3. Amputation Flashcards
List 4 Risk factor of LL amputation other than diabetes 🔑🔑
Vascular screening tests for amputee leg 🔑🔑 EXAM 2021
1. Ankle-Brachial Index (ABI)
Ratio of brachial systolic pressure to ankle systolic pressure.
ABI >1.30 may suggest calcified, noncompressible vessels, common in diabetics.
ABI 0.91 to 1.30: Normal
ABI 0.71 to 0.90: Mild PAD
ABI 0.41 to 0.70: Moderate PAD
ABI 0.00 to 0.40: Severe PAD
2. Doppler velocity waveform analysis
If screening ABI is abnormal, Doppler waveform analysis is performed to localize the lesion
3. Intraarterial contrast angiography (Contrast MRA)
Gold standard imaging test for PAD
Cuccurollo 4th Edition Chapter 6 P&O pg478
Myodesis vs Myoplasty in term of patient selection 🔑
MYOPALSTY
Muscles are sutured to each other and to the periosteum
Procedure of choice in severely dysvascular residual limbs
MYODESIS
Muscles and fasciae are sutured directly to bone through drill holes
Residual limb is more structurally stable
Contraindicated in severe dysvascularity, blood supply to the bone may be compromised
Diabetic foot examination. 5 marks
💡 MSK & Neurovascular
- Annual foot examination
- Monofilament for sensory evaluation
- Pedal pulses for vascular assessment
- Skin integrity in metatarsal heads and between toes.
- Evaluation of foot deformaties and limitation in ROM
PMR Secrets 3rd Edition Chapter 33 pg268
Definition of Mangled hand 🔑 Dr. Abdulrazaq
Amputation is considered if irreparable damage occurs to four of the six parts
Skin, vessels, skeleton, nerves, extensor, and flexor tendons
Cuccurollo 4th Edition Chapter 6 P&O pg466
What important triad is seen in two-thirds of patients who develop foot ulcer? 🔑 Dr. Abdulrazaq
- Peripheral neuropathy (loss of protective sensation)
- Minor trauma
- Poor foot wear
- Claw foot deformity (metatarsal heads, PIP and DIP pressure)
PMR Secrets 3rd Edition Chapter 33 pg268 q6
Name the most significant signs and symptoms of acute arterial occlusion. 🔑
5 Ps
- Pain
- Pallor
- Paresthesia
- Paralysis
- Pulslessness
PMR Secrets 3rd Edition Chapter 33 pg269 q9
Vascular complications of smocking. 4 marks.
- Increase atherosclerosis
- Increase blood viscosity
- Increase platelet aggregation
- Decrease in LDL and increase in HDL
PMR Secrets 3rd Edition Chapter 33 pg269 q11
What is ankle-brachial index? 🔑🔑
The ankle brachial index (ABI) is a noninvasive way to evaluate for peripheral arterial disease.
An ABl is calculated by dividing the systolic pressure measured in the limb (usually by Doppler at the dorsalis pedis or posterior tibialis artery) by the brachial artery pressure.
For example, if systolic pressure is below 60 mmHg at the ankle and 120 mmHg at the arm, the ABI would be 0.50.
- 1.30: Indicates a noncompressible artery
- 0.91-1.30: Normal
- 0.41-0.90: Mild-to-moderate peripheral arterial disease
- 0.00-0.40: Severe arterial disease
PMR Secrets 3rd Edition Chapter 33 pg270 q12
As you examine the residual limb, there are several important aspects to assess and document. List at least four of these. 4 marks 🔑🔑
Wound / Skin
- Shape of the residual limb
- Healing status of the surgical site
- Skin integrity
- Soft tissue mobility.
- Soft tissue coverage
MSK
- Bone length (AKA, from greater trochenter & BKA from medial knee joint)
- ROM / Contracture
- Muscle Strength (Hip & Knee)
Neuro
- Phantom Limb Sensation
- Phantom Limb Pain
- Neuromas
As you examine the patient, what are the three most critical muscle groups in the lower limb and the upper limb to prepare for prosthetic ambulation? 4 marks
Upper limb (Weight Shift)
Elbow extensors (triceps)
Shoulder depressors (pectoralis,latissimus)
Grade 4/5 strength in these muscles is necessary to allow a patient to support himself or herself with an assistive device and prevent falls.
