מבחן ריאשון Flashcards
LE Amputations
• Statistics
o 2 million people in US with some type of amputation (UE/LE, digit, toes)
o 185,000 amputations per year in US (could be traumatic or surgical)
o vascular amputees – survival rate is compromised
• 50% don’t survive beyond 5 years post amputation
• patients that on dialysis, cardiac history, multiple system failures
• a lot of them are likely to become bilateral amputees within a 5 year period – 55% within 2 years
• why patient education is so important in inspected that intact leg
• decreased ability to hop because of vascularity to intact leg
• lot of them in w/c
• work on functional distances
• Vascular Disease (diabetes and PAOD
1 cause
Could be diabetes, but the ones that don’t have peripheral arterial occlusive disease
PAOD
• Ex: affecting lower extremity, have chronic wounds
• May try and do bypasses to establish blood flow
• angioplasty to open up occluded blood vessels
• pharmacological agents
• if these treatments don’t work and patient has a low
ABI, chances for healing are not good) – they end up doing an amputation
Cause of Amputation
- Vascular Disease (diabetes and PAOD
- Infections
- Trauma
- Cancer
- Congenital
Trauma Amputations
o war vets
o bombings
o MVA - #1 traumatic event that leads to amputations
o Industrial accidents
Congenital: Amputations
o people that are born with malformed or missing limbs
o years ago – women taken medications before pregnancy
Toe amputation
- Distal, proximal phalange
- Metatarsal head is intact
- Can determine if it is a vascular issue based on wound – callus wound
• Will not give them a LE prosthetic device but they will put a filler in the shoe to take up space of phalanges that have been removed
o Prevents other toes from drifting
o Good orthopedic shoe + filler
• Most critical toe to amputate – big toe
o Affects push off
o Benefit from rocker bottom shoes
• Causes
o Frost bite
o Vascular
What toes amputated
- Distal, proximal phalange
* Metatarsal head is intact
What to give for toe amputated
• Will not give them a LE prosthetic device but they will put a filler in the shoe to take up space of phalanges that have been removed
o Prevents other toes from drifting
o Good orthopedic shoe + filler
Most Critical Toe amputation
• Most critical toe to amputate – big toe
o Affects push off
o Benefit from rocker bottom shoes
Causes toe ampuation
• Causes
o Frost bite
o Vascular
Trans metatarsal Amputation
- -what is it
- -what do we need to be careful about maintaining
1) Amputate proximal to metatarsal heads
Also called a “partial foot amputation”
2) Be careful to maintain dorsiflexion
3) Tendons – surgically attach it to remaining bone or muscle
***Would get a special shoe
Shoe for Trans metatarsal Amputation
1) Rocker bottom
They have lost MTP joints which allow us to get good push off
Moves the fulcrum proximal on the shaft
Good for RA
2) More involved shoe than someone with a toe amputation
Filler in shoe
Trans metatarsal Amputation: Who heals better? Who doesnt?
1) People that have traumatic trans metatarsal amputations do okay
2) Vascular people tend to go back for revisions
o Don’t heal as well
o Depends on individual whether they want to just start with BKA
What surgery done for trans metatarsal amputation?
2 techniques
1) Myodesis: Suture muscle/tendon to bone
2) Myoplasty: Suture it to other soft tissue (another muscle belly)
o Sometimes they just let it retract if it is not a critical muscle or tendon
As we go further up leg with amputation – typically do some sort of myodesis where thLisfranc Amputationey attach the anterior tib to a part of the limb
Lisfranc Amputation
- what is it
what is preserved
- what do we give them
1) Between metatarsal shafts and the distal tarsals
Keep cuneiforms, cuboid but metatarsals and everything distal is amputated
“partial foot amputation” – but specific to location of metatarsal shaft
2) special shoe with a filler, rocker bottom, and cushion heel for some shock absorption
cushion heel – compress it, allows the rest of the foot to plantarflex
ex: lost part of insertion on anterior tib and don’t have eccentric control, compress heel and allows rest of foot to go down in a controlled fashion
Chopart
- what is it
- what do they lose, what surgery?
