Amputation Flashcards
What are the majority of lower extremity amputation caused by? (2)
- Vascular disease
- Neuropathy
T/F: Amputations are more common in females.
False, more common in males
T/F: Amputations are more common in older individuals.
True
What are the majority of upper extremity amputations caused by?
- Trauma
What are some of the other causes of amputation? (3)
- Cancer
- Infection
- Congenital limb defects
What is peripheral vascular disease (PVD)?
- Condition characterized by narrowing of blood vessels that causes reduced blood flow to the extremities.
What are the most common causes of PVD? (2)
- Diabetes
- Smoking
What are some of the common co-morbidities associated with PVD? (5)
- Diabetes!!
- Obesity
- Hypertension
- High cholesterol (high lipid profile)
- Neuropathy
T/F: Patients with diabetes are at 4-5x more risk for claudications.
True
What are intermittent claudications?
- Patient experiences very painful cramping sensation in the lower limbs.
- Caused by decreased blood flow to lower limbs during activity (i.e. muscles are not getting enough oxygen or nutrients to support activity).
What is dysvascular amputation?
- Amputation is required due to impaired circulation (PVD) to the affected limb
T/F: If a patient undergoes amputation of one limb due to PVD, they will be less likely to have their other limb amputated in the future.
False, more likely. 55% of amputees caused by PVD in one limb will eventually have bilateral amputation.
Most amputations caused by diabetes are preceded by ________ _____________.
Foot ulcerations
What is the 30 day and 5 year mortality rates following major leg amputations?
- 40%, 70%
What is traumatic amputation? (3)
- Amputation is required when limb is damaged by some traumatic event.
- MVA, work injuries, combat/violent injuries, electrocution, and severe burns
- More common in young men
What is replantation?
- Reconnection of separated limb/tissues.
- Alternative to limb amputation
How much time do doctors have to replant tissues before the tissue is no longer viable?
- within 12 hours
T/F: Traumatic amputations are often accompanied by psychological trauma?
True
What are the advantages of replantation over amputation? (2)
- Less expensive long-term
- More psychologically acceptable
What are the advantages of amputation over replantation? (2)
- Lower risk of being rehospitalized
- Often associated with better functional outcomes
What is malignant amputation? (3)
- Amputation required due to malignant cancer
- Can be caused by primary or metastatic cancer
- More common in lower limbs
T/F: The incidence of malignant amputation is increasing.
False, decreasing due to earlier diagnosis, better treatments, and improved salvage/reconstruction techniques.
What is pediatric amputation? (4)
- Amputation done on children
- 3:2 male to female ration
- Majority of cases are congenital
- Less than half of cases are acquired (mostly trauma)
What are the benefits to amputation in children? (3)
- Disarticulation at the joint decreases risk of growth plate damage
- Children have excellent circulation > increases wound healing
- Children have superior tissue tolerance > early post-op prosthetic fitting
Surgeons most consider ____________ and ___________ growth when doing pediatric amputation.
Longitudinal (length), circumferential (girth)
T/F: Pediatric amputations are treated the same way as adult amputations because children are just miniature adults.
False
Name the 13 different types of lower limb amputations.
- Partial toe
- Toe disarticulation
- Partial foot/ray resection
- Transmetatarsal
- Syme’s
- Long transtibial
- Short transtibial
- Knee disartculation
- Long transfemoral
- Short transfemoral
- Hip disarticulation
- Hemipelvectomy
- Hemicorporectomy
Describe 1.) partial toe, 2.) toe disarticulation, 3.) transmetatarsal, and 4.) partial foot/ray resection
- ) Removal of a portion of one or more toes
- ) Amputation at MTP joint of the toe
- ) Amputation across the long axis of all 5 metatarsals
- ) Resection of the 3rd, 4th, and 5th metatarsals/digits only
Describe Syme’s amputation.
- Disarticulation of the ankle while preserving the heel
Describe 1.) long transtibial, 2.) short transtibial, and 3.) knee disarticulation.
- ) Retains >50% of tibial length
- ) Retains <50% tibial length
- ) Amputation through the knee joint that leaves femur intact
Describe 1.) long transfemoral and 2.) transfemoral.
