Amputations Flashcards
What are the general indications for amputation ?
- trauma
- burning
- anaerobic infection
- malignant tumor
- vascular disease (ex: peripheral artery disease)/ diabetic ulcers
What may be an alternative to amputation (when relevant) ?
Limb salvage
How to determine the level of amputation ?
- amount of tissue that could be saved
- severity of the lesion
- expected functionality with prosthesis
What are the two classifications for amputations ?
- classified after-injury-period:
Primary = within 24h
Secondary = around one week after
Re-amputation= at some point, after the first amputation - classified by surgical method:
Flap amputations (single or double flap)
Circular amputations (1 to 3 steps)
What are the different levels of amputations ?
- hemicorporectomy
- hemipelvectomy
- hip disarticulation
- transfermoral
- knee disarticulation
- transtibial
- syme
What is the level of hemicorporectomy
Pelvis L4-L5
what is the level of hemipelvectomy
Mid sacrum
Resection of lower half of the pelvis, loss of ischial tuberosity
What is the level of hip disarticulation ?
Head of femur (non included)
What is the level of transfemoral amputation ?
Everywhere alongside the femur bone:
- short transfemoral = less than 35% of femoral length is kept
- transfemoral = between 35% and 60% of femoral length is kept
- long transfemoral = more than 60% of femoral length is kept
What is the level of knee disarticulation ?
Underneath patella, above tibial plateau
Femur remains intact
Patella is repositioned
What is the level of a transtibial amputation ?
Anywhere alongside tibia
- short transtibial = less than 20% of tibial length is kept
- transtibial = between 20% and 50% of tibial length is kept
- long transtibial = more than 50% of the tibial length is kept
What is the level of syme amputation ?
Through the ankle joint where the heel pad is saved and attached to the distal end of tibial so the patient can put weight on the leg
= partial foot ablation
What is the level of trans metatarsal amputation ?
Around the mid section of the metatarsals
What is the impact of amputation on energy level ?
- Higher energy consumption than non-amputees
- the more proximal the amputation, the more effort required to walk (ex: transtibial = 25% increase, transfemoral up to 65% of O2 consumption increase)
- can be 20%-35% higher in patients whose amputation occurred due to vascular dysfunction (not traumatic)
List the components of prosthesis from pelvis to foot
- socket
- suspension system
- knee assembly
- shank
- terminal device
Give examples of sockets
Silesian belt
Pelvic belt
Close fitting
Define socket
The connection between residual limb and prosthetic device.
List the pressure sensitive areas to prosthesis in case of transtibial amputation
- patella
- lateral tibial condyle
- tibial tuberosity
- tibial crest
- anterior distal tibia
- fibular head
- distal end of fibula
- distal end of residual limb
- medial femoral condyle
- lateral femoral condyl
List the pressure tolerant areas in case of transtibial amputation
- supracondylar areas
- suprapatellar area
- patellar tendon
- medial flare of tibia
- lateral flare of tibia
- lateral flare of fibula
- posterior area of residual limb
- popliteal are (less)
- distal end of residual limb (contact only)
Give a list of terminal devices of prosthesis
- SACH = solid ankle cushioned heel
- EKF = elastic keel foot
- single axis foot
- multi axial foot
- dynamic response
Shortly describe SACH
Solid Ankle Cushion Heel. Combined with EKF (elastic keel foot) : basic and durable, is less expensive, without hinged parts and with limited variations in walking speed
Briefly describe single axis foot
Contains an articulation that improves knee stability for amputations above the knee
Briefly describe multi axial foot
Similar to single axis, but allows a better stance in uneven terrain, due to a multi axial joint that also demands higher muscle activity during gate
briefly describe dynamic response (prosthesis)
Stores and releases energy during the gait cycle. Often used in sports
What are the specific considerations for hip disarticulation ?
Canadian prosthesis with pelvic nest: allows gait with quadratus lumborum as main active muscle, increasing the energetic cost. To reduce this problem patients often use crutches or walkers
Give two brands of prosthesis for knee disarticulation
Genius X3 from Ottobock
C-Leg from Ottobock : allows to set the basic resistance during swing phase
What are the different phases of evaluation ?
Pre-surgical phase
Post-surgical phase
Pre-prosthetic phase
Post prosthetic phase
What is the evaluation in pre surgical phase ?
- respiratory function
- sensitivity
- ROM
- strength
- motor control and proprioception
What is the evaluation in post surgical phase
- respiratory function
- stump characteristics: circumference, skin, shape
- pain
- phantom limb sensation/pain
- neuroma formation : positive tinel’s test
- sensitivity
- ROM
- strength
- motor control and proprioception
What is the evaluation in pre prosthetic phase ?
- stump characteristics: circumference, skin shape
- pain
- phantom limb sensation/ pain
- neuroma formation: positive Tinel’s test
- sensitivity
- ROM
- strength
- Motor control and proprioception
- trunk control in sitting and standing
What is the evaluation in post prosthetic phase ?
