Amputations & prothestics Flashcards
1
Q
most common etiology of amputation?
A
pvd, particularly arteriosclerosis – usually skin ulceration fails to heal followed by osteomyelitis or gangrene
2
Q
What part of the bone is most commonly affected by osteogenic sarcoma?
A
distal end of the humerus or femur in adolesence or young adulthood
3
Q
How does radiation & chemotherapy affect pt?
A
skin more fragile, reduce energy level, decrease appetite, weight loss that can disturb socket fit
4
Q
What is hansens diease and what leads to amputations?
A
infection w/ mycobacterium leprae which infects sensory nerves, causing sensory loss- can lead to uleraction from repeated trauma then leads to resorption of bony & soft tissue (autoamputation) may lose ends of digits, portions of the nose , etc.
5
Q
What are causes of acquired amputations?
A
pvd, osteogentic sacroma meningitis, hansen’s disease(leprosy), malformation at birth , severe trauma
6
Q
guillotine amputation
A
all portions of the limb are severed at the same level (done in open amputation)
7
Q
when is open amputation indicated?
A
operative site contaminated
8
Q
what is a closed amputation?
A
skin edges are sutured to one another (myoplasty) or sutured through holes drilled in bone (myodesis). cut ends of bone are beveled and nerves cut under tension so they retract w/in the muscle
9
Q
most common partial foot amputations?
A
phalangeal, transmetatarsal, midtarsal disarticulation(choparts disarticulation)
10
Q
Describe a transmetatarsal amputation
A
shortens the foot, loss of metatarsal heads, increase wb’ing on calcaneus
11
Q
How is gait altered by a transmetatarsal amputation?
A
loss of metatarsophalangeal hyperextension during late stance phase, during swing the shortened foot can slip from the shoe
12
Q
Describe ray resection’s negative impacts
A
reduces bos in standing, loss of muscle attachments for planatarflexors, loss of 1st ray can be particularly disabling b/w it usually takes the load when walking on level/unlevel surfaces.
13
Q
describe choparts disarticulation
A
amputation btw the talus & navicular on the medial side of the foot & btw calcaeus & cuboid on the lateral side of the foot
14
Q
What happens to the triceps surae, dorsiflexors and achillies tendon w/ a choparts disarticulation?
A
triceps surae is kept intact, dorsiflexors transcented (foot in plantarflexion position), achillies tendon sectioned
15
Q
how does chopart disarticulation effect gait?
A
wb on plantar flexed foot places stress on amputation scar, produces very small wb’ing area & severely compromises terminal stance
16
Q
what does a syme’s amputation involved?
A
transection of the distal tibia & fibula through broad cancellous bone w/ preservation of the calcaneal fat pat, all foot bones removed, skin overlying the calcaneal fat pad is sutured to the anterior portion of the distal shank
17
Q
true or false the patient w/ a symes amputation can walk shrot distances w/out the prosthesis but requires one when walking long distances
A
true, walking long distances requires equal leg length and foot function
18
Q
describe ankle disarticulation amputation
A
separation of the foot at the ankle
19
Q
describe a transtibial amputation
A
through the tibia & fibula aka below the knee amputation
20
Q
describe hip disarticulation
A
separation of the femur from the acetabulum
21
Q
what is a transpelvic amputation ?
A
removal of any portion of the pelvis and all distal parts aka hemipelvectomy
22
Q
what is a translumbar amputation?
A
removal of the entire pelvis & distal components aka hemicorporectomy: requires creation of urinary diversion an colostomy
23
Q
True or false; hip disarticulation & transpelvic amputation are most often required because of pvd
A
false, b/c of malignancy in the bone or less common b/c trauma or soft tissue infection
24
Q
what is considered a minor upper extremity amputation?
A
partial hand or removal of any portion of the hand
25
describe a wrist disarticulation
separation of the radius from the proximal carpals or separation btw the proximal & distal row of carpals
26
what is a transradial amputation?
through the radius and ulna , aka below elbow
27
what is the name of amputation where the humerus is seperated from the ulna or amputation through the most distal portion of the humerus?
elbow disarticulation
28
describe a transhumeral amputation
through the humerus aka above the elbow
29
describe a shoulder disarticulation
separation of the humerus from the scapula
30
name the amputation where any part of the thorax together w/ any portion of the shoulder girdle and all distal parts are removed
forequarter
31
what info will be gathered at the beginning of the pt examination
pt's age, sex, race, employment, arm & leg dominance, general health status, past medical history/surgeries, present functional status
32
Why would the pt's expectations of therapy be discussed?
