Acute Post-operative Management of a Patient with an Amputation

Question 1

What are options to treat Residual Limb Pain (RLP)/post-surgical pain? (4)

Answer 1

Liberal narcotic use
Regional aesthesia
Non-narcotic medications, especially for neuropathic pain
Modalities (TENS, accupunture, etc)

Question 2

What modality should you use for neuropathic pain?

Answer 2

Non-necrotic medications, as seen in the first note card.q

Question 3

Is phantom limb pain (PLP) localized or diffuse?

Answer 3

Could be either.

Question 4

How long does phantom limb sensation or PLP last?

Answer 4

It depends.

Sometimes just after surgery, sometimes for life.

Question 5

Are medications effective for PLS or PLP.

Answer 5

No, especially not effective for PLS.

Question 6

How to treat PLS or PLP?

Answer 6

Re-train the brain and the limb.

Question 7

Do co-morbidities affect limb healing?

Answer 7

Yes. Patients should play an active role in management of their own health.

Question 8

Does residual limb healing have psychological consequences?

Answer 8

Yes, remember the stages of coping.
Limb loss is similar to losing a good friend
Make referrals as appropriate

Question 9

What are the three physical dimensions to measure during a residual limb eval?

Answer 9

Length to end of bone
Length to end of tissue
Circumferential girth (every 2.5 to 5 cm?)

Question 10

What are the 8 things to measure during a residual limb evaluation?

Answer 10

Physical dimensions
Appearance
Temp
Sensation
Wound Assessment
Dressings
ROM and Strength at Proximal Joints!
Contralateral limb assessment

Question 11

How does a residual limb typically present?

Answer 11

Incision usually red, may have drainage
Typically staples or sutures intact in incision
Edema common
Decreased sensation around incision (typically returns but may not)
DO SKIN CHECKS BEFORE WRAPPING (you fail the class if you don’t)

Question 12

What are 4 different post-op dressings?

Answer 12

Soft dressings
Rigid removable dressings (RRD)
Immediate post-op dressing (IPOP)
Nonweight bearing rigid dressing (NWB)
-Unna, gel

Question 13

What is the goal of residual limb wrapping?

Answer 13

Decrease edema and shape for patient’s prosthetic fitting

Question 14

What are 5 benefits of ACE Wrapping?

Answer 14

Transtibial and transfermoral
Inexpensive
Can use if stitches or staples or present
Available
Can provide gradient pressure

Question 15

What are 5 limitations of ACE Wrapping?

Answer 15

Can be difficult to apply
Frequent re-application needed
Least effective
Amount of compression is variable
Loses elasticity over time (especially latex-free ones)

Question 16

How many wraps should you use for Transtibial Residual Limb Wrapping?

Answer 16

Two, 4-inch wraps

Question 17

Do you wrap above the knee with Transtibial RL wrapping?

Answer 17

*Always wrap above the knee

Question 18

How many wraps should you use for Transfemoral Residual Limb Wrapping?

Answer 18

Two, 6-inch wraps and one, 4-inch wrap

Question 19

Do you anchor around the pelvis with Transfemoral RL wrapping? Why or why not?

Answer 19

Yes, to prevent development of an adductor roll

Question 20

Do you need to watch the wrapping videos on your own time?

Answer 20

Yes or you will fail. There’s a whole slide that discusses this. This is the “most challenging physical task.”

Question 21

When does acute post-op d/c planning start?

Answer 21

At time of admission

• dependent on pt’s situation
• May need to consider a temporary solution as well

Question 22

What are acute post-op rehab interventions?

Answer 22

Passive ROM (flex/ex and add/abd)
AROM of C/L limb FOR ALL MOTIONS!
Position to prevent hip and knee flexion contractures when sitting in bed
Progress to AAROM and AROM in all planes
Have program focus on pt assessment and typical problem areas

Question 23

What 6 PROM positions should you work on?

Answer 23

Prone Hip ext
Thomas test Hip Ext
Sidelying hip ext
Prone knee extension
Supine knee extention
Long-sitting knee extention

Question 24

What are 3 AROM ideas for the residual limb discussed in class?

Answer 24

Active hip ext in supine - modified bridging
Hip ext prone
Hip ext in quadriped

Question 25

What are 3 things to consider when positioning patients?

Answer 25

1. Position to prevent contractures
   - Hip ext/neutral hip
   - Knee ext
2. Position to promote healing
   - Pressure and edema management
3. What are the PT goals?

Question 26

What are ROM examples for the C/L limb

Answer 26

C/L hip ext

• prone
• thomas test
• sidelying

C/L ankle DF

• seated
• standing
• long-sitting

Question 27

Rehab interventions?

Answer 27

Strengthening
CV
Balance
ROM/Positioning

Question 28

What are key muscles to strengthen (6 LE, 2 UE)?

Answer 28

Hip ext, hip abd, knee flex, knee ext, C/L ankle PF, C/L ankle DF

Triceps and Latissimus Dorsi

Question 29

Should you incorporate CV component into therapy?

Answer 29

Yes. Establish cardiac precautions though. Also work on balance

Question 30

What do you want ROM / Positioning to accomplish? What to promote? (3)

Answer 30

Promote hip and knee ext
Promote the neutral hip position
Prevent loss of C/L ROM, especially Ankle DF

Question 31

Home Program Strengthening: what to include?

Answer 31

Preserve and improve hip ext and ABD
Strengthen knee flex and ext in TT amps
-Implement CV and Balance components too, if safe.

Question 32

What are cute post-op rehab interventions for Mobility (5) ?

Answer 32

Establish upright tolerance
Initiate and progress to independent bed mobility, rolling, and transfers
Initiate W/C mobility
Progress to single limb gait in parallel bars only if appropriate
Determine the most appropriate device for this patient at discharge

Don’t forget ADLs too (wound care included)

Question 33

What are 4 things to do regarding Community Integration?

Answer 33

Vocation and recreation (offer and promote trained peer visitation)
Home eval (assess pt’s home for accessibility and safety if not already completed, and provide info on home modifications)
Drivers Training
Prosthetist Interviews

Question 34

4 things to consider w/ equipment?

Answer 34

Provide equipment recommendations based on assessment of living environment (including stairs, W/C access, bathroom accessibility)
W/C and seating (most go home with manual WC)
-usually need to change axle due to no front weight
Mobility devices
Transfer devices