Lower limb (Glute & Quads)
Hip extensors & abductors.
Knee Extensors
Grade 4/5 strength in these muscles is critical to get from sit to stand and maintain stability during ambulation
List 4 indications for immediate postoperative rigid dressing (IPORD) 🔑🔑 MOCK
💡 Amputee will be pain full, edematous and wound still bleeding, so protect it.
- Oedema control
- Promotion of wound healing
- Pain control
- Protection from trauma
- Desensitization
- Prevention of contracture (i.e knee flexion contracture)
Randall L. Braddom 3rd edition p 270
Postoperative goals of preprosthetic management include 🔑
Goals of Postoperative Management of the Individual with an Amputation
Immediate Postamputation Period Goals
- Promote wound healing
- Pain control
- Control edema
- Prevent contracture
- Preparation of residual limb for prosthetic fitting
- Education about prosthetic fitting and care
- Independent mobility
- Independence in self-care and ADLs
- Muscle strengthening should be emphasized and should focus on:
- Gluteus medius (hip abductor) and gluteus maximus (hip extensor) muscles
- Any residual hamstring or quadriceps muscles
- Upper extremities
- Psychosocial support for the adaptations resulting from the amputation
- Aerobic Conditioning
- Balance Training
Cuccurollo 4th Edition Chapter 6 P&O pg484
DeLisa 5th Edition Chapter 74 pg2020 Table 74.2
Braddom 6th Edition Chapter 9 UL Prosthetics pg160 Box 9.6
PMR Secrets 3rd Edition Chapter 33 pg273 q21
Postoperative goals of preprosthetic management include 🔑
Goals of Postoperative Management of the Individual with an Amputation
Immediate Postamputation Period Goals
- Promote wound healing
- Pain control
- Control edema
- Prevent contracture
- Preparation of residual limb for prosthetic fitting
- Education about prosthetic fitting and care
- Independent mobility
- Independence in self-care and ADLs
- Muscle strengthening should be emphasized and should focus on:
- Gluteus medius (hip abductor) and gluteus maximus (hip extensor) muscles
- Any residual hamstring or quadriceps muscles
- Upper extremities
- Psychosocial support for the adaptations resulting from the amputation
- Aerobic Conditioning
- Balance Training
Cuccurollo 4th Edition Chapter 6 P&O pg484
DeLisa 5th Edition Chapter 74 pg2020 Table 74.2
Braddom 6th Edition Chapter 9 UL Prosthetics pg160 Box 9.6
PMR Secrets 3rd Edition Chapter 33 pg273 q21
55 years old lady who had right below knee amputation 2 weeks back comes to you in your OPD asking for advice regarding positioning. List 4 advices to the patient? 🔑🔑 MOCK
Knee Flexion Contracture
- Avoid placing a pillow under the knee
- Avoid dangling the residual limb over the side of the bed or wheelchair
- A knee extension board can be fitted underneath the wheelchair or chair to promote knee extension
Hip Flexion & Abduction Contracture
- Lie prone several times a day for 10-15 minutes at a time to prevent hip flexion contracture or lie supine while performing hip extension exercises
- Avoid placing pillows between the legs
Randall L. Braddom 3rd edition p 288
Transtibial amputee with a well fit socket and intact skin presents complaining of residual limb pain when he walks. List give 6 DDx for Residual Limb Pain
How to test and manage neuroma.🔑🔑
Test
Foot squeeze test (Mulder sign)
Investigation
MRI or US
Treatment
- Socket modification
- Gabapentin (Neurontin)
- Injection of Xylocaine and corticosteroid, Botox or Alcohol
- Surgical resection will be required
Transtibial amputee with a well fit socket and intact skin presents complaining of residual limb pain when he walks. List give 6 DDx for Residual Limb Pain
INTERNAL CAUSES
- Skin: Infection (bacterial, fungal), Pressure ulcer, Incisional pain
- Bone: Osteomyelitis, Heterotopic Ossification, Tumor, Arthritis, Stress Fracture, Hypermobile fibula, Bone spur
- Nerve: Phantom limb pain, Neuromas, Complex regional pain syndrome (CRPS)
EXTERNAL CAUSES
- Poor socket fit or limb malalignment
- Erythema persisting more than 15 to 20 minutes after wearing the limb
- Changing the number of sock plies, adding pads to the socket
- If failed, replacement socket.
