Amputations, Burns, Renal Disease

Question 1

Causes of amputation

Answer 1

• Disease
• Trauma
• Infection
• Tumor
• Congenital limb deficiency

Question 2

Acquired Amputations

Answer 2

Adults who have limb removed as a result of disease or trauma (NOT congenital limb deficiencies). These pts do not develop sensorimotor skills and self-image without the limb that younger pts with congenital deficiencies do.

Question 3

Primary cause of amputation of lower limb and upper limb

Answer 3

Lower Limb: dysvascular disease and diabetes

Upper Limb: trauma (work-related accidents, GSW, burns).

Question 4

Loss of the entire lower limb (LL)

Answer 4

Hemipelvectomy or Hip Disarticulation amputations cause loss of entire LL. Usually due to trauma or malignancy. Very slow healing, and may require skin grafting. In hemipelvectomy, a muscle flap covers the internal organs.

Question 5

Above-Knee Amputation (AKA)

Answer 5

Transfemoral Amputation. Loss of the knee and everything distal to it. Residual limb length varies from 10-12 inches from greater trochanter. Classified by distance from ischium: Upper, Middle or Lower Third.

Question 6

Through-the-Knee Amputation

Answer 6

Disarticulation Amputation. Loss of knee joint function but allows high level of prosthesis control/mobility.

Question 7

Below-Knee Amputation (BKA)

Answer 7

Transtibial Amputation. Preserves the knee and eliminates need for mechanical knee joint in prosthesis. Residual limb from 4-6 inches from tibial plateau.

Question 8

Syme’s Amputation

Answer 8

Ankle Disarticulation. Loss of both ankle and foot function; typically from trauma or infection.

Question 9

Metatarsal Amputation

Answer 9

From severing of foot through metatarsal bones, but ankle remains.

Question 10

Ray Amputation

Answer 10

Excision of the toe and part of the metatarsal.

Question 11

Causes of LL Amputations

Answer 11

• 95% due to peripheral vascular disease (PVD) (up to half of which are diabetes)
• Trauma 2nd most common
• Malignancy (to prevent spread)

Question 12

Shaping of Residual Limb

Answer 12

• By wrapping with elastic bandage to control edema post-surgery. Must be skilled/consistent technique to prevent poor shaping.
• Gradually smaller residual limb shrinkers (encourages constant, even shrinkage for prosthesis fitting)
• Jobst compression pump, if wrapping/shrinker ineffective; air-filled sleeve that surrounds, providing constant, equal pressure to shrink limb.
• Both can be used after surgery, and over dressings if a nylon stocking is applied first.
• Shrinker may continually be worn even after prosthesis fitting when not wearing; can take up to 3 months or longer.
• Scar massage may be used to prevent adhesions and enhance surgical site comfort.

Question 13

Main Components of Prosthesis

Answer 13

• SOCKET (direct connection to prosthesis)
• SOCK/GEL LINER (Adapts to limb volume changes; may be removed)
• SUSPENSION SYSTEM (Attaches socket to limb; belts, straps, wedges or suction)
• PYLON (Attaches socket to terminal device (TD); shock absorber or static)
• TERMINAL DEVICE-TD (Prosthetic foot, stable, weight-bearing surface and shock absorber; variable degrees of mechanical ankle movement/dynamic response)
* Some may include an articulating JOINT

Question 14

Socket Options

Answer 14

• SMART VARIABLE GEOMETRY SOCKET (SVGS): reduces challenge of adapting to volume changes; adds/removes liquid on basis of pressure during wear to maintain fit.
• STATIC ELASTOMERIC LINER: Liner choice based on variables such as fit, comfort, friction tolerance and price.

Question 15

Eschar

Answer 15

Dead epidermis and necrotic dermis attached to wound bed.

Question 16

Debridement

Answer 16

Removal of necrotic tissue

Question 17

Dermis

Answer 17

Layer of skin that provides THERMOREGULATION through control of skin blood flow, as well as:
• Growth factors
• Epidermal replication
• Dermal repair

Question 18

Total Body Surface Area (TBSA)

Answer 18

Used to measure burn injury severity.

Question 19

Rule of 9s

Answer 19

Body broken up into 9% sections, and % of body burned calculated by adding these. (ie: Chest is 9%, Abdomen is 9%, so a front burn of these areas is 18% of body burn)

• Percentages very different for infant. Abdomen or back are 13%. Head 21% (9% for adult). Arms 10% (9% on adult).

Question 20

Severity of Burn Wound

Answer 20

• Superficial
• Superficial/Partial Thickness
• Deep/Partial Thickness
• Full Thickness (no remaining dermis)

Question 21

Medical Mgmt of Burn

Answer 21

• Maintain open airway
• Manage edema
• Avoid infection: grafts
• Improve circulation: Escharotomies
• Regulate body fluids
• Assess body for viable graft sites

Question 22

2 Goals of Skin Grafts

Answer 22

1) Short Term Goal: Skin hydration

2) Long Term Goal: Coverage of burns, cosmetic appeal, maximize ROM

Question 23

3 Phases of Graft Healing

Answer 23

1) Imbibition
2) Neovascularization
3) Maturation

Question 24

Scar Types

Answer 24

KELOID: abnormal scar that grows beyond boundaries of original skin injury.

HYPERTROPHIC: widened or unsightly scar that does NOT extend beyond original boundaries of wound. Grows upward. Can develop into Keloid.

Question 25

Treatment Objectives for Burns

Answer 25

• Prevent deformity (ie: scarring and contractures over joints)
• Increase/Preserve independence with ADLs
• Compliance
• Evaluation
• Positioning
• Treatment techniques (scar massage, ROM, strengthening)

Question 26

Positioning for Burns

Answer 26

* Position of comfort = position of deformity!
• Edema reduction
• Joint alignment
• ROM maintenance/increase
• Elongated tissues
• Joint/scar remodeling
• Promote wound healing
• Relieve pressure points
• Protect grafts

Question 27

Scar Care

Answer 27

• Wear pressure garments 23 hours/day for 1 year
• Self ROM constantly
• Self scar massage when pressure garment off
• Moisturize daily
• Sunscreen under pressure garments

Question 28

End Stage Renal Disease (ESRD) symptoms

Answer 28

• Changes in mental status
• Impaired sensation of hands/feet
• Decreased urine output
• Nausea
• Vomiting
• Headache
• Easy bruising/bleeding
• Fatigue
**Dialysis is necessary!

Question 29

Peritoneal Dialysis vs. Hemodialysis

Answer 29

PERITONEAL: Completely via catheter in abdomen where fluid is replaced with automated exchanger. Can be done at home, all night long or every 2-3 hours during day.

HEMODIALYSIS: Done 3x/week at dialysis center via Gortex graft between vein and artery junction, typically in upper arm. May take several hours.

• Removes toxins and wastes and control symptoms

Question 30

Risks of Dialysis:

Answer 30

• Muscle wasting
• Clotting of fistula
• Graft “steal”
• Infection
• Hypotension
• Insomnia
• Bone disease
• Fatigue
• Cannot take blood pressure on arm with fistula

Question 31

Causes of Kidney Disease

Answer 31

• Diabetes*
• High Blood Pressure*
• Autoimmune disorders (lupus, scleroderma)
• Birth defects of kidneys (polycystic kidney disease)
• Toxic chemicals
• Glomerulonephritis
• Injury/trauma
• Kidney stones and infections
• Reflux nephropathy (backward flow of urine to kidneys)