- ) Retains >50% femur length
- ) Retains <50% femur length
Describe 1.) hip disarticulation, 2.) hemipelvecotmy, and 3.) hemicorprectomy.
- ) Amputation through the hip joint that leaves pelvis intact
- ) Resection of one half of the pelvis
- ) Amputation of both LEs and the entire pelvis below L4-L5
Name the 10 upper extremity amputations.
- Partial digit
- Digit disarticulation
- Transmetacarpal
- Transcarpal
- Wrist disarticulation
- Transradial
- Elbow disarticulation
- Transhumeral
- Shoulder disarticulation
- Forequarter amputation
Describe partial digit, digit disarticulation, transmetacarpal, and transcarpal amputation.
- Removal of part of one or more digits
- Amputation at the MCP joint
- Resection along the long axis of all 5 metacarpals
- Amputation of the entire hand while preserving the wrist (carpal) bones
Describe wrist disarticulation, transradial, and elbow disarticulation.
- Amputation of the digits and carpal bones at the wrist joint.
- Amputation through the radius and ulna
- Amputation through the elbow joint
Describe transhumeral, shoulder disarticulation, and forequarter amputation.
- Amputation through the humerus
- Amputation through the shoulder joint.
- Amputation of the clavicle, scapula and humerus
What are the 5 main surgical principles of amputation?
- Maintain circulation for wound/incision healing
- Remove all damaged/involved tissues
- Preserve as many joints as possible (esp. the knee)
- Preserve maximal amount of bone length
- Provide residual limb that will accept prosthesis and weight bearing
What surgical considerations are associated with dysvascular amputation patients? (2)
- Often have multiple co-morbidities
- Often have neuropathy, infection, vascular compromise, or osteomyelitis.
What surgical considerations are associated with traumatic amputation patients? (2)
- Patients often have open/comminuted fractures
- May have extensive soft tissue loss and damage to blood vessels/nerves
What surgical considerations are associated with cancer-related amputation patients? (2)
- Indicated in high grade neoplasms or cancer lesions located on proximal portions of the bone.
- Patients are at high risk for pathological fractures, damage to nerves/vasculature, and recurrent disease
________ _______ must be preserved in all amputation patients to prevent contractures and atrophy.
Muscle length
What are the 5 different types of surgical closure techniques?
- Myodesis
- Tenodesis
- Myofascial
- Myoplasty
- Open (guillotine), provisional, or delayed closure
Describe the myodesis closure technique.
- Transected muscles are re-attached by suturing through drill holes made at the distal ends of the bone.
Describe tenodesis closure.
- Intact tendons are re-attached to the bone
Describe myofascial closure.
- A fascial envelope is sutured over transected muscles.
Describe myoplasty closure.
- The muscles of one group are sutured to their antagonist muscle group.
Describe open, provisional or delayed closure.
- Used if severe infection or toxicity is present.
What is an osteomyoplasty (Ertl procedure)? (2)
- Used in transtibial amputations
- A bone bridge (periosteal flap) is harvested from the removed portion of the tibia that is then used to bridge the distal tibia and fibula ends together.
What is the benefit of using the osteomyoplasty for a transtibial amputation? (3)
- Stabilizes the distal ends of the tibia/fibula
- Prevents chopsticking of the distal bones
- Improves WBing of residual limb
What are the post-op complications for amputations? (8)
- Muscle contractures
- Edema
- Phantom limb sensation/pain
- Depression
- Pain
- Infection
- Respiratory compromise
- Risk of DVT
What are the acute rehab goals after amputation? (5)
- Prevent complications, allow healing
- Increase strength/ROM for prosthesis
- Maximize independence in mobility/ADLs
- Pre-prosthetic training/limb prep
- Increase endurance, prepare HEP
What are the goals of patient education? (7)
- Post-op goals/expectations
- Positioning to prevent contracture
- Pain relief/control
- Residual limb care/inspection
- Protection of contralateral leg
- Prosthetic information/time frame to use
- Encourage no smoking
What is an important thing to remember when educating your amputation patient?
