5.1- Amputation 1 Flashcards
How many amputees in the US? How many are new annually?
1.5 million w/ 120,000 new annually
What percentage of amputees are LE?
90% LE
10% UE (tend to be seen by OT)
What causes 75% of LE amputations? 20%?
75% due to peripheral vascular disease
20% trauma
Vascular disease (often due to diabetes) can result in amputation from ____ or ___ due to poor blood supply
gangrene or chronic nonhealing ulcers
Infection of ____ and ____ are often involved
skin (cellulites) and bone (osteomyelitis)
Dysvascular amputation (70%) is becoming more common. What are 6 risk factors?
- Diabetes- increases risk 4x
- Age- risk increases with age
- Sex- men>women
- Race- African American 2-4x risk
- MI or stroke- probably due to vascular problems
- Aortic Aneurism- most die, but if they do survive the tourniquets used on the LE’s when trying to save the client may be left on too long to save the leg
Trauma (20%) is becoming less common due to better medical care. What are 2 risk factors?
- MVA’s- car and motorcycle
2. Industrial accidents- machines, electrocutions, chemical burns
Other than dysvascular and trauma amputations, what are some other causes of amputations?
- Frostbite- seen with homeless population
- Malignancy (Osteomyelitis)- most common cause of amputation in 10-20 year olds
- Congenital Malformation- may be due to use of FALIDIMIDE- pregnancy anti-nausea drug used mainly in Europe
What European-used drug may cause congenital malformation?
Falidimide
2 types of amputations are BK and AK. These amputations are also known as _____ and ____.
BK or Transtibial- most common
AK or Transfemoral
With a BK, the _______ is left long as it has good blood supply and can be folded over the bone.
posterior flap of the gastroc
Why is the gastroc folded over the bone and sutured across the anterior portion of the shin with a BK amputee?
so person will not bear weight on the incision
With a BK, what is done with the tibia and fibula?
Tibia is beveled so it won’t puncture the tissue when weightbearing.
Fibula is cut 1” shorter so it will be non-weightbearing.
How is an AK cut?
Cut equally across
Femur is beveled so it won’t puncture tissue when WB
What does a surgeon do with blood vessels?
Large blood vessels are tied off and small cauterized
Why do nerves require special attention?
b/c they will form a neuroma at the end where cut off
- surgeon pulls nerve down, cuts, and then releases so it retracts back up into the tissue where they hopefully will not WB on it
- if the neuroma forms in the area of the prosthesis, surgery is required
What does a surgeon do with an amputee’s muscle at the cut?
generally attach them to muscle, tendons, fascia, or bone
- cut and anchored with slight tension so it does not retract up into the limb
What is myoplasty?
most frequent closure where the muscle is attached to fascia
What is myodesis?
muscle is attached to bone or periosteum
- not done often b/c periosteum often grows bone spurs in the area- interferes with WB
What is tenodesis?
muscle is attached to tendons
What are the 7 levels of LE amputation?
- Toes
- Mid metatarsal
- Lisfranc
- Chopart
- Symes
- BK
- AK
Usually no deficits, some gait difficulty if great toe is taken
Toes Amputation
No prosthesis or gait training required
Mid-metatarsal amputation
Just distal to the talus; not generally done b/c stump is very large making it difficult to do a prosthetic- also foot is pulled into PF making ambulation impossible
Chopart
Through joint superior to proximal met heads; no longer done
Lisfranc
- no longer done b/c of nasty contractures
- gastroc shortens=nasty contracture
Disarticulation at the ankle- talus and foot are removed, but heel fat pad is left to cushion the stump
Symes
- not used often, but occasionally
- difficult prosthesis due to shape of limb
A BK amputation needs to try to have ____ left below the knee.
6-8”
Why are short stumps difficult? (BK)
there is too short of a lever arm in the prosthesis- not enough leverage
Why are too long stumps difficult? (BK)
there is not enough muscle bulk left to cover the bone; also can’t use an ankle in the prosthesis
With an AK amputation, plenty of muscle is left but what is generally left only allows ____ and ____.
hip extension and abduction (adductors generally cut)
What are the advantages of knee disarticulation? Disadvantages?
Advantages- good for WB; athletes tend to like b/c of easy and quick recovery after
Disadvantages- b/c of the design of the prosthesis the knee will stick out when sitting; rarely done with women due to cosmesis
What are 8 AK amputations?
- Knee disarticulation
- Supracondylar
- Long AK
- Short AK
- Medium AK
- Hip disarticulation
- Hemipelvectomy
- Carparectomy
Why is a supracondylar amputation very rare?
