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Orthotics & Prosthetics > Amputations and Diabetic Foot > Flashcards

Amputations and Diabetic Foot Flashcards

1
Q

History of O&P Milestones

A
  • Earliest recorded amputation was 484 BC when soldier cut off his foot to escape imprisonment
  • tourniquet introduced 1674
  • 1863 - suction socket for TF amputee
  • 1846 - first amputation under anesthesia
  • 1867 - anticeptic surgery introduced
  • 1949 - myoplasty introduced
  • 1960s - myodesis introduced
  • 1954 - hip disarticulation prosthesis
  • 1956 - SACH foot
  • 1959 - PTB
  • 1971 - endoskeletal prosthesis
  • 2000 - microprocessor controlled knee
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2
Q

Incidence of Amputations

A
  • TFemoral more common than transtibial
  • 80,000 in US/year
  • men>women 3:1
  • amputation rate increases steep w/ age
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3
Q

Population Base of Amputation

of Limb Loss

A
  • 82% = dysvascular disease
    • PVD by peripheral neuropathy (HTN, cholesterol, tobacco)
  • 16.4% = Trauma -opt outcome surg<12hrs
    • machinery 40%
    • power tools 27%
    • firearms 8%
    • MVAs 8%
  • .9% cancer - carcinoma
  • .8% congenital limb deficiencies
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4
Q

INcidence of amputations in people >60

A
  • 90% vascular disease
  • 7% trauma
  • 2.5% tumor
  • .5% congenital
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5
Q

Rehabilitation Issues to Consider with Amputation

A
  • determing readiness for prosthetic fitting
  • involved decision about prosthetic components
  • coordinates prosthetic training
  • consult with prosthetist as needed
  • basic mobiity training
  • consuly and assist patient to return to employment/activities
  • AGE IS MORE IMPORTANT THAN ETIOLOGY FOR PREDICTING TOTAL LENGTH OF TIME IN REHABILITATION
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6
Q

Energy cost and Amputaiton

A
  • preservation of knee joint = key determinant for potential for functional ambulation and successful outcome
  • more of the limb you can leave the better the outcome**
  • increased energy for persons with bilat TF
  • some elderly may chose wheelchair
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7
Q

Factors Which influence the metabolic cost of walking

A
  • Length of residual limb
    • knee = key
    • longer lever arms = better
  • Cause of Amputation
    • trauma vs. vascular
    • other complications (TBI, atrophy, SCI, soft tissue injury etc) *life vs. limb
  • Age
    • linear relationship regardless of disability
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8
Q

Diabetes and High Risk Foot

A
  • DM is the diagnosis most frequently associated with foot ulceration and LE amputation
  • DUE TO PERIPHERAL NEUROPATHY
  • poor circulation, is not the primary cause of most foot ulcers though closely related
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9
Q

Diabetic Peripheral Neuropathy

A
  • Damage to nerves (40% of DM)
  • 60% of LE amp are related to DM
  • characterized by:
    • neuropathic pain/loss sensation
    • muscle weakness later stages
  • ppl w/ DMPN have 15x greater risk of foot ulcer than those with DM and intact sensat.
  • PRIMARY MECHANISM FOR INJURY/ULCER W/ DMPN IS REPETITIVE MECHANICAL STRESS THAT IS UNRECOGNIZED
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10
Q

Considerations and Controlling DM

A
  • Hb-A1C
    • Healthy = 5
    • DM = less than 7 = controlled
    • lower = less complications
  • other systemic diseases
    • stroke, TIA
    • CVD
  • Foot health hx
    • previous ulcer
    • ankle sprains
  • medications
  • visual deficits
  • footwear
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11
Q

Physical Exam of DM Foot

A
  • Vascular exam - pulses, doppler, ABI <.45
  • Sensory Exam - vibration, protective sens.
  • soft tissue
  • footwear
  • balance
  • gait
  • ms exam - jt mob, deformity,
    • Charcot’s foot - loss of arch, bones drop down, inflammatory process = bone disintegration
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12
Q

Treatment for Neuropathic Ulcer

A
  • Sharp debridement for necrotic tissue
  • appropriate dressings applied
  • pressure reduction
    • total contact casting
    • walking splints
    • removable cast walkers
    • half shoes
  • can participate in WB exercise
  • comprehensive foot care
  • MODERATE WALKING LIKELY DOES NOT INCREASE RISK OF FOOT ULCERS
  • need good footwear and daily inspection
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13
Q

Amputation Levels

PARTIAL FOOT

A

General Information

  • loss ant. lever arm foot affects term. stance
  • functional loss of DF @ ankle
  • tendency of ankle to become fixed
  • many different levels
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14
Q

Toe Amputations

A

Benefits

  • plantar surface WBing
  • most of foot intact
  • gait unaffected at normal speeds

Challenges

  • shoe selection
  • excessive pressure at amputation site
  • shear forces at suture area

Prosthetic Management

  • carbon foot plate with filler or silicone restoration
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15
Q

Ray Amputations

A

Benefits

  • plantar surface WBing
  • most of foot intact

Challenges

  • shoe selection
  • excessive pressure at amp site
  • shear forces at suture area

Prosthetic Management

  • carbon plate with toe filler or silicone restoration to minimize shear forces
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16
Q

Transmetatarsal Amputation

A

Benefits

  • partial plantar surface WBing
  • most of the ankle structure is intact

Challenges

  • shoe selection
  • excessive pressure at distal plantar metatarsal areas
  • shear forces at suture area

Prosthetic Management

  • carbon foot plate with toe filler or silicone restoration
17
Q

Lisfranc - Metatarsal Disarticulation

A

Benefits

  • distal bearing
  • ankle joint intact

Challenges

  • cosmetics of prosthesis
  • height discrepancy - no longer have long arch
  • loss of foot levers/rockers