DeLisa 5th Edition Chapter 74 U & LL Prosthetics pg2042-2043
Phantom Limb Pain & Sensation 🔑🔑 Definition 2 Non Pharmacological Treatment 2 Different Types of Oral Medications 2 Different Types of Local Medications
DEFINITION
💡 Neuron deafferentation hyperexcitability.
- PLS: Nonpainful sensation in the amputated part of the limb
- PLP: Painful sensation in the amputated part of the limb
- Generally phantom limb sensations that persist do not require treatment
- Phantom limb pain is pain in the absent limb and is considered neuropathic
- More intense at night and is characterized as burning, stabbing, and buzzing.
- 50% to 85% of amputees experience some phantom limb pain
- If pain persists >6 months, prognosis for spontaneous recovery is poor, usually 5% or less of the total amputee population.
💡 Socket or prosthetic modifications or surgical revision of the residual limb.
NON-PHARMACOLOGICAL TX
Desensitization techniques
They include compression, tapping, massage, and application of different textures.
Performed for 20 to 30 minutes three times per day
Pain modalities: Transcutaneous nerve stimulation, heat, and cold.
Mirrors therapy to visually trick the brain: Loss of a limb is emotionally “painful”
Range-of-motion exercises
PSYCHOLOGICAL TX
- Biofeedback
- Cognitive therapy
- Relaxation therapy
- Voluntary control of the phantom limb (mental imaging)
PHARMACOLOGICAL TX
💡 First line of treatment: tricyclic antidepressants and anticonvulsants (e.g., carbamazepine, gabapentin), either alone or in combination
- Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs)
- Anticonvulsants (Gabapentin)
- Tricyclic antidepressants (Amitriptyline)
- Serotonin-selective reuptake inhibitors/serotonin and norepinephrine reuptake inhibitors (SSRIs/SNRIs) (Cipralex/Cymbalta)
- Capsaicin Cream
- Lidocaine Patch
SURGICAL TX
- Nerve blocks, steroid injections, or epidural blocks
Cuccurollo 4th Edition Chapter 6 P&O pg500
DeLisa 5th Edition Chapter 74 U & LL Prosthetics pg2042
Braddom 6th Edition Chapter 10 LL Prosthetics pg179 Box10.1
Nabeelah BKA didn’t receive her prosthesis. Hx keeling activities. Now c/o amputee pain. 🔑🔑
1) Things to r/o 2) 4 DDx 3) Managment
INTERNAL CAUSES
- Skin: Infection (bacterial, fungal), Pressure ulcer, Incisional pain
- Bone: Osteomyelitis, Heterotopic Ossification, Tumor, Arthritis, Stress Fracture, Hypermobile fibula, Bone spur
- MSK: Knee bursitis
- Nerve: Phantom limb pain, Neuromas, Complex regional pain syndrome (CRPS)
EXTERNAL CAUSES
- Poor socket fit or limb malalignment
- Erythema persisting more than 15 to 20 minutes after wearing the limb
- Changing the number of sock plies, adding pads to the socket
- If failed, replacement socket.
RULE OUT
- Distal tibial fracture by xray
- Neuroma by US or MRI
TREATMENT
- Patient should use wheelchair for her ADLs and iADLs.
- No walking bare knee is allowed.
- Aspiration & send for analysis and culture.
- If MRI shows neuroma, start anti-neuropathic pain medications
NEUROMA
Test
Foot squeeze test (Mulder sign)
Investigation
MRI or US
Etiology
- Direct pressure from socket
- Traction on an adherent scarred nerve
Management
- Prosthetic modifications (reduce loading of pressure-sensitive areas)
- Use of gel socks or liners to better distribute loads
- Gabapentin (Neurontin)
- Local anesthetics combined with steroids (diagnostic and therapeutic)
- Surgery to resect and move the neuroma to a more protected location
DeLisa 5th Edition Chapter 74 U & LL Prosthetics pg2042-2043
1) Spot diagnosis 2) Name the test, is it positive? 3) Degree to fit prosthesis 4) Treatment.
