Amputation Flashcards
how many americans will undergo amputation
1 in 200
rates increase with age
twice as common in men
What is the estimated cost of amputation?
over $8.3 billion dollars
over 80% of lower extremity amputations are due to…
vascular disease and/or neuropathy
over 70% of upper extremity amputations are due to…
trauma
what are some other causes of amputation
cancer (especially adolescent bone malignancies), infection, and congenital limb defects
In what populations is vascular disease more common, and what is it associated with?
Most common African americans; more common in native americans and Hispanics than Caucasians
associated with diabetes and/or smoking
What are some comorbidities that increase risk for PVD and amputation?
obesity, HTN, HLP, nephropathy
What does diabetes increase risk for?
increases risk of intermittent claudication by 4-5 times, even after controlling for HTN, smoking, and cholesterol level
85% of amputations in those with diabetes are preceded by…
foot ulceration
55% of those whose PVD result in amputation….
will eventually undergo bilateral amputations
what is the 30 day mortality following a major leg amputation
it is as high as 40%
what is 5 year mortality?
as high as 70%
Causes of traumatic amputation? who most likely has them?
MVA, work or violence related combat injuries, severe burns, electrocution
more common among younger men
When does reimplantation have to occur?
must occur within 12 hour window
What is also associated with traumatic amputation?
psychological trauma and an extended period of adjustment
What are advantages and disadvantages of amputation vs. salvage
lifetime cost of amputation as much as 3 times higher
risk of subsequent hospitalization is greater after salvage
amputation may result in better functional outcomes
salvage may be more psychologically acceptable
When is malignancy involved with amputation?
can be due to primary cancer (osteosarcoma) or metastatic disease
more commonly involved the lower limbs
declining amputation rates due to earlier diagnoses, improved chemotherapy, and limb salvage/reconstruction techniques
What are causes for pediatric amputation?
3:2 male to female ratio
60% are congenital
40% are acquired: 90% are single limb, 60% are LE, most result from trauma
What must be considered with pediatric amputation?
Disarticulation minimizes growth plate disruption
Must consider longitudinal and circumferential growth
What make pediatric amputations different than adult?
Excellent circulation enhances wound healing
Superior tissue tolerance may allow early post-op prosthetic
Children are NOT miniature adults
What are surgical principles that must be considered?
maintain adequate circulation for wound/incision healing
remove damaged or involved tissues
preserve as many anatomical joints as possible, especially the knee
preserve maximal bone length
provide residual limb that will accept prosthesis and tolerate weight bearing
What are surgical considerations with dysvascular patients
often present with comorbidities, neuropathy, vascular compromise, infection, or osteomyelitis
What are surgical considerations for traumatic injuries?
often involved open, comminuted fractures with soft tissue loss and vascular/nerve disruption
What are surgical considerations for cancer related amputation?
indicated in high-grade neoplasms, proximal lesions, those risking pathologic fractures or neurovascular involvement, or recurrent disease
What is the modern technique for amputations
Skin and muscle are divided to form anterior and posterior flaps
Primary arteries and veins are dissected, clamped, and severed
Major nerves are dissected, severed, and allowed to retract into soft tissue
Bone is severed, distal end I filed and beveled to produce smooth surface
Muscle and skin flaps are sewn together, forming the residual limb
Why must there be muscle stabilization techniques?
muscle length must be preserved to prevent contracture and atrophy
What is myodesis
transected muscles are re-attached by suturing through drill holes at distal end of the bone
tenodesis technique
intact tendons reattached to bone
myofascial technique
fascial envelope is sutured over transected muscles
myoplasty technique
suturing of one muscle group to its antagonist
open (guillotine), provisional, or delayed closure technique
indicated if severe infection or toxicity are present
What is osteomyoplasty?
