Rehabilitation medicine curriculum standards (adult)
Knowledge guides
LG 15: Amputation of limb and prosthetics
Key presentations and conditions
Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.
Less common or more complex presentations and conditions
Advanced Trainees will understand these presentations and conditions.
Advanced Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.
Epidemiology, pathophysiology, and clinical sciences
Advanced Trainees will describe the principles of the foundational sciences.
Investigations, procedures, and clinical assessment tools
Advanced Trainees will know the indications for and how to interpret the results of these investigations, procedures, and clinical assessments tools.
Advanced Trainees will know how to explain the investigation, procedure, or clinical assessment tool to patients, families, and carers.
Important specific issues
Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management.
Rehabilitation presentations
- Community living
- Inpatient, outpatient, and community rehabilitation options
- Postoperative care
- Pre-operative assessment
Conditions
- Congenital limb deficiency versus acquired
- Upper limb versus lower limb amputation
Acquired amputation
- Traumatic versus non-traumatic
- Non-traumatic:
- diabetes mellitus
- infections:
- necrotising fasciitis
- severe sepsis
- peripheral vascular disease
- tumours:
- Ewing sarcoma
- osteosarcoma
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Conditions
Examples could include (please note this is not an exhaustive list)
- Amputations – traumatic digit and digit ischemia
- Burns
- Malignancy and tumours
- Multiple amputations
- Pain
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
- Biomechanics of normal gait
- Causes of amputation
- Epidemiology, aetiology, incidence and prevalence, mortality and morbidity of acquired major limb loss in Australia and Aotearoa New Zealand
- Haptics
- Osseointegration
- Sensory feedback
- Targeted muscle reinnervation (TMR):
- TMR at time of amputation (or as a revision) and integrated with multiple site sensors for myoelectric componentry
- Types of amputation
- Types of prosthetic designs
- VR training
Investigations
- Amputee mobility predictor with prosthesis (AMPRO) and amputee mobility predictor without prosthesis (AMPnoPRO)
- Angiography
- Ankle brachial index
- Arterial doppler ultrasound
- Functional classification (K level)
- MRI
- Ultrasound to assess for neuroma
- X-rays
Examples could include (please note this is not an exhaustive list):
Community services and reintegration
- Aids/Modifications in home environment
- Artificial limb funding schemes and services
- Community organisations
- Discharge planning
- Family and social reintegration
- Transport and driving
- Work and sports activities, including vocational retraining
Complications of amputation
- Common problems and faults in prosthetic ambulation
- Distortion of body image
- Heterotopic ossification
- Increased risk of falls
- Neuroma formation
- Skin infections and breakdowns
- Stump pain, phantom pain, and phantom sensation
- Swelling
Components and characteristics of prostheses for specific functions
- Showering
- Sport and recreation
- Swimming
- Work
Goals of prosthetic training
- Cosmetic
- Functional
- Recreational
- Social
- Vocational
Postoperative patient management
- Care of the surgical wound
- Control stump oedema – bandaging and rigid dressings
- Coping with loss, altered body image, and change in life roles
- Early resumption of assisted ambulation and self-care activity
- Level of amputation and healing of wound
- Maintenance of strength and ROM of residual limb
- Management of wound infection
- Pharmacological and non-pharmacological pain management
- Potential for prosthetic training
- Prevention of limb contractures and weakness
- Promotion of wound healing
- Psychological support
- Treatment of associated injuries
- Use of desensitisation techniques
Potential for prosthetic training
- Amputee mobility predictor with prosthesis (AMPRO) and amputee
- mobility predictor without prosthesis (AMPnoPRO)
- Functional classification (K level)
- General physical and psychological health
- Level of amputation
- Previous prosthetic use
- Surgical wound, limb contractures, and general condition of stump and residual limb
Pre-prosthetic patient management
- Age-related or other impairments of cardiopulmonary function, cognitive state, sensory deficits and neuromusculoskeletal function that might impact on prosthetic management
- Assess psychological adjustment to upcoming surgery
- Carers, social set up, home care environment assessment
- Condition of affected and unaffected limbs, and limb dominance
- Education and counselling regarding the phases of amputee rehabilitation
- Premorbid domestic, leisure, psychosocial, and vocational function
- Premorbid ambulation and mobility
- Range of motion, strength, and function of affected and unaffected limbs
Prosthetic management
- Adaptation or replacement of prosthesis with maturation of stump
- Application of prosthesis and liners
- Early fitting and training with an interim prosthesis
- Monitoring of wound and residual limb
- Prescription of appropriate prosthetic components
- Prosthetic alignment and adjustment
- Repairs and changes to the prosthesis as required over time
- Techniques of casting and fabrication of prosthetic socket
- Timing of definitive prosthesis
Prosthetic training
- Activity limitations and participation limitations
- Application of prosthesis and suspension
- Care and maintenance of prosthesis
- Haptics
- Muscle strength and conditioning exercise
- New techniques to improve prothesis control, including targeted muscle reinnervation (TMR) and myoelectrics
- Patient expectations of prosthetic use
- Self-care and domestic activities
- Special needs of the bilateral amputee
- Training in prosthesis operation
- Virtual reality training
Sports amputation
- Implications for the athlete
- Unique prosthetic needs and mobility goals