- problems with space for the artificial knee
- used when very unstable knee in elderly client
What AK amputation is most optimal?
Medium AK- 10” residual limb
Why is a short AK difficult to use?
short lever arm, not enough leverage in prosthetic
Hip disarticulation is very rare. So why would a hemipelvectomy be done?
part of pelvis is removed due to malignancy- no prosthetic
A carparectomy is a bilateral hemipelvectomy. Where is the cut?
Cut at L5 level (real severe cancer situation)
- no prosthetic
- need to reroute bowel and bladder
What is #1 post-op rehab goal?
control edema
- lots of swelling which inhibits normal blood flow
- causes pain and slow healing
- can’t fit prosthetic until edema is down and residual limb appropriate shape
What are post-op options, depending on the surgeon?
- Rigid cast
- Intermediate Postoperative Prosthetic (IPOP)
- Removal rigid cast
- Soft dressing- Ace wrap or Shrinker
- Applied to limb in recovery or after sutures are removed to reduce edema and shape the stump
- Suspension with a waist belt
- Change every 3-10 days
Rigid cast
What are some negatives with the rigid cast?
- good job with edema and shaping, but CAN’T INSPECT WOUND
- not appropriate for pt. w/ poor circulation
- Rigid dressing with pylon attached- foot attached for immediate WB
- Used with young patients w/ good skin/balance
Intermediate Postoperative Prosthetic (IPOP)
What is an advantage for the IPOP? Disadvantage?
Advantage- early WB (20# force) decreases edema and gives psychological boost
Disadvantage- can’t inspect wound; not appropriate for pt. w/ poor circulation
- Applied after sutures are removed
- Usually traumatic amputee
- Made of plaster shell, socks (plys changed as limb volume decreases), and plastic cuff closed by Velcro
Removal rigid cast
not applied right away like rigid cast or IPOP
What are some advantages for removal rigid cast?
- removed to inspect skin
- can WB on bed or chair, but not ambulate
An Ace wrap is not as good with edema but cheap, easy to change, and you can teach client how to wrap. What kind of Ace wrap should be used?
4” Ace bandage for BK
2- 6” sewn together end to end for AK
How is the Ace bandage applied?
- Figure 8 pattern used with more pressure distal than proximal
- Forces swelling out and shapes stump to a cone shape that fits prosthesis
How often should you teach patient to rewrap with an Ace bandage?
every 3 hours- allows blood flow and bandage loosens over time- also allows skin inspection
What happens if the Ace bandage is applied incorrectly?
can create tourniquet effect and cause bulbous limb
What is a Shrinker?
- works same way as Ace, but is easier to do on own
- must be replaced often as limb shrinks
- can use Ace and shrinker together- helps hold Ace in place
How long is some form of compression used?
constantly for 1 year- only taken off to bathe or wear prosthesis
One rehab goal is to control edema. Another rehab goal is to prevent contractures. Where are the worst contractures?
- often have even before amputation
- knee and hip are common due to laying in bed with pillow under the knee
- joint closest to the amputation will have worst contracture
How does PT/PTA prevent contractures?
- don’t hang stump over the bed when in supine
- don’t put pillow under the knee
- don’t sit with legs crossed (increases vascular problems)
- GET INTO PRONE POSITION ASAP
A PT/PTA needs to help maintain and increase strength in the affected LE. How?
- need abduction and extension to help with ambulation (esp AK- to pull limb thru gait swing)
- manual resistance and mat exercises
- quadraped to tall kneeling exercises- WB through limb and core stabilization
Rehab goals include controlling edema, preventing contractures, and maintaining and increasing strength in the affected LE. We also want to help regain independence with mobility and self care. How?
Work on bed mobility, transfers, ambulation with walker w/o prosthesis- gives idea about motivation and ability
- prosthetics are very expensive, so they won’t give one to someone who won’t use it
There is a very high energy expenditure with prosthetic so work on _______.
muscular and cardiovascular endurance
Why does the patient need to learn care of opposite extremity (sound leg)?
- already compromised- don’t want to loose other leg
- will have more stress on good leg now
- need good footwear to avoid pressure problems
A PT/PTA rehab goal should assist patient with adjustment to loss of a body part. We should also teach skin care. What should we teach about skin care?
- inspection and proper cleaning
- scar massage, especially on tibia with BK is necessary so it does not adhere to the bone
- desensitization (nerve ending will be very angry!)