Hip Flexion Contracture
Test
Thomas Test, positive if contralateral hip raises.
Degree allowance
Max 20 degree hip flexion contracture is allowed for prosthetic fit
Treatment
- Post-op casting
- Residual limb board when sitting
- Avoid pillows to support limbs in contracture-prone positions
- Aggressive physiotherapy for ROM
Common Post-Amputation LL contractures and how to avoid them. 🔑🔑
HIP FLEXION CONTRACTURE
- Avoid lying on an overly soft mattress
- Avoid pillow under the back or thigh
- Avoid bed elevation, keep it flat
- Avoid prolonged wheelchair use
- Prone lying for 15 minutes three times
- Lie supine actively extend the residual limb while flexing the contralateral leg
HIP ABDUCTION CONTRACTURE
- Avoid using pillow between legs
KNEE FLEXION CONTRACTURE (EXAM)
- Avoid residual limb hanging over the edge of the bed
- Avoid pillow placement under the knee
- Avoid sitting for a long period of time
- Knee extended on a board under the wheelchair cushion
Cuccurollo 4th Edition Chapter 6 P&O pg485
Figure 1. Spot diagnosis, Causes, Complication, Treatment 🔑
Hyperhidrosis (excessive sweating)
Caused by
- Non-breathable liner
- Not drying the liner before appliance.
Complication
- Might lead to skin irritation and infection.
Treatment:
- Antiperspirant – apply at night
- Rubbing alcohol should be avoided as they dry the skin excessively
- Change socks twice daily
- Use breathable socks
- Socket design
- Altering liner material
- Intra-dermal botulinum toxin
56 M, transtibial amp 5 years ago. Gained weight, socket tight, feels prosthesis is too long. Residual limb, hypertrophied and cracked. Small amount of serosanginous drainage. No signs of infection. 🔑🔑
What is your working diagnosis? Explain the pathophysiology.
In what situations does stump edema syndrome commonly occur?
How do you manage the patient? Mention 1 complication.
Choke syndrome & Verrucous hyperplasia
Pathophysiology
- Prosthetic socket being too tight proximally with lack of total contact distally
- Impaired venous return leading to edema
- Chronic choking syndrome may lead to verrucous hyperplasia of the distal residual limb
Risk Factors
- Inappropriate ACE bandage post operative
- Weight gain and tight prosthesis (loss of distal contact, tight proximally)
- Rapid shrinkage in limb (extra socks making it tight proximally)
- End pad lost or removed
Treatment
- Relieve proximal constriction (e.g. reduce number of socks, or stop prosthesis use altogether)
- Re-establish total contact of the stump distally in prosthesis (e.g. distal end pad, new socket)
- Treat any secondary infections
- Use shrinkers to control edema
Complication
Squamous cell carcinoma
Ref: Review notes 2012 (Dudek), Delisa p2043, Braddom p285
Treatment for edema other than wrapping or shrinker
Use of an oral diuretic, loop diuretic like furosemide (Lasix).
Residual Limb and Skin Care, give 4 advices to patient. 🔑🔑 (ALC Clinic)
- Look for skin irritation, breakdown, blistering, or erythema.
- Use mirror if there are areas, such as the distal end, that are not easily viewed
- Avoid excessive loading pressures
- Avoid humidity, sweating
- Cleaning the residual limb daily, preferably in the evening, with soap and water and then patting dry.
- If not wearing prosthesis, shrinker or an ACE wrap should be applied to minimize or decrease swelling.
- Nighttime washing of the liner with soap and water
- Spraying the inner part of the liner with diluted rubbing alcohol once or twice a week can reduce the buildup of bacteria
- Gentle massage decreases sensitivity to pressure
- Deep friction massage perpendicular to the scar prevents scar adhesions
- Use a thin layer of emollient to decrease the friction from massage, but discourage the use of thick creams.
- Shaving of the residual limb should be discouraged
Patient reported erythema, how long it should last if normal?
If erythema does not resolve within 20 minutes, the prosthesis should not be worn and a clinical professional should be consulted within the next few days
Patient reported erythema, how long it should last if normal?
If erythema does not resolve within 20 minutes, the prosthesis should not be worn and a clinical professional should be consulted within the next few days
