Amputation Flashcards
What are the considerations with amputations?
the boundaries of dead or diseased tissues
considering prosthesis
possible mobility and function
cosmesis
What is myodesis?
muscle secured to the bone by suturing the distal tendon through holes thats been drilled in the bones
- most often in BL/AKA to help with deformities of the residual limb
What is a myoplasty?
attaching sectioned muscle to opposing muscles
What is the difference between a minor and major amputation?
minor - toe or partial amputations
major - proximal to tarsometatarsal joints
What are the primary indications for amputations?
- peripheral vascular disease
- diabetic wounds
- trauma (MVA or gunshots)
- infections
- tumor/cancer
- congenital
How is balance affected by an amputation?
decreased balance if ankle joint is gone = loss of somatosensory, decreased WB, reduced confidence, limits of daily activities
loss of ankle joints changes postural control = increase reliance on other balance strategies
What is a partial foot amputation?
transmetatarsal
How does transmetatarsal amputation assist with balance?
Keeps ankle integrity
What is the most common amputation?
partial foot amputation - transmetatarsal
What is the return for tranasmetatarsal amputation?
use of prosthetic or standard foot wear
What are the effects of gait for partial foot amputation?
loss of power generation
What is symes?
removal of foot
- medal and lateral malleoli is removed
- heel pad relocated to distal tibia
What is chopart?
disarticulation between the navicular/cuboid bones and the talus/calcaneus bones
What is lisfranc?
tarsometatarsal joint amputation
What is transmetatarsal amputation?
midshafts of MTs
What is a transtibial amputation?
“BKA” - below-knee amputation
- this preserves the knee
- loss of muscular control of LE groups and foot/ankle (well man aint no more there tf)
What are the gait characteristics?
- decreased gait velocity
- shorter step length
- increased stance phase
- increased time on sound limb
- asymmetrical stance phase duration
What is transfemoral?
“AKA” - above-knee amputation
- preserves hip joints
- loss of joints below and impaired muscular below pelvis
UE amputation
Interscapular thoracic
whole ahhh upper limb with clavicle and scapula
UE amputation
Shoulder disarticulation
whole ahhh upper limb through shoulder joint
UE amputation
Transhumeral
through humerus
UE amputation
Elbow disarticulation
thru elbow joint
UE amputation
Transradial
thru radius and ulna
UE amputation
Wrist disarticulation
thru wrist joint and removing carpal bones
UE amputation
What is amputated with a partial or full removal?
hand, metacarpal, thumn and phalangeal
UE amputation
What is trans-radial?
“below elbow” amputation
UE amputation
What is trans-humeral?
“above elbow” amputation
What is the prevalence of UE amputations?
> 80% of UE amputations are because of trauma
- common in men ages 15-45
- followed by cancer/tumor
Risk increases with age
What age is at the greatest risk of UE amputation?
age 65 and over
What is the general goals for post-op amputations?
- promote wound healing in residual limb
- pain management
- optimize ROM and strength
- protect residual limb
- functional sitting/standing balance
- train for safety with bed mobility and transfers
- ambulation training with AD
- proper sitting and bed positioning education
- discuss next phases of rehab
When looking at shape, what are we looking at?
cylindrical shape
bulbous
“dog ears”
bone length
What should we be careful when measuring strength?
pressure on the surgical site
grade of test
Where are some common contracture sites?
hip flexion
hip abduction
hip ER
knee flexion
ankle PF
What are some considerations for stump pain and skin checks?
Look at the wound site
skin integrity
depending on healing - it can either slow or increase healing rate
delayed healing because of infection or non-compliance
What is phantom limb pain?
Its the perception of pain in the missing limb
- described as tingling, prickling, pins and needles
- the severity gets less with more stimulation
more common in women than men
What is the pain management for the residular limb?
- medication
- compression
- breathing and relaxation techniques
- massage, biofeedback and TENS
How is the total length including soft tissue measured?
taken from an easily identified bony landmark to the palpated end of the long bone, incision line or end of soft tissue
How is the circumference measured?
medial tibial plateu or tibial tubercle and at equally spaced points to end of limb
What is the post-op amputee rehab goals?
