L1: P&O INTRODUCTION Flashcards
OBJECTIVES:
GO OFF OF THESE WHEN REVIEWING DECK!!!
Many team members included with the P&O pt
These include…
Pt, family, ortho/vascular sx, social work, nurse, dietitian, psychologist, PCP, OT, CPO, PT***
Role of the Prosthetist
- design, fabricate, fits prostheses or artif. limbs
- create design to fit indiv’s particular functional and cosmetic needs
- approp mats and components
- casts, measurements and mods→ static/dynamic alignment
- evals fit/function→ teaches pt how to take care of it
Role of the Orthotist
*often same person as prosthetist
- Cares for pts w/ NMSK and MSK impairs that contribute to functional limits and disability→ design, fabricate and fitting orthoses/braces
- functional and cosmetic needs
- educates pt on proper use
Role of Physical Therapist
-
Assess pt as a WHOLE!
- areas to be tx’d
- skin, fine motor, strength, balance, ROM, pain, circulation
- personality/condition
- living arrangements
- assist from others?
- stairs?
- activity lvls ***
- areas to be tx’d
Activity Lvl ex’s
- Sedentary
- Household or community ambulator
- Athlete
- etc..
Impairments, Functional Limits or Disabilities
Examples:
- Dec comm access
- Diff w/ manipulation skills
- Edema
- Jt contracture**
- Impaired aerobic capacity (UBE***)
- Impaired gait
- Impaired integ and inadeq shape of RL
- Impaired ADL perform.
- RL pain
1 cause of amputations in Adults
PVD 82%
1 cause amputations in Children
Congenital 68%
Amputation and Gender/Age
Males 75%
Females 25%
Mean age amputation= 68yo
Mean age ambulatory amputee= 48yo
Top 3 Risk Factors/Predisposing factors for amputations
- Concurrent DM and HTN
- HTN w/o DM
- Dx w/o HTN
race, smoking, gender, vascular hx
Amputations occur _______ times more in diabetic pop
15x
___ to ___% amputations preventable w/ ______
50-70%
EDUCATION ***
Related to DM…
These 2 things together are the #1 cause of amputation
Chronic Arteriosclerosis Obliterans + DM
Half of neuropathic DM foot ulcers occur where
@ first three MET heads on plantar surface
most GRFs here***
Narrowing and hardening of arterial walls
pain, trophic changes such as hair loss and redness, intermittent claudication (pain w/ exercise or WB), swelling
PVD
MOST COMMON cause amputations in ADULTS
PVD***
ON TEST!!!!
EDUCATION for pts w/ fragile vascular limb
- avoid trauma
- footwear/avoid bare feet
- skin inspection
- cap refill, sensory, pulses
- temp extremes
- skin cleans
- min. moisture
- moisture— if too dry
- med attn
GOAL of Sx if amputation necessary…
Preservation of as many anatomical joints as possible
*ESPECIALLY KNEE!!!
GOAL of amp. sx is preservation of as many jts as poss….
especially…
the Knee!!!!
Sx decision making process for amputation
What are we looking @?
Adequate Circulation
What goes into looking @ adequate circulation?
- pulses in LE
- skin color/condition
- skin temp
- ABI
- TcPO2–transcutaneous oximetry
NOTE on ABI
Leg BP should be same or higher than arm @ rest AND after 5mins of exercise
During Amp Sx…. surgeon will traction the nerve
why?
Prevents retraction/recoil====Less phantom pain
This is an extreme WB’ing tendon and is attempted to be preserved when poss.
Patellar tendon
Myodesis
Re-attachment of mm’s onto bone OR periosteum (top aspect) of bone
Myodesis and Transfemoral Amputations (aka Above Knee Amputation)
Adductors and Extensors lose their attachments and are reattached to distal femur
W/ Transfemoral amps….Adductors and Extensors lose their attachments and are reattached to distal femur
What does this slight ADD do?
