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Prosthetics > Introduction to amputations & examination of patients with amputations > Flashcards

Introduction to amputations & examination of patients with amputations Flashcards

1
Q

Main cause of amputations

A

Non-healing ulcer (85%)

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2
Q

Dysvascular or neuropathy related complications

A

Includes PAD, PVD, and Diabetes 81%

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3
Q

Preventing dysvascular causes of amputations

A
  • 25% of patients with diabetes will undergo amputation
  • 50% of patients undergo contralateral amputation in 5 years
  • Prevention: exercise, smoking cessation, diet, pharm interventions, foot wear, skin care
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4
Q

Non-dysvascular causes of amputation

A
  • Trauma (17%)
  • Vehicular or work related accidents
  • Violence or warfare
  • Burns
  • Cancer (1%)
  • Congenital (1%)
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5
Q

Incidence

A
  • Lower limb 11 times more likely than upper limb
  • Of lower limb amputations: toes (33%), transtibial (28%), transfemoral (26%), Foot/ankle (11%), knee disarticulation (<1%)
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6
Q

Surgical process of amputation

A
  • Incisions made distal to amputation
  • Veins and arteries clamped at most distal point
  • Nerves & tendons are allowed to retract
  • Bones are beveled
  • Opposing muscle groups may be sutured to each other (myoplasty) or to the bone (myodesis)
  • Incisions are sutured on non-WB surfaces whenever possible
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7
Q

Toe levels

A
  • Phalangeal
  • Metatarsal head,
  • Ray resection (generally performed on non-healing ulcer)
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8
Q

Toe process

A
  • Sesamoids removed
  • May be at metatarsophalangeal, interphalangeal, or through phalanx
  • Incisions sutured along anterior or dorsal aspect of foot
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9
Q

Foot levels

A
  • Transmetatarsal (TMA)
  • Lisfranc procedure - tarsometatarsal disarticulation
  • Chopart procedure - midtarsal disarticulation
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10
Q

Foot process

A
  • Tendons are transferred to promote muscle balance, heel cord may be lengthened
  • Incision sutured along anterior or dorsal aspect of foot
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11
Q

Ankle Levels

A
  • Symes procedure - talocrural disarticulation
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12
Q

Ankle Process

A
  • Tendons are transected, except the achilles
  • Talus is disarticulated & malleoli are trimmed
  • Soft tissue heel pad is anchored to tibia & fibula
  • Likely to have drain
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13
Q

Transtibial (TT or BK) levels

A
  • Ideal length is approximately 15 cm (33-50% of original length) - mechanical advantage is 40-50%
  • Short residual tibia - improved comfort with increased surface for weight bearing; mechanical disadvantage
  • Long residual tibia - prosthetic options limited
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14
Q

Transtibial (TT or BK) process - long posterior flap

A
  • Anterior and distal tibia smoothed
  • Fibula generally 2 cm shorter than tibia
  • Incision approximated anteriorly
  • Highly vascular gastroc can be pulled forward to protect distal end of tibia, tendon secured to anterior compartment fascia
  • Will likely have drain placed
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15
Q

Transtibial (TT or BK) process - Modifications

A
  1. Removal of fibula, particularly for short limbs
  2. Removal of soleus and anterior tib most common, but may remove all lateral and anterior compartments, lateral gastroc
  3. Alternate incision lines - ERTL - osteomyoplatic (create bony bridge between tibia and fibula, closing intramedually canal; heterotopic ossification (abnormal bone growth, normally at distal end of amputation)
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16
Q

Knee Disarticulation levels

A
  • Most leave femoral condyles intact

- Transcondylar - remove condyles and flatten distal femur; mechanical advantage to increased length and weight bearing

17
Q

Knee Disarticulation Process

A
  • Quad tendon transected at tibial tubercle
  • Collateral & cruciate ligs transected at distal attachment
  • Muscle stability: ITB, biceps femoris, quad tendon
  • Distal gastroc is attached to anterior joint capsule
18
Q

Transfemoral (TF or AK) level

A
  • Ideal length preserves 50-66% of femoral length
  • Shorter length difficulty with suspension
  • Longer length difficulty with prosthetic options
19
Q