- stump characteristics: circumference, skin,n shape
- pain
- phantom limb sensation/pain
- neuroma formation : positive Tinel’s test
- ROM
- strength
- Motor control and proprioception
- Trunk control in sitting and standing
Which assessments must be performed in pre-surgical phase ?
- muscle strength : UL muscles (crutches) and amputation area surrounding musculature
- mobility of trunk and joints close to the amputation area
- coordination and balance : one leg stand security, trunk control and proprioceptive training
- patient education: possibilities, limitations, phantom limb pain and sensation and precautions related to the skin and wound management
What are the physiotherapy goals from 1st week post op until patient is discharged (depending on stump-scar healing) ?
- pain management
- patient education
- facilitation and promotion of function
- prevention of respiratory, MSK and vascular disorders
- scar tissue and stump management
Is early mobilisation recommended in post surgical stage ?
Lack of evidence regarding prevention of MSK complications
What are the post surgical complications of an amputation ?
- massive have Orr have
- skin damage and ulcers
- formation of neuromas
- phantom pain and sensation
- terminal bone necrosis
- formation of osteophytes
- poorly shaped stump
- erosive osteomyelitis
- pneumonia
Basic guidelines for stump wrapping
In figure of eight pattern
Circular pattern
The pressure of bandage should raise from distal to proximal, avoiding skin overlap and folds
What are the 3 different types of dressing that can be used ?
Hard dressings
Semi-rigid dressing
Soft dressing
Why is dressing necessary ?
To protect and shape the residual limb
What is the purpose of hard dressing ?
To support healing, reduce pain and oedema, reduces the time between PO and prosthetic phase
What is the purpose of semi-rigid dressing ?
Protects and shape the residual limb, but can get easily loose during movement
What is the purpose of soft dressing ?
Very practical and helps protect and shape the residual limb, even during weight bearing exercises.
What is the purpose of wrapping ?
- decrease fluids
- increase circulation
- shape limb for prosthetic fittings
What are the possible pain etiologies ?
- neuroma formation
- bony prominences
- poorly prosthetic fitting
- insufficient soft tissue coverage
- reflex sympathetic dystrophy (complex regional pain syndrome)
- phantom limb pain
- phantom limb sensation
What is a neuroma formation ?
It’s a benign tumor of nerve tissue. They develop as an injured nerve starts to heal in an uncontrolled manner resulting in a lump of unorganized axon fibers and non-neuronal tissue growth. It’s a physiological process of peripheral nerve regeneration. It occurs at the most distal area of the stump, needing to be stimulated through touch or pressure. The treatment can be surgical or thought the use of local analgesic/corticosteroids.
What is the sensation of phantom limb ?
It’s a sensation of presence of the non-existing extremity.
What is phantom limb pain ?
Various painful sensations, generally localized on the distal part of the non existing extremity.
What causes phantom limb pain ?
It’s caused by peripheral neural damage, stimulation/desensitization of the area.
It’s caused by inadequate cortical reorganization
What are the possible techniques to treat phantom limb pain ?
- peripheral damage = pharmacological therapy
- inadequate cortical reorganization = visual mirror feedback/ antidepressants
What are the PT interventions in the post surgical phase ?
- Prevention of cardio respiratory, dermatological and MSK complications
- residual limb dressing :
3 to 6 weeks post op => immediate post-operative prosthesis
6 to 8 weeks post op => post operative soft dressing - attention to signs of mental health disturbances, such as depression
What are the PT interventions in the pre-prosthetic phase ?
- residual limb shaping
- desensitization
- ROM and strength
- Motor control
- patient education
What are the the PT goals in prosthetic phase ?
- strength
- ROM
- Balance
- Motor control
- ADLs
What are the precautions in prosthetic phase ?
- adaptation to prosthetic
- skin damage
- residual limb care
- psychological effect of prosthetic use (expectations vs. limitations)
What are the dermatological complications to prosthesis use ? How to react ?
- friction to the skin caused by poorly regulated liner, improper socket and/or insufficient suspension system
- blister
- dermatitis
=> immediately halt the use of prosthesis
What is a liner ?
A residual limb cover, designed to protect the residual limb’s skin, reducing the movement of the socket and chafing.
Each liner is designed to work with a specific suspension system.
Available materials :
- silicone, polyurethane, copolymer
What are the three important aspects of prosthetic training ?
- increase of function/ mobility
- muscular and cardio respiratory demands
- aspect of postural control and balance
Describe the progression of gait training
Usually starts at 10 or 11 weeks post op
1) posture and weight bearing
2) proprioception and trunk control
3) weight shifting and stability in stance
4) symmetry during gait cycle
5) advanced training :
- uneven ground
- crowded places
- public transport