Slight ADD improves comfort during WB and maximizes ABD length-tension
Transfemoral amputations
IMMEDIATE Surgical/PT goals:
- Center femur/tibia in muscle mass
- Balance forces
- Strengthen RL
- Prevent ADD roll (from adductor mm retraction)
- in TFAs***
Myodesis
Downside (TFAs):
- Muscle does not hold sutures well→ not ideal for surgical attach’s
- Fascia better @ holding sutures BUT not much around thigh mm’s
- Often times→ myodesis unsuccessful limiting mm output and resulting in less than ideal alignment
- SOME pts feel myodesis stretching out or pulling free
This technique predominates in Transtibial Amputations (Below Knee Amps)
Myoplasty (muscle attached to opposing muscle)
Myoplasty (muscle to opposing muscle) tech predominates in TTAs
Explain it
Long posterior myofascial flap sewn anteriorly to anterolateral deep fascia and tibial periosteum and provides reasonable degree of muscle fixation w/out risk of strangulation
Muscle-to-bone suture aka
Myodesis
Muscle-to-bone suture (myodesis) reserved for the _______ patient
NONischemic
(good/normal blood supply)
REMEMBER….
W/ TTAs….
HS + Quads INTACT
Soleus REMOVED
What is still intact w/ TTAs?
HS’s + Quads
What is removed w/ TTAs
Soleus
Surgeries from Distal→Proximal
- Phalangeal (forefoot)
- Transmetatarsal (midfoot)
- Lisfranc (tarsometatarsal (TMT) joint)
- Chopart (bw talus and navicular and calcaneus and cuboids→ still working ankle in sag. plane)
- Syme amputation (talocrural disarticulation)
- shave malleoli to create flat WB surface and repositioning of fat pad under tib/fib
Surgery
Phalangeal or
Forefoot
Surgery
Transmetatarsal or
Midfoot
Surgery
Lisfranc or
Tarsometatarsal
Surgery
Chopart or
Bw talus and navicular and calcaneous and cuboids
*still working ankle in sag. plane
Surgery
Symes Amputation or
Talocrural disarticulation
*shave malleoli to create flat WB surface and repositioning of fat pad under tib/fib → thickest fat pad in body
Surgery
Transtibial (BKA)
Ideal length
40-50% of initial tib length
Surgery
TTA (BKA)
Shorter Tibia Length
<33%
Very LITTLE control of prosthetic
Surgery
TTA (BKA)
Longer Tibia Length
>66%
BETTER control of prosthetic AND more surf area dispersion…BUT often chronic skin irritation and sharper distal tib
Surgery
TTA
pics
see pics
Post-Sx Transtibial Length
see pics
Disarticulation safer vs Amputation
Why?
Less blood loss
Quicker sx + recovery (less chance for infx)
Nothing cut
Sx:
Knee Disarticulation/Transcondylar
aka Remove tib/fib
Explain Benefits
- LESS blood loss
- Quicker sx+recovery
- less chance for infx
- Sx does NOT transect (cut) any mm mass
- **Distal femur ideal for WB
- Growth plate remains intact (children)
Sx:
Knee Disarticulation/Transcondylar
aka Remove tib/fib
Explain Negatives
Femoral condyles (size) make don/doffing prosthesis difficult
*need shaved or special socket
Sx:
Transfemoral (AKA) Amputation
Preserve length of femur allows for:
- INCd prosthetic control
- Improved stabilization of RL due to INCd ADD/ABD strength
- LESS chance of hip ABD and hip flex contracture
Sx:
Hip Disarticulation
What is removed + more info?
- Entire femur, tibia, fibula, and foot removed.
- Extreme sx and only performed under emergency cases
- very few functional ambulators
Sx: uncommon
Hemipelvectomy
- Innominate bone AND distal LE removed
- No bony casing for abdom contents
- Often need NG tubes for feeding
- Min activity allowed post-op
Sx: uncommon
Hemicorporectomy
- Translumbar amputation→ removing entire bony pelvis, pelvic contents, external genitalia, LEs
- Rehab for ADLs, upright postures and balance
- Typ NOT gait candidates
Post-Amputation Sx:
Rehab Day 2:
Working on…
- Pt and limb positioning
-
adduction and extension***
- length-tension and prevent contractures
-
adduction and extension***
- Stump shaping
- shrinkers***
- Wound care
- Sitting balance
- COM shift, circulation changes***
- SL gait w/out prosthesis
Post-Amputation Sx:
Depending on condition of suture line, fitting for initial prosthesis from….
From 3-6wks to several months
Post-amputation Sx:
Regardless of lvl of amputee OR sx technique…….
The EARLIER the fitting and use of a prosthesis the BETTER the outcomes for functional ambulation.****
