Exam 1 Review Flashcards
Surgical Techniques for amputation (3)
- Myoplasty: attach muscle to muscle
- Better for patients with vascular problems
- performed between the agonist and antagonist muscle groups) reestablishing a muscle pumping action
- gives greater control to the limb and adds a muscle padding over the end of the limb.
- Myodesis: Attach Muscle to periosteal bone
- not recommended for ischemic patients
- causes bone trauma
- Myofascial: Attach muscle to fascia
Causes of amputation (6)
- Peripheral vascular disease
- most common cause of amputation in adults
- Diabetes
- Trauma
- Infections
- Tumors
- Limb deficiencies
Evaluating blood flow (techniques):
- Auscultation via a stethoscope
- Palpation
- Doppler Ultrasound Blood Pressure
- most readily available objective measure of blood flow and perfusion
- used to detect both arterial and venous blood flow
- Impedance plethysmography
* Often used to detect DVT
In a straight vessel blood flow is termed _______. In a diseased vessel with plaque formation, blood flow has a higher velocity through the occlusion. Distal to the occlusion blood flow is _________.
– laminar
– turbulent
Factors that determine level of amputation:
- Adequate circulation
- Save as much length as possible while removing all non-viable tissue
- A residual limb that allows a pain free return to functional activity
A residual limb that is very short may be:
Difficult to fit
A residual limb which is very long (trans-tib) may be:
Prone to circulatory problems
Saving as much length and as many joints as possible allows:
– ↑ amount of surface area for suspension
– ↓ rotation of knee units and foot/ankle components
– Leaves more of the adductor longus attachment to minimize contractures
– Creates a longer limb for sitting and transfers
Too long transfemoral amputation:
- Makes padding the residual limb more difficult
- Leaves less room for prosthetic components
- Difficulty matching leg length to prosthetic knee center
To Prevent neuromas
Resect nerves under gentle traction
Minimize soft tissue trauma from sharp or irregular bone edges
Bevel bone ends
To improve function and shape
- Muscle fixation
- Fibula ~ 1cm shorter than tibia
Suture line should:
…avoid bony prominences and the distal end
Transtibial amputations often use this closure:
Long posterior flap
- provide better vascular supply
Transfemoral Amputation commonly use this closure:
Fishmouth
- Equal length posterior/anterior flaps
“Problems” with closures:
- Dog ears
- Adherent scars
- Neuromas
Post-operative complications (Co-morbidities):
- Wound infections
- Cardio-vascular
- DVT
- Decubiti
Residual limb shapes (3):
- Conical
- Cylindrical
- Cylindrical shape is better suited for total contact prosthetic fitting devices
- Bulbous
Skin sensation may be assessed using
Semmes-Weinstein filaments
- If a patient cannot consistently feel the touch of a 5.07 filament, the protective sensation has been lost
Skin Inspection of the residual limb:
- scar adherence
- coolness
- possible arterial insufficiency
- abnormal warmth
- possible infection
- impaired sensitivity
Phantom Limb Pain vs. Phantom Limb Sensation
- Phantom pain is characterized by a perception of pain in the absent distal extremity
- Often desribed as shooting, burning, stabbing or crushing
- Phantom Limb Sensation is a perception of the absent distal extremity
Components of an evaluation of a patient with amputation:
- DEMOGRAPHIC INFORMATION
- FUNCTIONAL ASSESSMENT
- TESTS & MEASURES OF RESIDUAL LIMB
- TEST & MEASURES OF INTACT LIMB
Components of the functional evaluation:
- Ambulation
- Transfers
- Bandaging/Use of a shrinker
TESTS & MEASURES OF RESIDUAL LIMB
- LENGTH
- CIRCUMFERENCE
- SHAPE
- APPEARANCE
- ROM
- STRENGTH
- STABILITY
- SKIN
TEST & MEASURES OF INTACT LIMB
- STRENGTH
- ROM
- CIRCULATION
- TEMPERATURE
- SKIN
- HAIR ON EXTREMITY
Prosthetic/orthotic clinical procedure
- PRE-PRESCRIPTION
- PT (EVAL)
- PRESCRIPTION
- MD ONLY
- PREFITTING
- PT (WRAPPING, THEREX, ROM)
- FABRICATION
- INITIAL EXAM
- TRAINING
- PT (GAIT)
- FINAL EXAM
- PT
Medicare Reimbursement Levels
- 0 = No potential to ambulate/transfer with or without assistance
- 1 = Potential to ambulate/transfer with fixed cadence in home
- 2 = Potential to ambulate/transfer in low level environmental barriers
- 3 = Potential to ambulate/transfer with variable cadence in community
- 4 = Potential to exceed basic ambulation skills with high impact activities
Cost is determined by:
- sophistication of the components
- types of materials used for construction
- Costs of transtibial prostheses range:
- 4,000 to 16,000 dollars
- Costs of transfemoral prostheses range
- 5,500 to 40,000 dollars
Stages of Adjustment (Traumatic)
- Shock
- Anxiety
- Denial
- Depression
- Anger
- Toward self
- Toward others
- Acceptance
- Adjustment
Stages of adjustment (elective)
- Preoperative Stage
- realization that limb loss is a possibility
- grief
- concerns about pain
- Immediate Postoperative Rehab Stage
- realization that normal level of function is no longer possible
- Denial replaces grief
- euphoric mood, regression, withdrawal
- Return Home Stage
- Mixed reactions
- leaving hospital means recovery
- faced with lack of help available at hospital
- Reorganization of how the individual views oneself and the world and attempts to regain maximal functional potential
- Mixed reactions
Psychological adjustment factors
- ECONOMIC AND VOCATIONAL
- Patients cannot do their former jobs or are facing a loss of income will have more adjustment problems
- PSYCHOSOCIAL