- contraction prevention
- pain mangement
- emotional care
- post-op edema
- early ambulation
- residular limb protection
- bed mobility and transfers
- fall prevention
- trunk stabilization
- desensitization while loading of distal stump progressively
- scar management and mobilization
What are the precautions/contraindications for PT?
Signs and symptoms:
- excess drainage through bandages or rigid dressings
- sharp local pain on stump
- fever
- foul odor = infection
Hold PT and resume when pt is stable
What are the clinical considerations?
- cognitive dysfunction
- comorbidities
- cardio-pulm conditions
- ulcers or infection
- flexion contractions
- age
- psychoscial factors
Post-op dressing options
What are the advantages of ace wrap?
- edema control
- wound access
- inexpensive
Post-op dressing options
What are the disadvantages of ace wrap?
- does not protect wound/residual limb from external environment
- hard for patient to apply
- difficult for proper application and maintain even compression
- will not prevent contracture
Post-op dressing options
What are the advantages of a shrinker?
- edema control
- wound access
- inexpensive
- even compression layers
Post-op dressing options
What are the disadvantages of shrinker?
- may catch on staples/suture lines
- may increase pain during application
- does not protect wound/residual limb from external environment
- will not prevent contraction
Post-op dressing options
What are the advantages of rigid dressing?
- residual limb protection
- best edema control option
- residual limb protection in a fall
- BKA contracture prevention
Post-op dressing options
What are the disadvantages of rigid dressing?
- high risk of infection = pose barrier to non-removal type
- bulky, heavy
- needs to monitor closely
- limited wound access
Post-op dressing options
What are the advantages of an elastic roller bandage?
- readily available and accessible
- inexpensive
- easy to access to incision
Post-op dressing options
What are the disadvantages of elastic roller bandage?
- cabe hard for patients and family to get proper pressure
- can produce areas of high pressure that can impair healing
- needs frequent rewrapping
- increased likelihood of knee flexion contracture with transtibial amputation
Post-op dressing options
What are the advantages of semirigid dressing?
- better edema control than soft dressing
- RL protection
Post-op dressing options
What are the disadvantages of semirigid dressing?
- needs frequent changing
- can’t be applied by patient
- no access to incision
Post-op dressing options
What are the advantages of IPOP?
- excellent edema control
- excellent stump protection
- control of stump pain
- decreased time to fit with prosthesis
Post-op dressing options
What are the disadvantages of IPOP?
- no access to incision
- more expensive than other dressings
- needs proper traning for use
- needs skilled practioner for frequent reapplications and fittings
- patient needs to carefully adhere to all procedures
What are the causes of residual limb edema?
- possible delayed healing
- stump break down because of fitting hardships
- poor venous return
- other associated disorders
- arterial disease
What are some pre-prosthetic considerations?
- edema management
- skin care
- contracture positioning prevention
- mobility, strength, function and balance
- equipment needs
- vascular assessment
What is the goal for joint mobility strengthening and function?
- maintain or restore ROM above amputation
- prevent joint contractions (proper positioning)
- gait training
What is the gold standard for outcome measures?
Ampute mobility predictor
What is the MDC for amputee mobility predictor?
3.4-point change
What are the considerations for stump wrapping?
- from distal to proximal
- figure 8 pattern
- partial overlap of the layer before
- no gaps
- cylindrical shape
- even pressure = no wrinkles or creases
- with tape securing it
What are the bandages used for a BKA?
2 4-inch bandages
What are banadages used for AKA?
1 4-inch
1 6-inch
How often should bandages be removed?
Every 4 hours hours or sooner if it loosens up
Why is compression so important for all amputees?
- reduce edema
- pain control
- increase wound healing
- protects incision during functional activity
- faciliate prosthetic placement preparation by shaping it and desensitizing
Compression bandaging
When is a rigid banadage applied?
