Pain after amputation of the lower leg

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.” ### 1 What is the diagnosis? #### Short answer Phantom limb pain. #### Long answer First recognised by the French military surgeon Ambroise Pare 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 …