Amputation Flashcards
Surgical Consideration
Surgical consideration
- at most distal site compatible with wound healing
- Energy expenditure with walking inc. with more proximal amputation
Ankle/Brachial Index (ABI):
- compare BP in UL & LL
- Ratio<0.9= peripheral artery disease
*help determine level of amputation
Vascular cause of amputation
- Ischemia
- Diabetes mellitus
- Arterial insufficiency
- Peripheral vascular disease (the leading cause of lower limb amputation)
Level of amputation
- Hip disarticulation
- removal of entire limb at hip joint
- Extremely high energy expenditure to walk - but ambulation is still possible - Transfemoral (TF)/above knee (AK)
- WC if geriatric (esp. bil. amputations)
- short moment arm–>difficulty to walk - Knee disarticulation
- Femur intact
- Sagittal skin flaps come togehter bewteen femoral condyles
- Adductor magnus present–>stability in stance
- Durable bulbous end for WB
- Cons: larger prothesis needed with a knee/ankle joint - Transtibial/below knee
- varying lenght of residual stump
- shortest: must include tibial turbecle for Quad
- posterior skin pulled under and to the front (post. flap) - Ankle disarticulation/Syme’s
- Calcaneus and talus removed
- Heel flap with fat pad –>folded up over stump for cushion
-excellent wieght-bearing
-Cons:
*Risk of poor healing, bone spur, migrating heel pad, neuroma
*need large prosthesis - Tarsometatarsal/Lisfranc
- at TMTJ line - Transmetatarsal
- Metatarsal heads cut on angle
- Stiff rocker shoe–>push off at MTPJ
- Toe filler prosthesis–>fill the shoe
Contracture management:
Hip/knee flexion contracture >20º –> can’t use prosthesis
Common contracture:
Transfemoral: hip flexion, abduction and external rotation
Transtibial: knee and hip flexion
Education at POD 1
- Prone lying (if possible)
- No pillows under knees or thighs in supine
- No pillow between thighs for TF amputee
- Do not raise foot of the bed on electric beds
- Head of bed as flat as tolerable
- Use amp board for TT amps to keep knee in extended position
- No prolonged sitting
For every 1 hour sitting = 10-15 minutes flat
Pain management
Type of pain:
Stump/incisional pain: tenderness in the incision of the stump
Phantom pain:
Painful/noxious sensation:
Sawing, sticking, knife-like
in missing limb
Phantom sensation:
tingling, pressure, itching/tickling in the part of the limb
Neuropathic pain:
mild to severe burning, squeezing, cramping/ stabbing pain in stump
Treatment:
- Exercise
- Relaxation/ visualization
- Desensitization (Compression/massage)
- TENS
Stump shaping
-Worn all time, re-wrapped every 4 hours
-Distal to proximal pressure gradient
-Diagonal wrap
-Remove bandage if limb is throbbing/painful/cold
-Tensor in extension, back to front
Stump care
DO:
- Daily skin checking with mirror on the back of stump
- Check signs of pressure/infection
- Clean cotton swab–>for skin folds
- Touch/gentle massage stump regularly to decrease the sensitivity
DO NOT:
-Put any chemical/strong ointment on stump
- Use Heat/Ice on stump
- Touch open/broken skin
Exercise Choice
ROM:
- Positioning
- major focus on extension (hip and knee)
- Hip abd/add –> keep patient centered over stance leg during ambulation
Strength:
- Core, unaffected LL, Shoulder
- TF focus on: hip extension/flexion, add/abd
TT focus on: above + knee flex/ext
Pressure Tolerant and Sensitive Areas of Stump: Transtibial
Pressure Tolerant:
Patellar tendon
Anterior compartment
Medial flare of the tibia
Shaft of the fibula
Gastrocnemius
Popliteal fossa
Pressure sensitive:
Anterior distal tibia
Fibular head
Crest of tibia
Peroneal nerve
Distal end of fibula
Lateral tibial condyle
Distal end of the stump
Patella
Tibial tubercle
Pressure Tolerant and Sensitive Areas of Stump: Transfemoral
Pressure tolerant:
Ischial tuberosity
Gluteal muscles
Lateral sides of stump
Pressure sensitive:
Pubic symphysis
Perineal area
Distal end of the stump
Adductor tendon
Prosthetic management
-Pistoning: residual limb slip up and down inside hte socket while walking–>poor suspension
-Area of pressure (redness >20min)
Mild redness over pressure tolerant area=normal
No redness over pressure sensitive area
-Leg apprears too short/long (level of pelvis)
Circumduction
- Prosthesis swings out to the side in an arc
Cause:
- prosthesis too long
- locked knee (in extension)
- loose socket
- foot set in too much plantarflexion
- poor knee control
- abduction contracture
Vaulting
- Rises up on the sound limb to swing prosthesis through
Cause:
- prosthesis too long
- poor suspension
- foot set in too much plantarflexion
- too little knee flexion
Lateral trunk bending during stance
- Side flexes towards prosthetic side in stance
Cause:
- prosthesis too short
- weak hip abductors
- hip abductor contracture
- hip pain
Forward flexion during stance
- Forward flexion during stance
Cause:
- unstable knee
- hip flexion contracture
- gait aids too short
