Amputations Flashcards
Etiology
- Peripheral Artery Disease (M>F)
Most common cause. Most common is DM II > leading to infections > amputation - Trauma (M>F) - d/t high risk behavior. ** Generally more young
- Infection - osteomyelitis
- Congenital Deficiency
Require an amputation to fit a prothesis or cosmetic/functional
Syme’s Amputation
Also known as Ankle Disarticulation
Amputation through the malleoli
- Take out the talus & calcaneous - heel pad gets wrap under the the tibia/fibula = weight bearing stump
Lisfranc’s Amputation
Disarticulation at the tarsometatarsal joint - leads to mm imbbalance - leads to equinus gait & inversion
Chopart Disarticulation
Disarticulation at the mid tarsal joints
Leads to mm imbalances - causes equinus gait & inversion
Transtibial Amputation
Advantages & disadvantages
Advantages
- Greater potential for ambulation - still have good control w/ a knee joint
- DEC energy expenditure with ambulation (compared to TF
Disadvantages:
- Not a weight bearing end (weight bearing on patellar tendon)
- Bony prominences are at increased risk for skin breakdown - a lot of points of contact that can lead to skin breakdown
Transfemoral Amputation
Advantages & Disadvantages
Advantages:
- Greater healing in vascular amputees compared to transtibial amputees
** Lower down the PVD is going to be worse - less blood flow = poor healing
Disadvantages:
- Not a weight bearing end
- Lower potential for ambulation
- INC energy expenditure with ambulation
The higher up you go = the greater the energy cost
External knee joint = harder to control
Rotationplasty
Also known as Ves Nes rotationplasty
- Used to treat bone tumors in children which occur around the knee, when the lower leg and ankle are still health
- Part of the limb (leg or thigh) is removed, while the health remaining lower portion of the limb (lower leg & ankle) is rotated and reattached
- This procedure allows the ankle joint to act as a knee joint in prosthesis
Goal of Post-Surgicial Dressings
(4)
- Control edema - external dressings
- Edema can compromise healing and cause pain - Prevent infection
- Protect limb from external trauma - especially more rigid dressings
-
Shape residum in preparation for prosthesis
- If you do this incorrectly or not do it at all = lose opportunity to wear a prothesis in future
- Shape residuum for the prothesis - so when it is WB, it can accept the load & does not put to much pressure on a specific spot
Rigid Dressing
Types & Adv/Disadv
Non-removable
1. Immediate postoperative prosthesis (IPOP)
- Handmade from plaster
- Follows the general configuration of the prosthetic socket
- Put it on IMMEDIATELY - cut to take it off & as the limb chnages then casts are changed
- Removed at 10-14 days
Removable
1. Removable Rigid Dressing (RRDs)
- Handmade from plaster or refabricated plastic materials
- Comes in different sizes and adjustable as limb changes
- May be removed to inspect wound
Advantages:
- Excellent for edema control - BEST Dressing
- Excellent for pain control
- Excellent protection - harder
- Enhances healing
- May help prevent knee flexion contractures
Disadvantages:
- Can not inspect incision with IPOP
- More expensive than other dressings
Semi-rigid Dressing
Type & Adv/Disadv
Unna’s Paste
- Rolls of gauze soaked with a compound of zinc oxiden, gelatin, glycerin, and calamine
Advantages:
- Good edma control (better than soft dressing, not as good as rigid)
- Can remove and reapply easily to inspect incision
- Superior to soft dressing in enhancing healing
Disadvantages:
- May loosen easily
- Needs frequent changing (application is not easy)
- Takes time to dry
Soft Dressing
Types (2) & Advantage/Disadvantages
Elastic Wrap - oldest method of post-surgicial dressings
- Figure-8 compression (tensor) wrap is applied after a dressing is applied to the incision with some form of guaze pad
Advantages:
- Can remove and reapply easily to inspect incision (indicated in cases of local infection) Only real advantage
- Inexpensive
Disadvantages:
- Poor edema control
- Minimal protection
- Requires frequent rewrapping - does loosen up
- Movement of residuum will cause slippage & change in pressure & pressure distribution (may cause limb to not shape as well)
If not skilled in the application = might create a 1. TOURNIQUET Affect - put it on so tight that it could cut off blood flow to the more distal end. 2. May not come out evenly - may have applied pressure unevenly
Elastic Shrinkers - MAIN way residuum is shaped & prepared for prothesis
- Sock-like prefabricated garmets made of heavy rubber, reinforced cotton
- Not used until incision has healed & the sutures have been removed
Advantages:
- Easy to apply
- Inexpensive
- Good edema control (not as good as rigid or semi)
- Good stump shaping (not as good as rigid or semi)
Disadvantages:
- Requires changing of size as residuum shrinks (coorect size essential)
- Nnot used until incision has healed & the sutures have been removed - friction occurs during application
Need to wear it 24/7 - need more than one (requires frequent cleaning)
Postsurgicial Phase: Goals
(4)
- Healing of resdiuum
- Protecting unamputated limb (if circulation is compromised) - majority of amputations are d/t vascular complications & about 1/2 of these are d/t Type II DM