Ertl procedure, developed in 1920s and 30s
used in transtibial amputation
osteoperiosteal flap (bone bridge) is harvested from amputated tibia
flap is implanted, bridging distal tibial and fibular ends
incision is closed over bone bridge
Why is it important to stabilize distal tibia and fibula?
prevents chopsticking of distal bone ends
improves weight bearing on residual limb
What are post-operative complications
contracture, edema, phantom limb sensation or pain, personal grief and depression
surgical complications: pain, infection, respiratory compromise, DVT, etc
What are components of acute post-surgical examination?
medical history, social situation, pain level, sensation/proprioception, A/AROM or PROM, strength, bed mobility, sitting/standing balance, locomotion (gait and/or wheelchair), endurance, home and work environment, barriers to care or adjustment, knowledge (limb care and prosthetic use)
What are the goals of acute rehab?
prevent complications and allow healing
develop limb strength and ROM for prosthesis
maximize independence in mobility and ADLs
pre-prosthetic training and limb preparation
endurance training and initiation of HEP
What must you as a PT consider when educating a patient?
consider their level of understanding and readiness to accept information
you may already know them from wound care or by-pass grafting
prioritize
What can you educate the patient on?
post-op goals and expectations positioning pain relief residual limb care, inspection, and handling protection of contralateral leg prosthetic information and time frame stop smoking
What is important in post surgical phase?
compression, ROM, positioning, endurance
What must be considered in post surgical phase?
consider vascular factors in determining time frames for wound healing and prosthetic fittings
time until a temporary prosthesis can be tolerated is variable, depends largely on skin tolerance and healing
ends when patient is provided with a definitive prosthesis
What is a IPOP?
immediate post op prosthetic
plaster socket with removable pylon and foot
What are advantages of IPOP?
Limits edema, reduces pain, prevents contracture, protects limb, allows early weight bearing and gait, easier move to definitive prosthesis
What are disadvantages of IPOP?
Difficult to apply, requires very close supervision, cannot visualize wound or residual limb
What is a RRD?
Rigid Removable Dressing
after suture/staple removal a polypropylene or cast is fit from an impression of the residual limb
RRD is worn over the wound dressing or compression socks
What are advantages and disadvantages of RRD?
Advantages: allows skin inspection, provides consistent pressure, easily donned, protects residual limb
Disadvantages: may require frequent refitting
What is semi rigid dressing?
zinc-oxide, gelatin, glycerin, and calamine compound
applied in OR or PACU
What are advantages and disadvantages of semi rigid dressing?
advantages: controls edema, adheres to skin, allows some ROM, breathable, inexpensive, easy to contour
disadvantages: loses effectiveness as edema resolves, not as protective, may permit contracture formation
What is a soft dressing?
incision dressed with 4x4’s and Kerlix
compression provided with ACE bandages or elastic shrinker
What are advantages and disadvantages of soft dressing?
Advantages: inexpensive, lightweight, readily available
Disadvantages: inconsistent weak compression, requires frequent re-wrapping and replacement, does not prevent contracture, difficult for patient to self-apply
How should you wrap and ACE bandage?
rewrapped every 4-6 hours
distal to proximal pressure gradient
below knee: pull in medial to lateral, posterior to anterior direction
above knee: include adductor tissue (prevent adductor roll), pull into extension and adduction
figure 8 pattern to prevent tourniquet effect
What are limb shrinkers?
Elastic socks that help decrease edema and assist in shaping the residual limb
Have distal to proximal pressure gradient
When are limb shrinkers used?
used prior to prosthetic fitting and prosthetic wearing
worn 24 hours/day
How are limb shrinkers sized? What other requirements are needed?
Sizing determined by circumferential measurements and length
AKA socks require waist belt
MUST continue skin inspection
What are limb socks?
Cotton, wool or blended fabric that are used between residual limb and prosthetic socket for protection, friction, absorption, and to fill socket volume
Why are limb socks useful?
They absorb perspiration
Allows optimal socket fit and contact
1, 3, and 5 ply socks can be layered up to 15 ply
What is phantom limb sensation?
painless awareness of the amputated body part
incomplete sensation, often mild tingling
Is phantom limb sensation normal?
YES. Occurs in over 90% of traumatic and surgical amputees. Usually persists throughout life
What is phantom limb pain?
Painful sensation of amputated body part.
How is phantom limb pain described?
Constant or intermittent, with varying intensity
Often described as cramping, squeezing, burning, or shooting pain
In what populations is phantom limb pain common?