- Prioritize!!
- Not every patient needs the same information in the same order - Determine what that patient needs to most and their level of understanding/compliance
What are the 4 things patients need to focus on before they receive their prosthesis?
- ROM
- Positioning
- Compression
- Endurance
What are the 4 types of post-op dressings?
- Rigid (IPOP)
- Rigid removable
- Semi-rigid
- Soft
Describe rigid dressings.
- aka Immediate Post Op Prosthesis (IPOP)
- Consists of a plaster socket and removable pylon/foot
What are the advantages of IPOP dressing? (6)
- Limits edema
- Reduces pain
- Prevents contractures
- Protects residual limb
- Allows early WBing/gait
- Eases transition to permanent prosthesis
What are the disadvantages of IPOP dressings? (3)
- Difficult to apply
- Application requires close supervision
- Patient cannot see wound or residual limb
Describe rigid removable dressings (RRD). (3)
- Applied after sutures are removed
- A propylene covering or cast is made from an impression of the residual limb
- RRDs are worn over wound dressings/compression socks
What are the advantages of RRD? (4)
- Allows patient to inspect skin
- Provides consistent pressure
- Easily put on
- Protects residual limb
What is the disadvantage of RRD?
- May require frequent re-fittings
Describe semi-rigid dressings.
- Made of zinc-oxide, gelatin, glycerin, and calamine compound
- Applied in OR or Post-op Care Unit
What are the advantages of semi-rigid dressings? (6)
- Controls edema
- Adheres to skin
- Allows some ROM
- Breathable material
- Inexpensive
- Easy to contour to limb
What are the disadvantages of semi-rigid dressings? (3)
- Loses effectiveness as edema decreases
- Not very protective
- May allow contracture formation
Describe soft dressings.
- Wound incision is dressing with 4x4 Ace bandages and Kerlix
- Ace bandages or elastic shrinkers provide compression
What are the advantages of soft dressings? (3)
- Inexpensive
- Lightweight
- Readily available materials
What are the disadvantages of soft dressings? (4)
- Inconsistent and weak compression technique
- Requires frequent re-wrapping/replacement
- Doesn’t prevent contracture
- Difficult for patients to apply
Which types of post-op dressings can potentially allow contractures to form?
- Soft and semi-rigid
What are the guidelines for using Ace bandages on residual limbs? (4)
- Re-wrap every 4-6 hours
- Pressure gradient decreases distal to proximal
- Figure 8 pattern used to prevent tourniquet effect
- Patient and caretaker education is needed
Ace bandages need to be pulled ________ to _______ and ________ to __________ for BKA.
Medial, lateral, anterior, posterior
Ace bandaging of AKA need to include adductor tissues to prevent ________ ________ and the limb needs to be pulled into ____________ and __________.
Adductor roll, extension, adduction
What are limb shrinkers?
- Elastic socks that help decrease edema and shape the residual limb.
- Pressure gradient increases from proximal to distal
What are the guidelines for using limb shrinkers? (5)
- AKA socks require waist belt to prevent slipping
- Size is determined by circumference and length measurements
- Used prior to prosthetic fit/wearing
- Worn 24 hrs/day
- Patients/caregivers must examine skin!!!
T/F: Pressure from Ace bandages and elastic shrinkers is highest proximally and lowest distally.
False, highest distal and lowest proximal
What are limb socks?
- Fabric sleeve worn between residual limb and prosthetic limb socket
- Protects limb, prevents friction, optimizes socket fit/contact, absorbs perspiration
- Made out of cotton, wool or other blended fabric
What is phantom limb sensation?
- Painless awareness of the amputated bod part
- Causes incomplete sensation, mild tingling
- Usually persists throughout lifetime
What percent of surgical and traumatic amputees will experience phantom limb sensation?
- up to 90%
T/F: Phantom limb sensations are abnormal and need to be treated immediately.