Prosthetic Management

  • fiber foot plate with toe filler
  • AFO/prosthesis
  • tibial tubercle level prosthesis
18
Q

Chopart Amputation

Calcaneo-Cuboid Talo-Navicular Disarticulation

A

Benefits

  • distal bearing
  • ankle joint intact

Challenges

  • cosmetics of prosthesis
  • height discrepancy
  • loss of foot levrs

Prosthetic Management

  • fiber footplate with toe filler
  • AFO / prosthesis
  • tibial tubercle level prosthesis
19
Q

Boyd/Pirgoff Amputation

A

SImilar to Symes Amputation however the calcaneus is cut and attached to the cut end of the distal tibia

20
Q

Symes Amputation

Malleoli are partially sheared off for Cosmesis

Heel Pad reserved and anchored to distal end of Tib/Fib

A

Advantages

  • distal end bearing
  • less traumatic surg
  • sulf suspending
  • long lever arm
  • >surface area
  • <stresses>
    </stresses>

</stresses>

Disadvantages

  • potential problems with the heel pad/flap
  • component option limitations
  • cosmesis

Suspension Options

  • windows: either medial or posterior
  • expandable bladders
  • partial inserts
  • supramalleolar
21
Q

Transtibial Amputation

A
  • Conical = Larger surface area and less pointiness because you have 2 long bones providing support
  • when amp is done for vascular reasons, very short anterior flap and very long posterior flap (otherwise equal flaps)
  • optimal:
    • typically mid tibial
    • length allows space for prosth foot and sufficient muscle padding
    • too much - no room for ankle
  • minimum
    • junction of middle 3rd and prox 3rd of tibia just below the flair of tibial plateu to allow suff. WB
22
Q

Through Knee Disarticulation KD

A
  • Good comfort and function
  • poor cosmesis
  • patellar tendon sutured to remnants of cruciate ligaments
  • few muscles and no bone cut = less traumatic surgery
23
Q

Transfemoral Amputation

A
  • equal length ant/post flaps
  • nerves cut at level to ensure they are well covered
  • trying to avoid neuromas so you cut them high so they have less pressure on them
  • myoplasty = sow muscle to other muscle
  • myodesis = sow muscle to the bone
  • end of bone is smoothed
  • Optimal length
    • allows space for uncompromised knee system
    • typically above condylar flare
  • Minimal Length
    • junction of middle 3rd and prox 3rd (below less troch) to allow for suff fem length/lever arm to operate prosthesis
24
Q

Hip Disarticulation and HemiPelvectomy

A
  • blood loss can be a problem
  • symphysis pubis is divided
  • anterior - above and paralleled to inguinal ligament
  • posterior - preserves variable portion of gluteus maximus
  • hemipelvectomy - all or part of ilium is removed
25
Q

Determining Appropriate level of amputation prior to surgery

A
  • patient goals and priorities
  • patients general condition
  • risks of additional surgery
  • potential healing of the limb
  • predicted probably outcome (age)
26
Q

Common Techniques used at ALL levels of Amputation

A
  • Flaps
    • decrease tension
    • trim them down - want =
    • provides cushion
  • nerves cut high
    • prevention of neuroma
  • myoplasty/myodesis
    • ms stabilization, shape, fxn
27
Q

Ateriosclerosis Obliterians

A

Narrowing and occlusion of the arterial lumen of the larger arteries

  • etiology
    • 50+
    • male
    • tobacco
    • obesity
    • HTN
    • HLD
    • sedentary
  • symptoms
    • inttermitten claudication
    • decreased pedal pulse
    • dry skin
    • hair loss
    • clubbing toe nails
    • ulceration
    • pain relieved w/ standing
28
Q

Arteriosclerosis with Diabetes

A

Narrowing of the Medium and Smaller arteries - w/ neuropathic changes

  • etiology
    • same as arteriosclerosis obliterans (ASO)
    • 40+
  • Symptoms
    • same as ASO
    • decreased foot sensation
    • renal complication
    • impaired vision
    • decreased strength
29
Q

Chronic Venous Insuffiency CVI

A

Compromised blood flow of superfiscial veins as a result of perforating valves, increased SBP, decreased blood flow, edema and cell death

  • 1% of population
  • edema
  • dilated veins
  • dermatitis
  • ulcers (above malleoli)
  • pain relieved by elevation
30
Q

Thromboangitis Obliterans

(Beurger’s Disease)

A

Inflammation of the small and medium arteries and veins of both UE and LE directly related to smoking

  • male 20-40, tobacco use
  • bilateral ischemia
  • ulcers
  • phlebitis
  • pedal claudication
  • pain with rest
31
Q

Stages of Amputation

A
  • Pre-amputation = everything before
  • Pre-Prosthetic = amp to first OP fitting
  • Transitional = first OP fitting to limb stab
  • Mature = everything after limb stabilization
  • Post Amp -> Pre Prosthetic assess:
    • pain
    • residual limb size
    • wound healing
    • circulation
    • ROM/flex
    • joint mob
    • muscle performance
    • gait/balance
32
Q

Phantom Limb Sensation vs. Phantom Limb p!

A
  • 85% of amputees experience phantom sensation, pain or actual limb pain
  • Phantom sensation = non painful sensation or awareness that occurs below the residual limb
  • Phantom limb pain = painful sensation that occurs below the residual limb
  • Residual limb pain = pain arising in the residual limb from a specific anatomical structure that can be identified
33
Q

5 Steps of Loss with Amputation

A

Denial

Bargaining

Anger

Depression

Acceptance

34
Q

Amputation in the 1st Year

A

Healing

Grief

Rehabilitiation

Adjustment

Integration

Reintegration

Orthotics & Prosthetics (10 decks)

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