can affect compliance w/ recommendations & satisfaction w/ treatment outcomes
33
What are some psychsoical issues that are measured during the pt examination?
education level, cultural beliefs, caregiver resources, living environment, medications, lab test, clinical findings
34
What does the pt's postural assessment focus on?
pelvic alignment, scoliosis, kyphosis
35
what anthropometric measurements are taken of the residual limb? and why
length & girth b/c it will effect what type of prothesis and the snugness or looseness of the socket
36
name common bony landmarks that are used to measure residual limb girth & length
acromion, medial humeral epicondyle for transhumeral & transradial
greater trochanter, medial tibial plateau for transfermoral & transtibial
37
when is the final prosthetic fit and why?
until girth remains stable, edema resolved, atrophy peaked so that limb volume is table and fit will remain good
38
why are rom restrictions addressed early?
avoid contractures early from inactivity, faulty positioning, & muscle imbalance
39
muscle strengthening interventions are needed to
optimize function & prosthetic use
40
depression is common among amputees, what are major contributors to depression ? (referring to pain)
phantom limb pain, residual limb pain, back pain
41
What is phantom sensation & pain?
pt remain's aware of the missing part for the rest of their lives sometimes subsides w/in a yr, pain maybe felt in the missing body part
42
is phantom sensation normal after an amputation?
yes
43
what might the phantom limb feel like?
distorted, pain sensations (burning, electric shocks or unpleasant feelings)
44
What body part has a large cerebral representation that causes phantom pains very often after amputation?
the hand
45
poor circulation increase the risk of
ulceration & gangrene
46
routine inspection for circulatory status includes
color changes, palpation of limb, contralateral foot palpation, checking peripheral pulse, skin temp
47
abnormal warmth of the skin may indicate_______ while cold skin may indicate____
infection, poor circulation
48
what is the first stage of a pressure ulcer?
redness that does not quickly resolve, non blanchable erythema
49
why are patients w/ an amputation at risk for another amputation especially w/ pvd & diabetes?
poor wound healing,amputation of the contralateral extremity , increased energy consumption and reduced walking speed will further decrease activity levels = increasing negative side effects of inactivity and co-morbities
50
Why would a pt w/ bilateral transtibial or bilateral transfemoral amputation end up using a wheelchair to ambulate instead of protheses?
b/c its more energy efficient
51
what are some factors that contribute ongoing prothesic use? (they dont just throw it in the closet)
adults who graduation from high school, employment, emotional acceptance of the amputation, and the perception of the prosthetics being expensive
52
What factors influence early pt rehab program?
level of amputation, surgical procedure, pt's health
53
what does the optimum preoperative program include?
psychological counseling, joint mobility, general conditioning, functional activities
54
What should be part of the early rehab program?
active rom, bed & wheelchair positioning
55
what position is preferred for a pt post amputation when in bed and where should pillows be placed?
pt should lie in prone or sidelying if prone is not tolerated due to breathing difficulties, DONT PLACE PILLOWS in a way that fosters flexion b/c this causes contractures
56
these types of activities provide constructive activity and foster self care.... pt therex is aimed to mimic these activities
functional activities
57
what are the 2 main goals of postoperative management?
wound healing & to promote maximum function
58
residual limb care should focus on...?
wound healing, pain reduction, edema control, joint mobility, strengthening
59
when does early rehab end for a pt who did not receive a prothesis?
when the residual limb is no longer painful and max function is achieved
60
an open wound is vulnerable to infection which can also have which other serious medical consequences?
gangrene, reamputation, sepsis and death
61
what modalities can help increase the healing processes?
e-stim, uv, us, intermittent pneumatic compression, hydrotherapy, negative pressure
62
list 3 positives of controlling edema?
promotes wound healing, reduces pain, facilitates prosthetic fitting
63
which interventions are intended to stabilize limb volume after amputation?
soft dressings (elastic bandage and elastic shrinker sock), semirigid dressings (unna bandage & air splints), rigid (plaster or plastic) dressings
64
what type of dressing should be placed directly on the amputation wound if there are sutures or staples in place?
a thin dressing
65
What are the most common types of dressings used and why?
soft dressings, inexpensive, dressing & removal simple
66
what happens if the transfermoral bandage ends up rolling distally?
patient develops an adductor roll which is a mass of tissue in the medial thigh and can cause chafing and breakdown of tissue
67
what are some disadvantages of elastic bandages?