- INC independence in transfers and mobility
- Understanding and demonstrating proper positioning
Positioning: TT & TF
Main goal: PREVENT contractures
TT:
- Common contractures are Knee flexion & Hip flexion
- Encourage patient to spend time in PRONE - 15-20 min/day minimum
- Do not place a pillow under residual limb in supine or between legs
- Use a stump board when sitting in W/C - prevents hanging in knee FLEX for prolonged periods
TF:
- Common contractures: Hip flexion, abduction, and ER
- Encourage patient to spend some time in prone
- Do not place a pillow under residual limb in supine or between legs - could cause an ABD contracture
- Do not place rediaul limb in abduction and ER
Post-Surgicial Phase: Balance
Sitting balance may be a problem w/ patients with LE bilateral amputations
Standing balance on unamputated limb is beneficial for gait aid use & living an active life during preposthetic phase
**Want pt to move - teach them how to use crutches & to have good SLS (balance)
Post-Surgicial Phase: Transfer Training
In early postsurgicial period patient should transfer leading with unamputated limb in order to protect residual limb from possible injury against transfer surgace
T/F towards good side - more limits of stability on sound side & also it is better to fall on that side compared to the side with an incision/healing
Post-Surgicial Phase: Mobility Training
(3)
- Fit patient with appropriate mobility aid - should occur prior to Sx = easier transition afterwards
- Walker provides greater stability, while crutches provide greater mobility & help train balance in preparation for prosthetic use
Advantage (crutches): Helpful for quick ADLs @ home (ex. going to the bathroom at night) & can use them on the stairs - Wear a shoe on the remaining limb to prevent slippage & protect remaining foot
Post-Surgicial Phase: Residual Limb Care
(4) + 2
- Teach patient and family how to properly wrap limb
- Teach patient how to protect residual limb while moving in bed or transferring
1. Do not drag residuum on bed - shearing forces on skin - lift residuum up
2. To transfer from supine-sit, slightly raise residual limb while rolling to unamputated side & then move from side-lying to sit - Teach the patient gentle ROM exercises for residual limb w/in a pain-free range
- Resisted exercises for the residual limb in contraindicated in this phase (still healing)
Preprosthetic Phase: Goals
(4)
- Independent in residual limb care
- Independent in mobility, transfers, and functional actvities
- Understanding of home exercse program
- Remaining limb care (if circulation is compromised)
Preprosthetic Phase: Physical Examination:
Residual Limb
(6)
Skin
- Incision: healing, adherent scar, draining
- Lesions: dermatological reasons
- Sensation: intact - want them to be aware of the sensation around the residual limb so they can be aware if there is skin breakdown
Shape
- Normal: Cylindrical (**ideal), Conical (fibula is shorter than the tibia - not ideal), Bulbous end (Not ideal for trans amputations - difficulty w/ fitting prothesis - bulbous end gets in BUT the rest of the limb is loose)
- Abnormal: “dog ears” (pointy ends), skin folds, edematous
Length:
- Bone length
- Soft tissue length (not excess tissue)
Circumduction:
- Edema - to much = longer time to the prothesis phase. Want the volume of the limb to stabilize
Pain
- may feel sharp, sticking, or pressure at end of stump
- Commonly “prosthogenic” - due to improper fitting of the prothesis
Joint Proprioception
Preprosthetic Phase: Physical Examination: Strength
(2)
- Gross motor strength (functional activities) - pushing through arms, transfers = more functional things
- MMT of residuum must wait until most healing has occurred
TT - NEED good strength in hip EXT, ABD, ADD & knee FLEX, EXT in order to be ambulating well w/ the prothesis
Preprosthetic Phase: Physical Examination: Phantom Limb
(2)
Phantom Limb Sensation
- Sensation in the area of the limb that is no longer there = Hypo: pain d/t involvement of the somatosensory cotext - mapping - the area that controlled that limb still has memories of that body part & mvmt - why they have the “feeling”
- May feel burning, tingling, itching, pressure, numbness, or wet
- Majority of amputee patients will experience phantom limb sensation (may last months or years)
TENS, IFC, massage, ultrasound
Phantom Limb Pain
- Noxious sensation in the area of the limb that is no longer there
- Not well understood - somatosensory cortex plays a role in this
- Type of pain varies - so painful that they cannot start fitting of prothesis
Mirror Therapy - retraining the brain
Virtual Reality
Preprosthetic Phase: Intervention
Skin Care
(3)
- Education on proper hygience & skin care
- Inspect Residuum
Inspect with a mirror daily
Look for sores, cuts, or other problems and report to doctor if found - Friction Massage
Gently peform friction massage over the incision to prevent or mobilize adherent scar tissue - want to prevent adherence = INC risk of skin breakdown (shearing forces)
Incision must be healed and should be clear of infection
Desensitizes residuum to touch & pressure
** Rub, slap, vibrations - getting used to a variety of sensations to INC tolerance so it is not a problem later on
Key muscles for ambulation with prosthetic?
