2: Amputation Key Impairments and Interventions Flashcards
What are the two main purposes of pt positioning?
- Prevent the development of joint contractures while considering comfort and function
- Minimize edema
What are the four positions we consider to prevent contractures and minimize edema?
Supine, prone, sidelying, sitting
What are four general considerations for pt positioning?
- Do not put pressure on healing surgical sites or wounds on residual limb
- Change positions at least every two hours
- Positions should vary during the day
- Must teach patient and caregiver proper positioning
How long can volume fluctuate in the residual limb following amputation?
12-18 months
What are common contractures following an transtibial amputation?
Hip: flexion, abduction, ER
Knee: flexion
What are common contractures following a transfemoral amputation?
Hip: flexion, abduction, ER
What are causes of contractures of the LE?
Poor positioning, prolonged sitting, wheelchair use
What are consequences of contractures developing in the LE?
Functional leg length discrepancy, poor prosthetic alignment
How do you manage the development of contractures in the LE?
Appropriate positioning, ambulation, prosthetic modification, casts, surgical release
What are common contractures that can develop with a transhumeral amputation?
GH: flexion, adduction, IR
What are common contractures that can develop with a transradial amputation?
GH: flexion, adduction, IR
Elbow: flexion
What are the 7 functions of post-op dressings?
- Control edema
- Pain control
- Enhance wound healing and absorb drainage
- Protect incision during functional activities
- Shape and desensitize residual limb
- Allow for early weight bearing
- Acclimate pt to caring for the residual limb
What are the three types of post-op dressings?
Rigid, semi-rigid, soft
Describe the two types of rigid post-op dressings
Removable: applied over soft dressings
Non-removable: application of rigid cast
What are advantages of a rigid post-op dressing?
Allow for early ambulation with pylon, promote circulation and healing, stimulation proprioception, soft tissue support, limit edema, utilize IPOP
What are disadvantages of a rigid post-op dressing?
Immediate wound inspection is not always possible, does not allow for daily dressing changes, requires professional application
What are complications that care result from a rigid post-op dressing?
Infection, damage to wound, pressure or traction from pistoning
Describe semi-rigid post-op dressings
Better edema control that soft, but not as good as rigid dressings, unna paste, air splint, specialized gauze with zinc oxide
How wide is the bandage typically for a semi-rigid post-op dressing?
4”
What are advantages of semi-rigid post-op dressings?
Reduce edema, provide soft tissue support, provide protections, easily changeable
What are disadvantages of semi-rigid post-op dressings?
Does not protect as well as rigid, requires more changing than rigid, may loosen and allow for development of edema
What would you use a soft post-op dressing?
If the pt is at high risk for infection so it would allow for easy wound inspection
What are the two types of soft post-op dressings?
Elastic/ace wraps and shrinkers
What is the purpose of using soft dressings?
Control edema and promote ideal shape of the residual limb and stable volume to allow for receipt and use of prosthesis
When would you chose to use a residual limb shrinker?
Once a more consistent volume is reached
Describe a shrinker
Elastic garment that encompasses the limb that can be of varying pressures
When would you use a 3” ace wrap?
Average size UE
When would you use a 4” ace wrap?
Transtibial or larger UE
When would you use a 6” ace wrap?
Transfemoral
What are advantages of a soft post-op dressing?
Reduce post-op edema, provide some protection, easily removed for would inspection, allow for AROM
What are disadvantages of a soft post-op dressing?
Poor edema control, tissue healing interrupted by frequent dressing changes, AROM may delay healing of incision, less control of residual limb pain, cannot control amount of tension, risk of tourniquet effect
What is a contraindication for using a shrinker?
Sutures or stables still present over incision
When wrapping a limb, how should the pressure be dispersed?
Distal should have more pressure than proximal
What direction should the dressing be applied in?
Obliquely in a figure 8 pattern
How often should a soft post-op dressing be worn?
24 hrs/day
How often should a soft post-op dressing be re-appllied?
Every 4-6 hrs or as needed
What percentage of pts will experience phantom limb pain following an amputation?
80%
What is the mechanism of phantom limb pain?
Unclear - abnormal regeneration of neurons, sensitization, chronic pain prior to amputation
What are treatments for phantom limb pain?
Massage, ultrasound, ice, TENS, biofeedback, guided imagery, psychotherapy, nerve blocks, mirror therapy
What are examples of interventions for sensory desensitization?
Gentle massage, toweling of extremity, lotion, TENS
What is the purpose of strengthening following an amputation?
Remediate weak areas, maximize overall strength, muscular endurance for safe energy efficient gait with prosthesis
What is required to add resistance to strength training following an amputation?
Medical clearance from MD
When will a pt typically have medical clearance for resistance training following amputation?
7-10 days when the drains and sutures/staples are removed and the wound is closed
What is the purpose of stretching following an amputation?
Remediate shortened areas, maximize overall ROM, flexibility, decrease risk of contractures
What are 7 considerations for appropriate care of a residual limb?
- Wash daily with warm water
- Shower at night with miild soap
- Pat limb dry
- Be careful of incision
- Check skin daily
- Moisturize with fragrance free lotion
- When not wearing prosthesis, wear ace wrap or shrinker
What is the function of nylon sheaths?
Provide a moisture barrier and control the friction between the skin, sock, and prosthesis
How should you care for a sheath?
Wash in luke-warm water and hang to dry
What is the purpose of a prosthetic sock?
Maintain congruent and comfortable fit due to volume loss
When the ply exceeds ___, the prosthetist should be notified as recasting may be required
12-15
What is the purpose of a liner?
Comfort and health
What is a gel liner?
Silicone, used for cushioning residual limb and hosting a suspension mechanism such as pin or lanyard
What is a transfemoral seal-in liner?
Maintains suspension through negative pressure
What is a socket?
Interface between the residual limb and prosthesis
Why is it important for the socket to have a proper fit?
Disperse pressure throughout the limb and provide more contact with the surface
What is the most common socket for a transfemoral amputaiton?
Ischial containment socket
What is the most common socket for a transtibial amputation?
Total surface bearing or patellar tendon bearing socket
What three things are important in relation to care for the socket?
- Inspect for signs of wear before every use
- Do not make mechanical adjustments or minor repairs
- Inspect connection points for stability
What is the oder of donning a prosthesis?
- Gel liner
- Socks
- Soft liner
- Prosthesis
How often should a pt wear their prosthesis at the start?
One hour per day, spending half of the time ambulating
How often should the prosthesis be removed to inspect the skin when initially starting to wear a prosthesis?
Every 30 minutes or immediately after walking
If the pt is tolerating the prosthesis well, how should you progress the duration of their wear time?
15-30 minutes per day following the 50% rule
What is the 50% rule?
The pt should be ambulating for half of the time they are wearing their prosthesis
What proportion of patients will experience a fall during inpatient rehab following a LE amputation?
1/5
What are the risk factors for falls after LE amputation?
> 71, inpatient stay of more than 3 weeks, four or more significant comorbidities, cognitive impairment, use of benzos or opiates
