Residuals of Amputations

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. The location of the amputation site.
2. If symptoms exist, describe precipitating factors, aggravating factors, alleviating factors, alleviating medications, frequency, severity, and duration.
3. If there are periods of flare-up of condition:

   State their severity, frequency, and duration.

   Name the precipitating and alleviating factors.

   Estimate to what extent, if any, per veteran, they affect functional impairment during the flare-up.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Swelling, deformity, tenderness of stump.
2. Skin, including scar.
3. Circulation.
4. Muscles.
5. Describe any limited motion or instability in the joint above the amputation site.
6. A detailed assessment of each affected joint is required.

1. Using a goniometer, measure the passive and active range of motion, including movement against gravity and against strong resistance.
2. If the joint is painful on motion, state at what point in the range of motion pain begins and ends.
3. Describe presence or absence of: pain (including pain on repeated use); fatigue; weakness; lack of endurance; and incoordination.

7. Bones.
8. Length of stump.
9. Neuroma, if present.
10. Is amputation of lower extremity improvable by prosthesis controlled by natural knee action?

Measurement of the Stump:
The stump of an amputated thigh will be measured from the perineum, at the origin of the adductor tendons, to the bony end of the stump, with the claimant recumbent and the stump lying parallel with the other lower limb. It is to be kept in mind that if the limb is abducted, flexed, rotated or adducted, its length will be altered. The effective length of a thigh stump is governed by its inside dimension. Measure length of normal thigh if present and indicate whether amputation is in upper, middle, or lower third. When amputation is bilateral, estimate the same for a person of similar height.
The stump of an amputated leg below the knee must be measured from the insertion of the internal hamstring muscles to the bony end of the stump with the patient recumbent and the leg flexed at 90 degrees.
The stump of an amputated arm should be measured from the anterior axillary fold to the bony end of the stump, with the stump hanging parallel to the chest wall. Indicate whether the amputation site is above or below the insertion of the deltoid muscle. A statement of the remaining function is the best indicator of a disability's severity.
The stump of an amputated forearm should be measured from the insertion of the biceps tendon to the bony end, with the elbow flexed at 90 degrees. Indicate if the amputation site is above or below the attachment of the pronator teres.
Amputations of fingers should be described as through the distal, middle, or proximal phalanx or as disarticulations through the distal interphalangeal, proximal interphalangeal, or metacarpophalangeal joint. Resection of the head of the metacarpal will always be reported if shown. Complete or partial loss or resection of bones of the hand will described in terms of the fraction of each remaining. If surgery has altered the usefulness of remaining or transplanted digits, this will be described.
Complete or partial loss of toes or metatarsal or tarsal bones should be described as in the subparagraph above. Always report loss of metatarsal head or other defects. Indicate if amputation is through the tarsal-metatarsal joint and if any other portions of the bones of the foot remain.

D. Diagnostic and Clinical Tests:

1. X-ray if exact amputation level is not of record.
2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Amputations must be described in accordance with the following levels:

1. ARM:

1. Disarticulation.
2. Amputation above insertion of deltoid muscle.
3. Amputation below insertion of deltoid muscle.

2. FOREARM:

1. Above radial insertion of pronator teres (function is best indicator of disability).
2. Below insertion of pronator teres.

3. THIGH:

1. Disarticulation, with loss of extrinsic pelvic girdle muscles.
2. Amputation of upper, middle or lower third, always measured from perineum to the bony end of the stump with the claimant recumbent and stump lying parallel with the other lower limb.
3. State whether this level permits satisfactory prosthesis.

4. LEG:

1. Give level of amputation and condition of stump.
2. State whether this level permits a satisfactory prosthesis.
3. Describe any stump defects (e.g., painful neuroma or circulatory disturbance).

F. Additional Limitation of Joint Function:

Impairment of joint function is determined by actual range of joint motion as reported in the physical examination and additional limitation of joint function caused by the following factors:

1. Pain, including pain on repeated use
2. Fatigue
3. Weakness
4. Lack of endurance
5. Incoordination

Do any of the above factors additionally limit joint function? If so, express the additional limitation in degrees.

Indicate if you cannot determine, without resort to mere speculation, whether any of these factors cause additional functional loss. For example, indicate if you would need to resort to mere speculation in order to express additional limitation due to repetitive use.