have to be re-applied several times b/c they loosen up during the day, difficult for transfemoral amputations to wrap themselves, must be applied in a figure 8 pattern, pressure varies w/ each application making volume stabilization relatively ineffective
68
describe shrinker socks and their advantages
closed ended tubes made of fabric knitted w/ elastin, easy to roll up and compress uniformly, transfemoral may require a belt w/ garters for suspension
69
What type of dressing significantly increases rehab for pt's w/ an transfemoral amputation?
unna dressing
70
what is the unna dressing?
is made of gauze permeated w/ zinc oxide & calamine, w/ glycerin and gelatin added as moisture retention agents
71
how is the unna dressing applied?
applied over a thin sterile wound dressing & is placed obliquely on the residual limb w/ turns requiring cutting the bandage rather than twisting
72
what are the advantages of the unna dressing?
adheres to the skin, assuring compression & suspension, relatively thin
73
when is the unna dressing removed?
until the sutures are removed or w/ signs of infection
74
with transtibial, transradial, transhumeral amputations the sutures are generally removed...? while transfemoral amputations the sutures are removed....?
7-10days, 14-18days
75
what is an air splint?
inflatable plastic limb encasement
76
advantages & disadvantages of an airsplint?
advantages: easy to apply & remove, self suspending
disadvantages: bulky & susceptible to punctures
77
describe the layers of a rigid dressing
1st layer elastic sock, 2nd elastic plaster 3rd reinforcing layer of regular plaster, cotton or dacron webbing straps are plastered in place to provide suspension
78
what is an IPOP?
immediate postoperative prosthesis, rigid dressing w/ a pylon w/ foot is plastered into the dressing
79
can a neuroma near fascia cause either local or phantom pain?
yes, excision of the neuroma may help
80
name some of the modalities/therapies used after amputation to manage pain
massage, resistive exercise of the contralateral extremity, relaxation, acupuncture, US, TENS, biofeedback
81
how should the nearest proximal joint be positioned ?
kept extended w/ a splint or rigid or semirigid dressing
82
how should the patient sit in a wheel chair?
good posture, w/out a pillow btw the legs, knee extended w/ leg support
83
describe the type of patient usually under goes ue amputation
young healthy man who can readily preserve or increase strength
84
describe the type of patient who under goes a le amputation
often older and have multiple co-morbiities
85
what muscles must be strengthened for a pt w/ le amputation and why
hip extensors, abductors b/c important during stance phase when walking
86
what specific muscles should be strengthened for a pt w/ a transtibial amputation and why?
knee extensors (quads), b/c strong knee extension is essential for transferring from 1 seat to another & for use w/ prothesic
87
what type of resistive exercises can be used to increase strength for pt's w/ amputations?
isokinetic, manual, active, elastic, pulley
88
why is strength training so IMPORTANT for a pt post amputation?
help the body become more energy efficient reducing fatigue
89
name some strengthening exercises for the pt w/ le amputation
bridging, hip extension, hip abduction in sidelying, quad sets, knee extension, SLR, hip adduction
90
why is it so important to take care of the remaining extremity ?
to reduce the risk of future amputation
91
What activities aggravate pvd?
smoking, bathing in hot water, using a heat pad, exposing feet to radiation or fire, wearing circular garters, using chemical callus removers, walking barefoot, wearing hose, flip flops== increase risk of trauma or infection
92
What should the pt look for when inspecting the residual limb?
redness, blisters, cuts, toenail discoloration, edema
93
around how much wb'ing should the pt w/ an ipop be placing during pt?
only as much weight as the physician says or 25lb max
94
why must the wheel chair have the wheels displaced posteriorly or have tip guards for a pt w/ le amputation?
so that the rearward transposition of the seated pt's cog will not cause the chair to tip back
95
w/ ue amputation, what should be taught to the pt if their dominant hand was amputated
practicing one handed activities, change dominance to the sound hand which can be used todo ADLs (feeding, dressing, toileting)
96
what type of adaptive equipment can be used for pts who suffer from ue amputation?
combination fork or spoon, etc.