TT & TF
TF:
- hip extensor, abductors, adductors
TT:
- Hip extensors, abductors, adductors, Knee extensors & flexors
Preprosthetic Phase: Intervention:
ROM
Key Detail
ROM helps with MILD contractures
Not effective at improving MOD-SEVERE
Techniques:
1. Positioning
2. Manual mobilization
3. Active exercises
4. Stretching
5. PNF - more effective at preventing contractures than stretching
Prosthetic Training: Goals
(4)
- Smooth, energy-efficient gait in order to perform ADLs, employment, and recreational activities
- Do as much training as possible w/o ambulatory aids
- Cane may be used if necessary
- Never use a walker as part of prothetic training (unless patient was using walker before amutation)
** want to optimize function
Train more stability -> less stability
Pressure Sensitive & Tolerant Areas
Definition & Sensitive & Insensitive
In order to maximize prostetic comfort, pressure is relieved from pressure sensitive areas & increased over pressure intolerant areas
Presure sensitive structurers:
- End of bone cut during amputation
- Bony prominences
- Nerves or neuromas exposed to pressure
- Cord-like tendons (adductor longus, hamstrings, etc)
- Non-weight bearing bone surfaces (pubic ramus)
Pressure tolerant structures:
- Flat bone surface
- Flat tendons (patellar tendon) - pressure bearing surface
- Normal wt-bearing surfaces (ischial tuberosity, joint surfaces)
- Muscle
- Fat
Pressure Sensitive Areas:
Transtibial Stump
(10)
- Patella
- Lateral tibia condyle
- Tibial tuberosity
- Tibial Crest
- Anterior-distal end of tibia
- Fibular head
- Distal end of fibula
- Distal end of stump with surgical suture
- Medial femoral condyle
- Lateral femoral condyle
Pressure Tolerant Areas:
Transtibial
(8)
- Supracondular areas
- Suprapatellar areas
- Patellar Tendon
- Medial flare of tibia
- Latreal flare of tibia
- Lateral flare of fibula
- Posterior area of the stump
- Popliteal area (gently)
- Distal end of the stump for total contact socket
(No pressure, contact only
Pressure Sensitive Areas:
Transfemoral
(8)
- Greater trochanter
- Ramus
- Anterior Superior Iliac crest
- Adductor tendon
- Distal end of the femur
- Inguinal fossa
- Pubic tubercle
- Surgicial suture
Pressure Tolerant Areas:
Transfemoral
(6)
- Ischial Tuberosity
- Lateral flare of stump
- Medial flare of stump
- Anterior flare of stump
- Posterior flare of stump
- Distal end of stump for total contect socket
(No pressure, contact only)
Prosthetic Training: Critical Elements
(9)
- Stability - both legs - w/o holding onto anything
Weight shift - want to encourage them to shift wt onto the prothesis - Knee control (TF) - have a prothetic knee to control - ** feel of knee w/ different socket pressures
- Stability on prosthesis - SLS - stepping up/down on stool OR kick a ball
- Prosthetic control - kick a ball w/ prothetic leg
- Proprioception - standing on “clock & shift body to a specific time
- Pevlic control - walking - PT resists pelvis from tanslating foward & tihs encourages pt to ranslate wt smoother
- Stepping with prothesis (forward & backwards)
- Stepping with sound leg
- Side stepping/backward stepping - more advance skills
Prothetic: More Advanced Training
(6)
- Going up & down stairs and ramps
Good goes to Heaven, bad goes to Hell
Walking sideways to get stability - Sitting on the floor - flex knee (TF)
- Getting up from the floor
Many ways: Most common is kicking prothetic leg out to the side & into EXT - SL squat on sound leg & push w/ arms - Kneeling
- Picking up an object from the floor
- Clearing obstables
