What is the treatment for a displaced fracture of an amputated stump?

Treatment of Displaced Fracture of an Amputation Stump

Displaced fractures of amputation stumps should be treated primarily with operative fixation for displaced femoral stump fractures and hip fractures, while carefully considering the patient's ambulatory status and vascular supply, as nonoperative management often leads to poor functional outcomes and prolonged wheelchair dependence.

Initial Assessment and Diagnosis

• Maintain high clinical suspicion as delayed diagnosis occurs in over 25% of stump fractures 1
• Evaluate the fracture location (distal femur vs. hip region), degree of displacement, and soft tissue integrity 1
• Assess vascular status of the stump, particularly in dysvascular amputees who have the poorest prognosis 1
• Determine pre-injury ambulatory status, as this significantly impacts treatment decisions and outcomes 1

Treatment Algorithm Based on Fracture Location

Hip Fractures in Amputees

• Most hip fractures require operative treatment 1
• For displaced femoral neck fractures: Consider arthroplasty (hemiarthroplasty or total hip replacement) based on patient functional status 2
• In frail patients, hemiarthroplasty is preferred due to shorter operative time and lower dislocation risk 2
• For active, independent patients without cognitive dysfunction, total hip arthroplasty provides better long-term function 2

Distal Femur/Stump Fractures

• While some femur fractures can be treated nonoperatively, displaced fractures generally require surgical stabilization 1
• Operative fixation is preferred for displaced fractures to maintain stump length and enable prosthetic fitting 1
• Consider internal fixation techniques that preserve bone length while providing stable fixation 1

Critical Management Considerations

Operative vs. Nonoperative Decision-Making

• Nonoperative management of displaced stump fractures carries significant risk of poor functional outcomes 1
• Dysvascular amputees have particularly poor outcomes: 50% of previous household ambulators become wheelchair-confined after stump fractures 1
• The decision must balance fracture stability, soft tissue condition, vascular supply, and pre-injury functional status 2

Perioperative Care

• Provide appropriate pain management and antibiotic prophylaxis 2
• Correct postoperative anemia and monitor for complications 2
• Implement early mobilization protocols when fracture stability allows 2
• Assess for pressure sores, nutritional status, and wound healing 2

Rehabilitation and Prosthetic Considerations

Stump Management Post-Fracture

• Maintain stump length whenever possible to optimize prosthetic function 3, 4
• Ensure adequate soft tissue coverage with durable, sensate skin for prosthetic interface 3, 4
• Implement continuous exercises to maintain range of motion and prevent contractures 4
• Perform desensitization and edema management to facilitate prosthetic fitting 4

Long-term Functional Outcomes

• The overall incidence of stump fractures is 3% in lower-extremity amputees, but functional impact is substantial 1
• Rehabilitation success depends heavily on fracture treatment adequacy and pre-injury ambulatory status 1
• Dysvascular amputees require particularly aggressive management to prevent wheelchair dependence 1

Common Pitfalls to Avoid

• Do not miss or delay the diagnosis - maintain high suspicion and obtain appropriate imaging promptly, as over 25% of stump fractures have delayed diagnosis 1
• Avoid nonoperative management of significantly displaced fractures in patients who were previously ambulatory 1
• Do not underestimate the impact on quality of life - these fractures frequently result in loss of ambulatory status 1
• Consider vascular consultation early in dysvascular patients, as they have the poorest outcomes 1