- what do we give them
1) Keep the talus and calcaneus but everything distal is removed (cuneiforms, navicular)
• Partial foot amputation
2) Lost insertion on metatarsal but also anterior tib on medial cuneiform
o Lost insertions of fib brevis
o Lose a lot of extrinsic and intrinsic attachments
o Surgically reattach tendons to stabilize and fix muscles
3) `Cushion in shoe for shock absorption, shoe filler, rocker bottom shoe
chopart and lisfranc: what are they susceptible to?
A lot of these patients (chopart and lisfranc) are very susceptible to plantarflexor contraction (muscle imbalance due to loss of attachments of muscles)
o Inform patient families to do ROM
Syme’s Amputation
What surgery
what device
1) Another name “ankle disarticulation”
Take out talus and calcaneus, preserve heel pad, wrap the heel pad around distally and suture it anteriorly
2) Use a prosthetic device – foot
–Most common is the SACH Foot
• Solid ankle cushioned heel
- Simple, inexpensive
- Cushioned heel allows for nice plantarflexion
- Has a shell, bivalved (Can take it apart in two pieces, Velcro closed, Do this because you tend to have bulbous shape in the residual limb)
- Patella tendon shelf (Look inside, a little indentation that goes into the socket, Puts some of the weight bearing forces on the patella tendon so not all weight is going down into the bulbous limb)
Boyd’s Amputation
Same as Syme’s but they maintain calcaneus
Transtibial (TT) Amputation
- BKA
- Keep a long posterior flap (gastroc, and soft posterior tissue) and wrap it around anteriorly: A lot of the time, you will see the suture line distally and anteriorly
- Keep the fibula – normally cut it shorter than tibia
- Never do a transtibial amputation in the lower quarter of the leg
- –Because there is not a lot of soft tissue distally and a lot of time have a problem with skin breakdown due to prosthesis
- –Want it as long as possible but in this case, cannot make it super long
• A lot of patients will be BK’s
- –About 96% will be BK or AK
- –Probably about 65% of them being BK
• Very important to maintain knee extension, very susceptible to flexion contractures
—Have the board under their leg in W/C
Knee disarticulation
- Not common, see more in children
- Take tib and fib, sometimes they leave patella, sometimes not
• More challenging for prosthetic fitting
—Symmetry between anatomical and prosthetic knee is hard to achieve
• Spasticity and susceptible to knee flexion contracture, do this instead of BKA
—Or someone with non-functional knee
- Rationale for children as opposed to adults – don’t want to amputate near growth regions of bone, growth tends to be more normal with this
- Not common for vascular amputees
Transfemoral
- No rules, can go as long as you want but do not want it to be shorter than the lesser trochanter (then you don’t have a functional lever to control device)
- A lot less issues with skin breakdowns
• Longer lever – good for sitting and pressure distribution
—The longer the residual limb, the more control you have over prosthetic device
• Don’t see suture line as much
• Opposite of BKA – do a longer anterior flap and wrap it posteriorly, see suture line at the bottom of the residual limb
—Myoplasty and myodesis techniques
Hip Disarticulation
- Could be traumatic, cancer, severe osteomyelitis,
- Remove femoral head from acetabulum
- Person puts a lot of weight bearing on soft tissue
- Wont get a prosthetic device right away
- Has to do pelvic tilting to control the prosthetic device
- A lot do hip hiking but it is not as energy efficient – train them to do pelvic tilting to control device
- A lot of weight bearing on ischial tuberosity and overlying gluteal tissue
Hemipelvectomy
- Disarticulated from SI joint and symphysis pubis (removing half of pelvis)
- Device very similarly but don’t have ischial tuberosity
- Weight bearing on residual limb side will be inside the socket
- Pelvic tilting and trunk movements to control prosthesis
