 – 20 cm

Type of Amputation              Traditional Length of Stump
Above knee                         12 cm
Below knee                         14 cm
Below Elbow                       18 cmQ
Above Elbow                       20 cm


Q. 13

In flap method of amputation which structure is kept shorter than the level of amputation:

 A

Bone

 B

Muscles

 C

Nerves

 D

Skin

Q. 13

In flap method of amputation which structure is kept shorter than the level of amputation:

 A

Bone

 B

Muscles

 C

Nerves

 D

Skin

Ans. A

Explanation:

A i.e. Bone

• Bone is kept shorter than soft tissue in flap method of amputation to facilitate closure of amputation stumpQ.
• In guillotine amputation, limb is transected at one level through skin, muscle & bone.


Q. 14

Ring sequestrum is seen in

 A

Typhoid osteomyelitis

 B

Chronic osteomyelitis

 C

Amputation stump

 D

Tuberculosis osteomyelitis

Q. 14

Ring sequestrum is seen in

 A

Typhoid osteomyelitis

 B

Chronic osteomyelitis

 C

Amputation stump

 D

Tuberculosis osteomyelitis

Ans. C

Explanation:

C i.e. Amputation Stump

Excessive periosteal stripping is contraindicated as it may result in formation of ring sequestrum in amputation stumpQ
Type of Sequestrum                      Found In
Ring sequestrum                       – Amputation stumpsQ
                                            – Around pin tracks (external fixator)
Tubular sequestrum                   – Hematogenous osteomyelitis
                                            – Segmental fractures (middle segment)
Rice grain sequestrum                – Tuberculosis


Q. 15

Which of the following is true regarding a phantom limb:

 A

Occurs in leprosy

 B

Follows amputation

 C

Follows a psychiatric illness

 D

After filariasis

Q. 15

Which of the following is true regarding a phantom limb:

 A

Occurs in leprosy

 B

Follows amputation

 C

Follows a psychiatric illness

 D

After filariasis

Ans. B

Explanation:

B i.e. Follows amputation.

‘Phantom limb’ is a late complication of amputationQ, and is used to describe the feeling that the amputated limb is still presentQ.


Q. 16

Myodesis is employed in amputations for all of the following indications except:

 A

Trauma

 B

Tumor

 C

Children

 D

Ischemia

Q. 16

Myodesis is employed in amputations for all of the following indications except:

 A

Trauma

 B

Tumor

 C

Children

 D

Ischemia

Ans. D

Explanation:

D i.e. Ischemia:

• Myodesis is contraindicated in cases of severe dysvascularity (ischemic limb) in which blood supply to the muscle appears compromised for fear of damaging the already precarious blood supply.
• Myodesis should not be performed when vascularity is compromised (Ischemia) In Myodesis the residual musculature is stitched to the bone such that it retains the ability to develop
tension. This helps in achieving structurally stable residual limbs and to reduced atrophy. Myodesis is not preferred in ischemic limbs for fear of damaging the already precarious blood supply.
• Myodesis may be used in children (Kulkarni 2nd/3909) ‘When amputation is performed in children, the bone may overgrow the muscles and protrude under the skin (stump overgrowth). To prevent this myodesis must be preferred at the time of amputation which will stimulate the muscles to grow along with the bone’.

• Myodesis may be used in Amputation for Tumors & Trauma Maximum preservation of stump length and the use of reconstructive techniques such as myodesis and myoplasty are of
particular importance.


Q. 17

Pain due to post-amputation neuroma is best treated by:

 A

Infrared therapy

 B

Interference therapy

 C

Ultrasound therapy

 D

Surgical Excision

Q. 17

Pain due to post-amputation neuroma is best treated by:

 A

Infrared therapy

 B

Interference therapy

 C

Ultrasound therapy

 D

Surgical Excision

Ans. D

Explanation:

D i.e. Surgical Excision

A painful neuroma can be prevented by gentle traction on the nerve followed by sharp proximal division, allowing the cut nerve end to retract deep into the soft tissue away from the end of amputated limb. A painful neuroma usually is palpable and often has a positive Tinel sign. Initial treatment consists of socket modification. If this fails to relieve symptoms, simple neuroma excision or a more proximal neurectomy may be required and the severed nerve is replaced into healthy tissue. Some authors recommended neuroma excision combined with centrocentral anastomosis of the proximal stump or a procedure to seal the epineural sleeve.

Phantom limb pain, although rarely when is significant, can be extremely difficult to treat. More that 50 different methods of treatment are in use. Although no one specific method is universally beneficial, some patient may benefit from such diverse measures as massage, ice, heat, increased prosthetic use, relaxation training, biofeed back, sympathetic blockade, local nerve block, epidural block, ultrasound, trans cutaneous electric nerve stimulation (TENS), placement of dorsal column stimulator, interferential therapy, and acupuncture etc.


Q. 18

Most Imp. technical consideration at the time of doing below knee amputation is –

 A

Post. flap should be longer than the anterior flap

 B

Stump should be long

 C

Stump should be short

 D

Ant flap should be longer than post flap

Q. 18

Most Imp. technical consideration at the time of doing below knee amputation is –

 A

Post. flap should be longer than the anterior flap

 B

Stump should be long

 C

Stump should be short

 D

Ant flap should be longer than post flap

Ans. A

Explanation:

Ans. is ‘a’ ie. Post flap should be longer than the anterior flop 

  • Posterior flap should be longer than the anterior flap as the posterior skin has a good blood supply (and anterior skin has poor due to lack of muscle on anterior aspect). A good blood supply helps in easy healing of stump.

– Equally short anterior and posterior flaps are used only when the long post flap technique is not feasible because of previous wounds or extensive tissue ischemia.