Applied surgeon in the OR
- removed in 3-4 days
- can put new IPOP = lets limited TTWB in 2-3 days by the prosthetist
Compression bandaging
What is rigid bandage not good for?
for patients with higher risk for infection because of wound status
- can’t really it unless its removed
Compression bandaging
When is a semi-rigid applied?
By the prosthetist with a negative mold or when rigid is removed in 3 days post op
Compression bandaging
What kind of materaial is semi-rigid made of?
Polyethylene making it lightweight, easy to clean and more durable than plaster
Compression bandaging
When is soft bandaging applied?
once a suture line is healing (10-21 days)
- using shrinker TT/TF
- Jobst for TF (???????)
What are the principles of Ace-wrapping?
- distal pressure should exceed proximal
- pressure applied on oblique turns only - no wrinkles
- reapplied every 4 hours
- no metal clips dummy
- remove if aching, burning or numbness
- wear 23 hrs of the day (remove it to clean it bro)
- continue until pt. has definitive prosthesis and pt can leave stump unwrapped overnight and don it easily
What are the strategies of phantom limb pain?
- patient education (them boys be standing thinking they got both)
- look for neuroma or infection
- compression
- prosthesis use
- desensitization techniques (rub that thang)
- heat
- some medications (wack stuff frfr)
What are the pain management when it comes to PT treatments?
- give time for pain meds (dey be complainin)
- education on imagery and relaxation
- TENS = wound and relaxation methods
- US (america??)
- cold therapy
- massage (rub that thang)
- wearing prosthesis/compression bandages
What is the most common contractures to prevent for transtibial (BKA)?
hip flexion
knee flexion
Why are BKA contractions happening?
- long periods of sitting in w/c and bed = flexion is position of comfort
- protective flexion withdrawl is associated with LE pain
- muscle imbalances
- loss of sensory input from foot in WB
What are the contractures common in transfemoral amputations?
hip flexion
hip abduction
hip lateral rotation
Contraction management
How do you keep the knee in extension in bed?
avoid using pillows under the residual limb
Contraction management
How do you keep the knee in extension in the W/C?
using an amputee board, elevated amputee hanger
- avoid long periods of sitting
Contracture management
What are other forms of management?
- prone
- PNF
- manual stretching
- mobility
- AROM
- PROM
Strengthening Principles
What is the reason for UE/LE/trunk strengthening and endurance?
- safety
- energy efficient prosthetic gait
- contraction prevention
- mobility
Strengthening Principles
What kind of exercises for post-op muscle strengthening?
isometric contraction with limited ROM @ proximal joint to prevent stress across incision
- no valsalva
progression of wound healing = longer arc of motion, active resistive exercise, the reg ya know?????
What are other POC considerations?
- hip ext, abd, add and knee ext
- overall strengthening
- aerobic to increase endurance
- mobility
- posture COG shifted up, back and toward remaining leg (feeling bad frfr)
- skin integrity
- balance
Medicare functional classification scale
K0
not able to ambulate or transfer without assistance
Medicare functional classification scale
K1
Use of prosthesis and walks mainly on level surfaces or fixed cadence
- household ambulator
Medicare functional classification scale
K2
uses prosthesis and walks in limited community distances, uneven surfaces, curbs and stairs
Medicare functional classification scale
K3
Use prosthesis and waks community ambulation distances
- can traverse most barriers in environment
- variable cadence
Medicare functional classification scale
K4
potential for prosthesis and walks without any limitations
- exceeds basic abilities/demands for gait
- can handle high-impact activity
who/when to prescribe a prosthesis to a TTA?
- patient has their own knee power
- prosthesis helps w/ transfer
- prosthesis helps with STS
Who/when to prescribe a prosthesis to a TFA?
- patient has no knee power
- prosthesis has no knee power
- transfers - often easier without prosthesis
- STS - prosthesis makes it more challenging
What should the patient master before a TF prosthesis?
- transfer independently
- STS independently
- walks in parallel bars or walker for at least 6-8 meters