97
when is a prosthesis contraindicated?
severe cardiovascular or pulmonary disease( excess strain on the heart), the prothesis makes the pt unsafe, dementia (dont understand directions to don/doff prothesis), no motivation
98
name medical factors that influence but do not preclude prosthetic prescription?
neuropathy, arthritis, lack of skin integrity, contracture , weakness
99
are prothesis necessary for phalangeal amputations?
no, it has minimal effect on standing & walking although amputation of the 1st or 5th phalanges compromise late stance phase
100
why would a pt w/ a phalangeal amputation want a custom made filler? What does the filler accomplish?
walk more comfortably w/ one, custom made fits the residual foot precisely and minimizes risk of abrasion that can jeopardize the scar and cause ulcers
101
if the entire toe removed what support would be most effective?
a longitudinal arch support b/c the plantar aponeruorsis supports the longitudinal arch becomes less effective
102
what type of resection would require a custom made foot prothesis to restore the width of the foot & increase the wb'ing area
any ray resection
103
what type of prothesis is recommended for a pt w/ a transmetatarsal amputation?
custom made, total contact resilient socket attached to a toe filler to protect the residual limb from abrasion. shoe should have the fastening on the proximal dorsal surface, cushioned or beveled rocker sole.
104
how does a custom made prothesis for a transmetarsal amputation help normalize function?
helps restore normal function during the late stance phase of gait (plantar surface curved to help facilitate late stance) and helps avoid an unsightly transverse crease in the upper portion of the shoe.
105
what type of shoe is recommended for a chopart or similar intertarsal amputations?
since this amputation produces a shorter foot that can slip out of shoe during swing phase, pt should wear a shoe that fastens high on the dorsum of the foot. often a partial foot prothesis that replaces the forefoot & midfoot is used
106
what phase of gait is effected by a toe amputation?
late stance: propulsion
107
what phase of gait is effected by a transmetatarsal or midtarsal amputation?
late stance: decreased propulsion during swing phase
| prothesis should remain on foot
108
what phase of gait is effected by a ray amputation?
minimal effect
109
what phase of gait is effected by a syme's amputation?
comparable to transtibial
late stance: decreased propulsion during swing phase
prothesis should remain on foot
110
what type of prothesis is used for a symes amputation?
prosthesis foot , custom made plastic socket that encases the leg up to the level of the tibial tuberosity, may have no opening son the side walls
111
what are the components of a transtibial prothesis?
foot, shank, socket & suspension
112
true or false? all feet support weight when the wearer stands or is in the stance phase of gait and all absorb shock at heel contact for a transtibial prothesis
true
113
With a transtibial prothesis how are the feet designed to help during the gait cycle?
to simulate metatarsophalangeal hyperextension during late stance and remain neutral during swing phase
114
Can a prosthetic foot provide sensory feed back?
no, the socket can provide sensory but no the foot (proprioception)
115
are prosthetic feet able to plantarflex the when the knee if flexed or allow for tip toe walking?
no
116
what is the difference btw a nonarticulated and articulated foot prothesis?
nonarticulated- have no seperation btw the foot and the prosetic shank but do permit some passive motion in all planes, lightweight , durable
articulated- seperation btw the foot and the shank, allowing motion to occur around 1 or more axial bolts
117
What does SACH stand for?
solid ankle cushion heel
118
Describe a SACH foot
basic type of nonarticulated foot, rubberlike compressible heel, rigid longitudinal support known as keel, rubber like toe section and over all covering
119
How is energy stored for ambulation w/ a nonarticulated foot prothesis?
energy is stored during the stance phase and released late stance and early swing phase
120
what happens during late stance phase w/ a sach foot prothesis?
the foot hyperextends at the junction btw the distal end of the keel and the toe section
121
what is flex-foot an example of? describe how it works during the gait cycle?
example of a dynamic energy response foot, carbon-fiber leaf spring extending from the toe to the proximal shank and carbon fiber heel section. long leaf spring stores energy as the wearer moves forward on the foot (midstance) recoils during late stance to release energy
122
The dynamic energy response foot prothesis simulates the propulsive action of which muscle?
triceps surae
123
why does plantarflexion in early stance occur somewhat faster with a articulated foot compared to nonarticulated foot ?
once the pt applies minimal load to the rear foot, the foot moves downward, compressible bumpers control this motion
124
describe the shank portion of the prosthesis and what is it criteria
portion btw the foot and socket, must be rigid enough to support the wearer's weight, made to match the contour of the contralateral leg
125
describe the two types of shanks avaliable
exoskeletal (crustacean) w/ rigid wb'ing plastic or wood shell or endoskeletal consisting of a central wb'ing metal or plastic pylon and a cosmetic cover
126
what may also be installed into the shank for those pt's that like to play golf or walk on uneven terrain?