More common after crush injury or amputation in later life
Uncommon in individuals with congenital amputation
How common in phantom limb pain?
incidence is unclear- anywhere from 30-75%
What are interventions for phantom pain?
desensitization and massage compression exercise limb handling and use modalities: TENS, US, ice psychological counseling
What is mirror therapy?
intervention for phantom pain
patient performs a movement with the unaffected limb
movement is viewed in mirror positioned in front of patient
simultaneously, patient attempts to perform the movement with their residual or phantom limb
When should you start desensitization?
initiate gentle touch and textural stimulation after wound is closed
initiate scar and deep friction massage after the incision is fully healed
When should massage be used?
Should be used as an adjunct to daily skin inspection and care routine
When does skin heal and does it return to normal?
Scar maturation continues for up to 1 year
Skin integrity and pressure tolerance only 40% of normal
When should you start ROM?
Initiate ROM as soon as surgeon allows (usually immediately post-op)
When should you start positioning?
Initiate positioning immediately; prone positioning as soon as medically feasible (if tolerated)
Optimize positioning both in and out of bed
When should you start wrapping?
Initiate wrapping or shrinker as soon as surgeon allows; monitor application
Monitor edema and limb volume fluctuation
What ther ex should be done with amputation?
maintain full ROM and strengthen hip extensors, hip adductors, and knee extensors
closed chain functional exercises
What happens to cardiovascular endurance with amputation?
unilateral BKA increases energy cost of ambulation by 20% unilateral AKA by 49-65% bilateral BKA less than unilateral AKA hip disarticulation by 200% bilateral AKA by 280%
When should transfer training start and what assistive equipment should be used?
Start POD 1 if medically stable
if able, stand pivot with RW, have RW positioned so patient’s elbows are in full extension
Use sliding board if unable to stand
transfer prosthesis may be useful for non-ambulatory patients
What are considerations for wheelchair use?
provide w/c and cushion for those at high risk fro skin compromise or socket intolerance
decision to use w/c is largely based on energy cost of ambulation
consider offset rear axis, power system, and anti-tip system
consider specialized cushions for long-term use
What is involved with prosthetic potential?
level of amputation and pre-surgical function are the best predictors of prosthetic potential
Who is more likely to be functionally independent after amputation?
any unilateral BKA
younger bilateral BKA
Who is more likely to not be functional after amputation?
older unilateral AKA amputees will have difficulty regaining upright tolerance
most bilateral AKA amputees are not prosthetic users
What are the contraindications for prosthetic use?
dementia
institutionalization
advanced cardiopulmonary or neurologic disease
bilateral transfemoral amputations with inability to transfer or stand
unacceptable energy expenditure for ambulation
What are residual limb requirements before getting a prosthetic?
fully healed incision no signs/symptoms of infection no drainage from incision site ability to tolerate weight bearing frequent skin inspection
Whose input must be considered for prosthetic decisions?
based on input from patient, prosthetist, PT, and MD; as well as patient’s performance with temporary prosthesis
How are components chosen for prosthetic?
selected based on patient’s age, activity level and vocational demands, funding sources, and compliance
patient and PT must have understanding of selected components and their functional implications
What is the point of a temporary prosthesis?
Shapes residual limb
Allows early gait training and independence
Evaluation of potential for prosthetic use
Allows endurance training
Discourages contracture development
NOT intended for full time wear
Definitive socket provided when volume stabilized
What should be done with gait training?
sit to stand transitions, single leg stance, weight shifting with prosthesis in parallel bars
Progress to stand to stand transitions and hopping or stepping with RW or SW
Integrate functional tasks: standing, reaching, bending, turning, etc
Emphasize stance and stability on the prosthesis
What are examples of advanced gait training?
Step up/downs onto prosthetic leg Resisted ambulation Running and jumping Transfers to and from the floor Uneven terrain, congested community ambulation Curb and stair training Reaching Lifting and carrying objects
What must be considered when working with prosthetist?
Refer if weight gain, volume changes, ROM or functional changes or demands significantly or consistently affect prosthetic fit
DO NOT make significant adjustments to prosthesis without input from prosthetist
Are there UE prosthetics?
Typically utilize harness and body powered cable control systems
Myoelectric control systems are increasingly prevalent
Acceptance is issue- especially in kids
