Endgames Case Report

Pain after amputation of the lower leg

BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4578 (Published 11 November 2010) Cite this as: BMJ 2010;341:c4578
  1. Adam Low, core trainee year 2, anaesthestics,
  2. Sandeep Kapur, consultant anaesthetist/pain management
  1. 1Department of Anaesthesia, Russells Hall Hospital, Dudley, West Midlands DY1 2HQ
  1. Correspondence to: A Low aelow{at}doctors.org.uk

A 59 year old man sustained an open comminuted fracture of the right tibia and fibula in a collision between a car and a motorcycle. This was initially treated by intramedullary nailing and bone grafting of the tibia, with subsequent extensive skin grafting. His mobility remained limited because he developed continuous diffuse pain over the right ankle, which was subsequently fused. The case was complicated by osteomyelitis associated with a dental abscess 21 months later. In view of poor mobility and infection associated with the intramedullary nail, it was agreed to amputate the leg below the knee. He was given bupivacaine epidurally from 24 hours before surgery until three days after surgery, and this provided adequate acute pain control. The stump healed with good cosmetic results and a prosthesis was fitted. The patient, however, still has “a variety of constant pains, including cramp in the foot (related to the length of time using the prosthesis), a burning pain in the right ankle, and the feeling of the lower leg being in a manacle resulting in a hot, intermittent shooting pain, scoring an eight to nine out of 10 pain score.”

Questions

  • 1 What is the diagnosis?

  • 2 What mechanisms are responsible for this condition?

  • 3 What are the risk factors for developing this condition?

  • 4 Can any preoperative treatments help minimise its incidence?

  • 5 What are the management options for this patient?

Answers

1 What is the diagnosis?

Short answer

Phantom limb pain.

Long answer

First recognised by the French military surgeon Ambroise Paré in the 14th century, phantom limb pain is found in 60-85% of patients after amputation of a limb.1 2 3 The pain is usually intermittent; described as sharp, shooting, squeezing, throbbing, or burning in …

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