torque absorber
127
what is the most important part of the prothesis and why
socket, b/c it contacts the wearer's skin
128
describe the main components of a socket
custom made of plastic that is entirely rigid or flexible on the inside w/ a rigid frame, contact portions of the residual limb
129
what areas tolerate pressure best for a le prothesis?
patellar ligament, triceps surae belly, pes anserinus (medial tibial flare)
130
what areas of the le do not tolerate pressure well for a prothesis?
tibial tuberosity, crest, condyles, fibular head, hamstring tendons, distal end of the tibia and fibula
131
Which socket has a prominent indentation at the patellar ligament ?
patellar tendon bearing (PTB)
132
What type of socket has basic contours of the ptb socket but are designed to be worn w/ a compressible liner and are especially suited for suspension by a distal attachment
total surface bearing socket
133
Describe the hydrostatic socket design
smoother contours and is most appropriate for short fleshy residual limbs, distal tissue cushions the bottom of the socket
134
most transtibial sockets are worn w/ 1 or more
interfaces or liners
135
in addition to cushioning impact the liner makes it easier to..?
alter the size of the socket
136
sock thickness is described by ply and can be made of what materials?
wool, cotton or orlon acrylic
137
a nylon sock worn next to the skin provides a smooth surface to reduce
risk of abrasion
138
in addition to or instead of socks and the resilient socket liner the pt made wear a linear made of
silicone or polyurethane sometimes w/ gel-filled or mineral oil-filled channels to equalize pressure w/in the socket
139
What is the 4th component of the transtibial prothesis?
suspension
140
in what phase of gait does suspension assist the prothesis?
during swing phase and whenever the prothesis is hanging such as during climbing stairs and ladders
141
What are the pros and cons of a rubberized sleeve suspension from the distal thigh to the proximal portion of the prothesis?
creates a smooth contour about the knee that makes it more attractive when the wearer sits but does require 2 strong hands to don and will not fit a large thigh.
142
What is the simplest and least expensive type of suspension for a transtibial prothesis?
supracondylar cuff which is attached to the proximal portion of the socket & buckled or strapped around the distal thigh
143
what type of suspension has been tested to creat a large suction distally during swing phase?
silicone liner and metal pin that lodges in a receptacle in the proximal portion of the shank but CAN compromise skin
144
describe the pros and cons of the corset suspension for a transtibial prothesis
pros: readily adjustable, supports some weight on the thigh
cons: more difficult to don, can cause pressure atrophy of the thigh, retains heat, heavy and bulky
145
describe the features of a supracondylar suspension for a transtibial prothesis
features a brim extending over the medial and lateral femoral epicondyles and the socket covers the patella to accommodate a very short residual limb
146
what is the purpose of slightly flexing the socket in the sagittal plane ?
reduce the tendency of the residual limb to slide downward in the socket, increase loading on the patellar tendon, enhance quad function
147
in what position would the prothetic foot be placed for a frail person versus a more athletic person?
frail the foot would be located more forward so that the weight line passes well in front of the knee while a more athletic person would have the foot located slightly behind the socket so that the knee is easy to flex
148
describe how the socket is adjusted in the frontal plane?
adducted slightly to enhance loading on the proximal medial aspect of the residual limb
149
how is the foot aligned in reference to the socket
slightly medial to the socket to augment proximomedial loading and to maintain a relatively narrow walking base - it is shaped to present an attractive apperance
150
what two type of sockets are generally used in a knee disarticulation?
older- anterior opening and fastens w/ straps or laces, good for bulbous shaped residual limb
newer- flexible liner, more streamlined residual limb w/out protruding femoral epicondyles (socket usually keeps prothesis on , no need for additional suspension)
151
what does the transfemoral prothesis consist of?
foot, shank, knee unit, socket, suspension
152
what type of foot should a transfemoral prothesis use if the pt is hesitant abt applying weight to the prothesis?
single axis foot b/c this will planterflex w/ less force than a sac foot
153
what type of skeleton for shank allows it to be adjustable and lightweight but the cover is subject to considerable erosion at the knee when the pt sits or kneels
endoskeletal shank
154
all knee prosthetics are design to allow what motion?
flexion when the wearer sits
155
what type of knee axis is simple and only requires 1 transverse bolt?
single axis
156
what type of knee axis has 2 or more pairs of pivoting side bars ?
polycentric axis
157
what type of knee axis is more durable?
single axis b/c the other has more moving parts
158
what is the purpose of a friction mechanism?
resits shank movement during the swing phase of gait to prevent excessive knee flexion during early swing phase and abrupt extension at late swing