  • ‘The longer (the stump) the better’, is the general rule for amputation at all sites, but below knee amputation is an exception.
  • The amputation level is kept proximal to the lower third of tibia, since the preponderance of tendinous structures in the lower third predispose to poor circulation and an unstable painful lump.
  • The best level below the knee as, for, as prosthetic fitting is concerned is at the distal musculotendinous junction of the gastrocnemius muscle.
  • Some other imp. points about BK amputation
  • The fibula is transected slightly above the tibial level.
  • No essential differences in healing rate is noted in pts. with or without popliteal pulses, but the absence of a femoral pulse is associated with a high failure rate for BK amputation.
  • The nerves are pulled gently down, transected and then allowed to retract, and the vessels are ligated above the level of the end of tibia.

Q. 19

Extensive surgical debridement, decompression or amputation may be indicated in the following clinical setting except –

 A

Progressive synergistic gangrene

 B

Acute thrombophlebitis

 C

Acute haemolytic streptococcal cellulitis

 D

Acute rhabdomyolysis

Q. 19

Extensive surgical debridement, decompression or amputation may be indicated in the following clinical setting except –

 A

Progressive synergistic gangrene

 B

Acute thrombophlebitis

 C

Acute haemolytic streptococcal cellulitis

 D

Acute rhabdomyolysis

Ans. B

Explanation:

Ans. is ‘b’ i.e., Acute thrombophlebitis


Q. 20

Liability for wrong limb amputation can be considered under:

BHU 12; NIMHANS 14

 A

Criminal negligence

 B

Civil negligence

 C

Both civil and criminal

 D

Contributory negligence

Q. 20

Liability for wrong limb amputation can be considered under:

BHU 12; NIMHANS 14

 A

Criminal negligence

 B

Civil negligence

 C

Both civil and criminal

 D

Contributory negligence

Ans. C

Explanation:

Ans. Both civil and criminal


Q. 21

Most common cause of amputation in India is ‑

 A

Diabetic gangrene

 B

Gas gangrene

 C

Road traffic accident

 D

Tumors

Q. 21

Most common cause of amputation in India is ‑

 A

Diabetic gangrene

 B

Gas gangrene

 C

Road traffic accident

 D

Tumors

Ans. C

Explanation:

Ans. is ‘c’ i.e., Road traffic accident

Amputation

Amputation is a procedure where a part of the limb is removed through one or more bones.

Disarticulation is a procedure where the limb is removed through a joint.

Indications of amputation

Indications of amputations may be absolute or relative :‑

A) Absolute indications

  • Gas gangrene
  • Diabetic gangrene
  • Irreparable loss of blood supply due to trauma or disease
  • Peripheral vascular disease (Burger’s gangrene)

B) Relative indications

  • Trauma
  • Tumors
  • Severe loss of function of limb
  • Nerve injuries
  • Congenital anomalies
  • Overall most common cause of amputation is trauma (injury) to a limb.
  • Most common cause of trauma is road traffic accident.

Q. 22

Patient comes with crush injury to upper limb, doctor is concerned about gangrene and sepsis what can help decide between amputation and limb salvage?

 A

MESS

 B

Guliton score

 C

Gustilo Anderson classification

 D

ASIA guidelines

Q. 22

Patient comes with crush injury to upper limb, doctor is concerned about gangrene and sepsis what can help decide between amputation and limb salvage?

 A

MESS

 B

Guliton score

 C

Gustilo Anderson classification

 D

ASIA guidelines

Ans. A

Explanation:

Ans. is ‘a’ i.e., MESS

MESS (Mangled Extremity Severity Score) :

  • Estimates viability of an extremity after trauma, to determine need for salvage vs empiric amputation.
  • Following parameters are looked for :-

i)  Limb ischemia

ii) Patient age range

iii) Shock

iv) Injury mechanism


Q. 23

Amputation through Line 1 as represented in the photograph below is known as ? 

 A

Ray amputation.

 B

Gille’s operation.

 C

Lisfranc’soperation.

 D

Chopart s operation.

Q. 23

Amputation through Line 1 as represented in the photograph below is known as ? 

 A

Ray amputation.

 B

Gille’s operation.

 C

Lisfranc’soperation.

 D

Chopart s operation.

Ans. C

Explanation:

The Lisfranc is a ligament of the foot that runs between two bones called the medial cuneiform and the second metatarsal. The name comes from French surgeon Jacques Lisfranc de St. Martin (1790-1847), who was the first physician to describe injuries to this ligament.

Lisfranc’soperation- Tearing of the Lisfranc ligament can lead to instability and disruption of the joints in the middle of the foot. The goal of surgery is to restore normal alignment to the foot. Whether the injury results in a subtle malalignment of the bones or a more obvious dislocation of joints, the surgery is intended to put the bones back into their original position.

Surgery for a Lisfranc injury is indicated when there is significant displacement of the midfoot joints with instability. Most commonly this displacement is identified on X-ray. CT and MRI scans can also be helpful in diagnosis. Surgery is needed to realign and stabilize the joints. Some injuries may require a patient to have a fusion of the joints, which encourages the bones to grow together in the areas of damaged cartilage


Q. 24

The type of incision shown in the picture below can be used in which of the following cases ? 

 A

Ray amputation of a Digit.

 B

Ray amputation of a toe.

 C

Ray amputation of lip.

 D

A and B.

Q. 24

The type of incision shown in the picture below can be used in which of the following cases ? 

 A

Ray amputation of a Digit.

 B

Ray amputation of a toe.

 C

Ray amputation of lip.

 D

A and B.

Ans. D

Explanation:

The incision shown in the picture above represents Tennis Racket Incision.

The incision is made around the cannulated duct and then extended radially towards the lump.Tennis Racket Incision is also used for the Ray amputation of a Digit or a Toe.



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