Amputation Flashcards
Causes of Amputation
Top 2 =
- Vascular Disease
- Neuropathy
Others =
- Trauma
- Malignancy
Peripheral Vascular Disease
-risk factors
-Most common in african americans, more common in NA & hispanics than caucasians
- Diabetes –> increases risk of intermittent claudication by 4-5x, even w/ control of HTN, smoking & cholesterol levels
- -> what that means is they are lacking sufficient vascular supply by 4-5x to support function
- Smoking
- Comorbidities: obesity, HTN, HLP, & nephropathy
If leads to amputation then…
40% 30 day mortality rate &
70% 5 year mortality rate
Trauma
-examples, what does it lead to?
MVA, work or violence related, combat, severe burns, electrocution, etc.
More common in young men
Leads to salvage or traumatic amputation
- Salvage = more physiologically acceptable but risk of subsequent hospitalization is greater
- great loss of soft tissue replaced by scar tissue (limited function)
- only performed dependent on type of injury, prognosis & goal of function - Traumatic amputation = may result in better functional outcomes BUT lifetime cost as much as 3x higher
When does replantation need to occur for it to be successful?
w/n a 12 hour window of the trauma occuring
Malignancy
Amputation can be due to primary cancer (osteosarcoma) or metastatic disease
-more common amputations in lower limbs
Decreasing rates due to earlier diagnosis, improved chemo, & improved limb salvage/reconstruction techniques
What must you consider w/ pediatric amputations
- disarticulation minimizes growth plate disruption
- must consider longitudinal & circumferential growth
- excellent circulation enhances wound healing
- superior tissue tolerance may allow early post-op prosthetic fitting
Causes for pediatric amputations
- Congenital - 60%
- Acquired - 40%
- 90% single limb & 60% are LE
- most commonly from trauma
Ertl Procedure
aka osteomyoplasty
Performed in transtibial amputations
- surgeons harvest part of the amputated bone and build a bridge between distal tibia & fibula
–> stabilized distal limb, improves WB on residual limb
Post-operative Complications (6)
- Contracture (our PRIMARY concern)
- Edema
- Phantom limb sensation
- Phantom limb pain
- Personal grief & depression
- Surgical complications (pain, infection, respiratory compromise, DVT, etc)
Phantom limb sensation
-what is it and how does it present
NORMAL (>90% effected) - PAINLESS awareness of amputated body part
Often presents w/ mild tingling & persists throughout lifetime
Phantom Limb Pain
- what is it
- symptoms
- interventions
NOT NORMAL (30-75% effected) - painful sensation of amputated body part
Presents as constant OR intermittent, & can be cramping, squeezing, burning or shooting pain w/ varying intensities
Uncommon in congenital amputations, more common in crush amputations or later in life
Interventions: desensitization & massage, exercise, compression, limb handling & use, TENS, US, icing, psychological counseling, mirror therapy
Rigid Dressing
- what is it
- adv/disadv
Most aggressive type of dresssing - immediate post-op prosthesis (IPOP)
It is a plastic socket put in immediately during surgery w/ a removable pylon and foot
ADV: limits edema & better shaping, reduces pain, prevents contracture of knee, protects the limb, allows for early WB, easier to move to definite prosthesis
DISADV: difficult to apply, requires very close supervision, cannot visualize wound or residual limb
Rigid Removable Dressing (RRD)
- what is it
- adv/disadv
polypropylene or cast fit from impression of residual limb
-applied once the sutures/staples have been removed
ADV: allows for skin inspection, provides consistent pressure, easily donned, protects residual limb
DISADV: may require frequent refitting (swelling flucuates)
Semi-rigid Dressing
- what is it
- adv/disadv
thick paste that turns into a semi-flexible/rigid cast (more common for foot ulcers)
ADV: controls edema, adheres to skin, allows some ROM, breathable, inexpensive, easy to contour
DISADV: loses effectiveness as edema resolves, not as protective, may permit contracture
Soft Dressings
- what are they
- adv/disadv
MOST common type of dressing b/c inexpensive, lightweight and readily available (ADV)
- Ace wrapping - figure 8 pattern of distal to prox pressure gradient
- must be rewrapped every 4-6 hours
- below knee: pull medial to lateral, post to ant direction
- above knee: include adductor tissue & pull into ext & adduction - Limb shrinkers: elastic socks that decrease edema and promote shaping; more consistent pressure gradient
- can wear 24/7 but must inspect skin
DISADV: inconsistent, weak compression, requires re-wrapping, difficult for patient to self-apply, does NOT prevent contractures
Limb Socks
For protection, friction, moisture absorption and to fill socket volume…
NOT for edema control or residual limb shaping
1,3, & 5 ply; can be layered up to 15ply
Goals of Acute Rehabilitation for Amputations
- Positioning - prevent complications, contractures & allow for healing
- ROM & strength
- Shrinking/compression - to prepare limb for prosthetic
- also do desensitization, balance & strengthening of uninvolved limb
- Endurance training & initiation
- Maximize independence
Interventions (overview)
- Desensitization & massage
- Positioning
- Therapeutic Exercise
- Transfer training
- Gait Training
- Advanced Gait training
Densensitization & massage
-why?
Initiate gentle touch & textural stimulation & progress to scar/deep tissue friction massage
Skin integrity & pressure tolerance is only 40% of normal so you must build it up
Scar maturation will continue for 1 year
Positioning
If able, get patient to prone w/ wrapping/shrinker ASAP
Optimize positioning in and out of bed & monitor edema & limb volume fluctuation
Therapeutic Exercise
-why is it important?
Maintain full ROM & strengthen specifically hip adductors, extensors & knee extensors
-closed chain and functional activities asap
Must include cardiovascular endurance b/c amputations GREATLY increase energy expenditure for ambulation
- -> unilateral BKA = 20% increase
- -> unilateral AKA = 49-65% increase (why BKA is better than AKA)
- -> bilateral BKA less than unilateral AKA
- ->hip disarticulation by 200%
- -> bilateral AKA by 280%
Transfer Training
-when to start
Start POD1 if possible & medically stable
GOAL = stand pivot w/ RW
(position RW w/ patients elbow in full extension)
May use transfer prosthesis for non-ambulatory patients to make it easier
Pre-gait & Gait Training
- sit to stand, single leg stance, weight shifting on prosthesis in parallel bars
- ->progress to stand to stand transitions, hopping or stepping
- ->integrate functional tasks w/ standing
Emphasize STANCE on prothesis - single & most hardest & important thing to learn
Advanced Gait training
step up/down resisted ambulation running & jumping transfers to and from the floor uneven terrain, congested community ambulation curb & stair training reaching lifting & carrying objects
What are the best indicators for prosthetic potential?
Level of ambulation & pre-surgical function
- -> unilateral & younger bilateral BKA’s can be functionally independent
- -> older unilateral AKA’s will have difficulty regaining upright tolderance
- -> most bilateral AKA’s are NOT prosthetic users
Contraindications for Prosthetic Use
- Dementia
- Institutionalization
- advanced cardiopulmonary or neurologic disease
- bilateral transfemoral amputations w/ inability to transfer or stand
- unacceptable energy expenditure for ambulation
Residual LImb Requirements for Prosthetic Use
- Fully healed incision
- No signs/symptoms of infection
- No drainage
- Ability to tolerate WBing
- Frequent skin inspection
When is a temporary prosthesis beneficial?
shape residual limb allow early gait training & independence evaluation of potential prosthetic use allow endurance training discourage contracture development
BUT not intended for full time use
What are important factors to communicate to a prosthetist about?
- Weight gain
- Volume changes
- ROM or functional changes or demands