- Excellent family and peer support will have fewer problems with psychological adjustment
- TRAUMATIC/ACCIDENTAL LOSS
- Traumatic or accidental limb loss may react with varying forms of denial
- Elective amputations may benefit from preparation and exploration of alternatives; may exhibit realistic expectations and cooperation
- Disability caused by negligent care or behavior of others often produces self-doubt and bitterness
- PREPARATION TIME
- Individuals with adequate warning and preparation adjust better in the immediate postoperative stage
- Support groups could provide safe environment for discussion
- Speaking with previous amputees helps understanding of what is to come
- REHABILITATION
- Earlier a prosthesis or orthosis is used after the disabling event, the less psychological distress observed
- AGE
- Reaction by age varies
- Often children and adolescents show resilience to acquired disability
- Adults show little disruption of positive body-image after amputation
- Younger patients who sustained traumatic amputations exhibited more anxiety and a more-negative body image
- Reaction by age varies
- SOCIAL SUPPORT
- Complications of disability can be lessened by involving family members in patient interventions
- SEXUALITY
- Sexuality may be affected by psychological and physical reasons
- Resumption of sexual activity assists with self-esteem and self-confidence, which facilitates successful rehabilitation
- COMMUNITY REINTEGRATION
Open vs. closed kinematic chains
- Open chain:
- distal end is not fixed
- limb moves independently and unpredictably
- Increases degrees of freedom at distal joints
- Closed chain:
- Distal end is fixed
- Movement is predictable
- Movement at one joint imposes movement at another
- ex. supination of the foot in standing incurs medial rotation of the hip
Areas of relief and build up:
- Pressure/Stress
- Relief should be built in to areas:
- that are firm
- pressure sensitive
- convex
- Build-up [support] should be built into areas:
- that are soft
- pressure tolerant
- concave
- Relief should be built in to areas:
Treatments/Interventions for Phantom Pain
- Increasing peripheral input
- massage, wrapping, application of heat, use of a prosthesis
- tapping or rubbing the residual limb for 20-60 minutes
- Local anesthetics
- TENS
- Psychotherapy
- Mirror Therapy
- Pharmacological agents:
- Antidepressants
- phantom pain is best treated with low doses of tricyclic antidepressants (ie, nortriptyline or amitriptyline 10-25 mg PO qhs) that aim to improve sleep. [Per instructor notes]
- Narcotics/Opioids
- Muscle relaxants
- Antidepressants
Intrinsic Pain
- Pain caused within the limb
- Causes
- ambulating on bone with minimal soft tissue covering
- vascular spasm
- Intermittent claudication
- Neuroma
- CRPS
- Causes
Extrinsic pain
- Pain caused by sources external to the limb
- examples:
- overly constrictive prosthetic shrinkers
- inadequate prosthetic or orthotic fitting
- excessive end bearing
- uneven skin pressure due to muscle hypertrophy, weight bearing, or edema
- examples:
Cost of prosthesis includes:
- components
- materials
- labor
- office visits
- adjustments
- usually covers adjustments for 90 days
- (letter of justification usually required by insurance companies for reimbursement for an orthosis or prosthesis. May be completed by MD or PT depending on needs of insurance company)
Oprtions for individuals who cannot pay for a prosthesis or orthosis:
- Medicaid
- approval based on need and income level
- Local or national organizations for assistance
- Muscular Dystrophy Association
- National Cancer Society
- The Barr Foundation
- National tax-deductible, non-profit that often pays for prostheses
Stress equation:
- S = F/A
- Stress = force per unit of area
- amount of stress is determined by the magnitude of the force and the size of the area to which the force is applied
Weakness of the Gluteus Medius results in:
- Lateral trunk lean toward the side of weakness to shift the LOG closer to the joint axis
Hip extensor weakness results in:
- Posterior lean
- changes flexion moment at the hip to extensor moment increasing hip joint stability
Gait deviations due to limb length discrepancy (long limb):
- Hip hiking on ipsilateral side
- lateral trunk lean on contralateral side
- circumduction
- excessive hip and knee flexion to clear the limb
- vaulting on the shorter limb to clear the longer one
STATIC TRANSTIBIAL PROSTHETIC ALIGNMENT:
- USES PLUMB LINE FROM THE CENTER OF THE POSTERIOR WALL OF THE SOCKET TO ½ INCH LATERAL TO THE CENTER OF THE HEEL
- MAINTAINS NORMAL BOS
- LOADS MORE PRESSURE TOLERANT AREAS ON THE MEDIAL RESIDUAL LIMB
- Usually aligned with 5-10 DEGREES OF FLEXION OF THE SOCKET
Three theories as to why patients experience phantom limb pain and sensation:
- One theory is that the remaining nerves continue to generate impulses.
- A second theory is that the spinal cord nerves begin excessive spontaneous firing in the absence of expected sensory input from the limb.
- The third theory is that there is altered signal transmission and modulation within the somatosensory cortex.
Phantom limb sensation may be described by the patient as:
- From the amputated part
- numbness
- pressure
- position
- temperature
- pins and needles sensation
Three tasks of gait:
- Limb advancement
- Single limb support
- Limb advancement
If the ankle cannot dorsiflex normally:
- Individual will
- bear weight on the toe
- or
- the knee must hyperextend to get foot to flat on the ground
- bear weight on the toe
