5.1- Amputation 1 Flashcards by Kristen Gleim

How many amputees in the US? How many are new annually?

1.5 million w/ 120,000 new annually

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What percentage of amputees are LE?

90% LE

10% UE (tend to be seen by OT)

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What causes 75% of LE amputations? 20%?

75% due to peripheral vascular disease

20% trauma

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Vascular disease (often due to diabetes) can result in amputation from ____ or ___ due to poor blood supply

gangrene or chronic nonhealing ulcers

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Infection of ____ and ____ are often involved

skin (cellulites) and bone (osteomyelitis)

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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

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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

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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

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What European-used drug may cause congenital malformation?

Falidimide

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2 types of amputations are BK and AK. These amputations are also known as _____ and ____.

BK or Transtibial- most common

AK or Transfemoral

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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

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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

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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.

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How is an AK cut?

Cut equally across

Femur is beveled so it won’t puncture tissue when WB

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What does a surgeon do with blood vessels?

Large blood vessels are tied off and small cauterized

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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

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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

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What is myoplasty?

most frequent closure where the muscle is attached to fascia

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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

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What is tenodesis?

muscle is attached to tendons

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What are the 7 levels of LE amputation?

Toes
Mid metatarsal
Lisfranc
Chopart
Symes
BK
AK

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Usually no deficits, some gait difficulty if great toe is taken

Toes Amputation

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No prosthesis or gait training required

Mid-metatarsal amputation

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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?

1. Knee disarticulation 2. Supracondylar 3. Long AK 4. Short AK 5. Medium AK 6. Hip disarticulation 7. Hemipelvectomy 8. 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?

1. Rigid cast 2. Intermediate Postoperative Prosthetic (IPOP) 3. Removal rigid cast 4. 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!)