False, they are perfectly normal
What is phantom limb pain? (4)
- Painful sensation of amputated limb
- Pain my be constant, intermittent, and vary in intensity
- Pain can be cramping, squeezing, burning, or shooting sensations
- 30-75% of amputees may experience phantom pain
Phantom pain is uncommon in __________ amputees and is more common after _______ injuries or amputations done _______ in life.
congenital, crush, later
How is phantom limb pain treated? (7)
- Desensitization/massage
- Compression
- Exercise
- limb handling/use
- Modalities (TENS, US, ice)
- Psychological counseling
- Mirror therapy
What is mirror therapy?
- A mirror is placed in front of the patient.
- The patient completes a movement with their unaffected limb while watching in the mirror and then attempts to complete the same movement with their affected limb.
How should desensitization and massage be used? (3)
- Gentle touch and texture stimulation should be used after wound is healed
- Deep friction massage should be used on scars after incisions are healed
- Remember, patients skin integrity and pressure tolerance is only 40% what it use prior to injury
How long does scar massage need to be used as a part of amputation treatment?
- Up to 1 year or longer because new scar tissue is still forming up to 1 year after injury.
What are the guidelines when working on positioning after amputation? (5)
- Initiate ROM after surgery ASAP
- Initiate positioning immediately; prone positioning as soon as medically feasible
- Use wrapping or shinkers as soon as surgeon allows
- Optimize positioning in and out of bed
- Monitor changes in limb volume/edema
What is the TherEx program after amputation? (4)
- Maintain full ROM
- Increase strength in hip extensors/adductors and knee extensors
- Progress to closed chain and functional activities
- Improve cardiovascular endurance
Guidelines for transfer training after amputation. (5)
- Start day 1 post-op if possible
- Start with stand pivot w/ walker
- Adjust walker so pt’s elbows can be fully extended
- If patient cannot stand, use sliding board
- Use of transfer prosthesis may help non-ambulatory patients
If a patient is able you should initiate _________ ________ transfer w/ a ________; if the patient is unable to stand initiate a ________ _________ transfer.
Stand, pivot, walker, sliding, board
Wheelchair use considerations (4)
- WC should be used if energy cost of ambulation is too much for patient
- Use cushions to reduce friction/skin compromise
- Long-term WC should be powered, offset rear axis, and anti-tip
- Use long-term specialized cushions
What are the best predictors of prosthetic use potential?
- Level of amputation and pre-surgical functional level
Which patient groups are the most and least likely to regain function with their prosthesis after amputation? (3)
- Any unilateral BKA and bilateral BKA in younger patients can be completely functional
- Older AKA have problems regaining upright function
- Majority of bilateral AKA do not use prosthetics
What are the contraindications of prosthetic use? (5)
- Dementia
- Patient institutionalized
- Advanced cardiopulmonary/neurological disease
- Bilateral AKA w/ inability to transfer/stand
- Unacceptable energy expenditure during ambulation
Requirements of residual limb before prosthetic use. (5)
- Incisions completely healed
- No signs of infection
- No incision site drainage
- Tolerate WBing
- Patient compliant w/ frequent skin inspections
Decisions about which prosthesis is best for each patient is determined by who?
- Input taken from patient, prosthetist, PT, and MD
- Patient’s performance w/ temporary prosthesis
Prosthetic components are determined based on what? (5)
- Patient’s age
- Activity level
- Vocational demands
- Sources of funding
- Patient compliance
What is a temporary prosthesis used for? (7)
- Shapes residual limb
- Early gait training/independence
- Evaluates eventual prosthetic use
- Allows endurance training
- Reduces contractures development
- Not worn full-time
- Permanent socket size determined when limb volume normalizes
What should gait training for amputees focus on? (4)
- Sit-stand, single leg stance, weight shifting w/ prosthesis
- Progress to standing transfers and hopping/stepping with walker
- Integrate functional tasks like reaching, bending, turning
- Work on stance and stability on the prosthesis
What should later gait focus on? (6)
- Stair straining
- Curbs,
- Uneven terrain
- Lifting/carrying objects
- Transfer to and from floor
- Running/jogging
When should a PT refer their patient back to their prosthetist?
- If residual limb volume, weight, functional status, and ROM change that significantly affect prosthesis fit.
- PTs should never make major adjustments to a prosthesis w/out instruction from prosthetist
