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Musculoskeletal I > Amputation > Flashcards

Amputation Flashcards

1
Q

Causes of Amputation

A

Top 2 =

  1. Vascular Disease
  2. Neuropathy

Others =

  1. Trauma
  2. Malignancy
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2
Q

Peripheral Vascular Disease

-risk factors

A

-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

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3
Q

Trauma

-examples, what does it lead to?

A

MVA, work or violence related, combat, severe burns, electrocution, etc.

More common in young men

Leads to salvage or traumatic amputation

  1. 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
  2. Traumatic amputation = may result in better functional outcomes BUT lifetime cost as much as 3x higher
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4
Q

When does replantation need to occur for it to be successful?

A

w/n a 12 hour window of the trauma occuring

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5
Q

Malignancy

A

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

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6
Q

What must you consider w/ pediatric amputations

A
  1. disarticulation minimizes growth plate disruption
  2. must consider longitudinal & circumferential growth
  3. excellent circulation enhances wound healing
  4. superior tissue tolerance may allow early post-op prosthetic fitting
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7
Q

Causes for pediatric amputations

A
  1. Congenital - 60%
  2. Acquired - 40%
    - 90% single limb & 60% are LE
    - most commonly from trauma
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8
Q

Ertl Procedure

A

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

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9
Q

Post-operative Complications (6)

A
  1. Contracture (our PRIMARY concern)
  2. Edema
  3. Phantom limb sensation
  4. Phantom limb pain
  5. Personal grief & depression
  6. Surgical complications (pain, infection, respiratory compromise, DVT, etc)
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10
Q

Phantom limb sensation

-what is it and how does it present

A

NORMAL (>90% effected) - PAINLESS awareness of amputated body part

Often presents w/ mild tingling & persists throughout lifetime

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11
Q

Phantom Limb Pain

  • what is it
  • symptoms
  • interventions
A

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

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12
Q

Rigid Dressing

  • what is it
  • adv/disadv
A

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

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13
Q

Rigid Removable Dressing (RRD)

  • what is it
  • adv/disadv
A

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)

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14
Q

Semi-rigid Dressing

  • what is it
  • adv/disadv
A

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

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15
Q

Soft Dressings

  • what are they
  • adv/disadv
A

MOST common type of dressing b/c inexpensive, lightweight and readily available (ADV)

  1. 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
  2. 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

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16
Q

Limb Socks

A

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

17
Q

Goals of Acute Rehabilitation for Amputations

A
  1. Positioning - prevent complications, contractures & allow for healing
  2. ROM & strength
  3. Shrinking/compression - to prepare limb for prosthetic
    • also do desensitization, balance & strengthening of uninvolved limb
  4. Endurance training & initiation
  5. Maximize independence
18
Q

Interventions (overview)

A
  1. Desensitization & massage
  2. Positioning
  3. Therapeutic Exercise
  4. Transfer training
  5. Gait Training
  6. Advanced Gait training
19
Q

Densensitization & massage

-why?

A

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

20
Q

Positioning

A

If able, get patient to prone w/ wrapping/shrinker ASAP

Optimize positioning in and out of bed & monitor edema & limb volume fluctuation

21
Q

Therapeutic Exercise

-why is it important?

A

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%
22
Q

Transfer Training

-when to start

A

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

23
Q

Pre-gait & Gait Training

A
  • 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

24
Q

Advanced Gait training

A 
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
25
Q

What are the best indicators for prosthetic potential?

A

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
26
Q

Contraindications for Prosthetic Use

A
  1. Dementia
  2. Institutionalization
  3. advanced cardiopulmonary or neurologic disease
  4. bilateral transfemoral amputations w/ inability to transfer or stand
  5. unacceptable energy expenditure for ambulation
27
Q

Residual LImb Requirements for Prosthetic Use

A
  1. Fully healed incision
  2. No signs/symptoms of infection
  3. No drainage
  4. Ability to tolerate WBing
  5. Frequent skin inspection
28
Q

When is a temporary prosthesis beneficial?

A 
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

29
Q

What are important factors to communicate to a prosthetist about?

A
  1. Weight gain
  2. Volume changes
  3. ROM or functional changes or demands

Musculoskeletal I (11 decks)

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