Transfemoral (TF or AK) Process

A
  • Incisions should be made to preserve adductor magnus

- Incision along distal residual limb or slightly anterior is most common

20
Q

Hip & Pelvis levels

A
  • Hip disarticulation - pelvis intact; femur dislocated from acetabulum
  • Hemipelvectomy - External = removal of half of pelvis; Internal - removal of portion of pelvis
21
Q

Hip & Pelvis Process

A
  • Incision made for long posterior flap
  • Neurovascular structures are stabilized
  • Hip disarticulation - muscles crossing hip joint detached; gluteal muscles detached from greater troch; posterior flap sutured anteirorly
22
Q

Post-op Care

A
  • Pain
  • Wound care
  • Skin care
  • Edema management
  • Limb shaping
  • Post-op dressing
23
Q

Phantom sensation & pain

A
  • Almost all patients experience phantom sensations

- 50% of patients will have phantom pain

24
Q

Reason for phantom sensation

A
  • Peripheral neuroma
  • Spinal cord mechanisms
  • Central mechanisms and cortical remapping
25
Q

Interventions for pain

A
  1. Nerve block
  2. Prescription medications
  3. Physical therapy
26
Q

Surgical incision

A
  • Initial post op dressing for 2-5 days
  • Staples or sutures for at least 2 weeks
  • Wounds are usually covered as long as they are draining
  • Antibiotics to prevent infection but 25% of patients get them
  • Complicated wounds or poorly healing ones may have skin grafts or wound VACs
27
Q

Skin Care

A
  • Patient education for regular skin checks
  • Moisture
  • Sound side considerations: increased shearing, weight, skin checks
28
Q

Edema control benefits

A
  • Decreased pain
  • Increased wound healing
  • Protection during mobility
  • Desensitization
  • Shaping for prosthesis (cylindrical to conical)
29
Q

Soft Dressings & Compressions

A
  • Ace wrap
  • Shrinker socks
  • Custom pressure garments
30
Q

Ace wraps

A
  • Can be used at amputations of all levels
  • Helps control post-op edema
  • Inexpensive
  • Easily removed
  • Does not offer a lot of protection
  • Reapply frequently (every 4-6 hours)
31
Q

Ace wrapping precautions

A
  • Severe pain
  • Infection
  • Wound dehiscence
  • Impaired sensation
  • Elevated BP
  • DO NOT use on patient with wound vac
32
Q

Ace wrap application

A
  • Figure 8/diagonal pattern
  • Must cover all skin, smooth application, no wrinkles
  • Distal to proximal graded pressure
33
Q

Shrinker socks

A
  • Can use when suture line is healed enough to tolerate shearing forces
  • May be shaped at bottom or tubular
  • Measured for proper fit
  • Generally twisted at the end and reflected back up the residual limb
  • Continued use during prosthetic phase
34
Q

Custom pressure garments

A
  • Jobst
  • May be beneficial for long term wear if shrinker socks are challenging
  • Difficult to develop early post-op due to significant volume changes initially
35
Q

Non-removable rigid dressings

A
  • Common for TT amputations
  • Helps to protect residual limb and maintain position of knee
  • Potential for skin breakdown
  • Unable to monitor wound healing
  • Appropriate for patients with good sensation and lower risk for infection
36
Q

Removable rigid dressings

A
  • May be bi-valved non-removable rigid dressing or plaster/fiberglass cap
  • Benefits = ability to monitor wound and skin
37
Q

Semi-rigid dressings

A
  • Similar to removable rigid dressings except made from polyethylene
  • Requires prosthetist for fabrication, higher costs associated
  • Able to be cleaned
  • Can be found pre-fab with adjustable straps
38
Q

Immediate post-op prosthesis

A
  • For patients who are partial WB
  • Allows patients to ambulate earlier following amputation
  • Dressings with ability for pylon attachment
  • Non-removable rigid dressing
  • Pneumatic compression
39
Q

Patient education

A
  • Positioning (*hip extension)
  • Skin care/checks
  • Pain management
  • Exercise program
  • Safety

Prosthetics (4 decks)

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