L6 Amputee Post-op Flashcards
Post Op Dressings are determined by
cause of amputation
level of amputation
potential for infection
Goals of post op dressing
protect the incision and residual limb
promote healing
control and reduce edema
control post-op pain
maintain extension ROM
facilitate advancement to prosthetic fitting
Types of post-surgical dressings
soft dressing
shrinker
IPOP
rigid removable
semi-rigid dressing
Soft Dressings Advantages
indicated in cases of local infection
easy to apply
inexpensive
easy to the incision
allow for active jt ROM
Soft Dressings Disadvantages
less edema control
minimal protection
requires frequent rewrapping
joint ROM may delay healing
can’t control amount of tension
can create tourniquet effect
Shrinkers can’t be used until
sutures are removed and drainage has stopped
Rigid Dressings Advantages
Non-removable thigh length cast
maintains knee in extension
promotes wound healing
helps with residual limb shaping
pain mgmt
protection against trauma
edema control
increased speed of prosthetic fitting
Disadvantages of Rigid Dressing
no ability to inspect the incision
requires skill and time under anesthesia to apply
Removable Rigid Dressings Advantages
easy to don/doff
allows access to healing wounds
good edema mgmt
protects the incision site
accommodates edema fluctuations
prevents contractures
Removable Rigid Dressings Disadvantages
not appropriate for someone w/drainage or bulbous limb shape
Rigid Dressing with IPOP/EPOP Advantages
edema control
RL protection
early ambulation
promotes circulation and healing
accelerated healing
facilitation of early definitive prosthetic fitting
IPOP
immediate postsurgical prosthesis
rigid dressing with attachment for a pylon and prosthetic foot
EPOP
early postoperative prosthesis
rigid dressing with attachment for a pylon and prosthetic foot
Disadvantages of IPOP/EPOP
limited WB
no access to incision
more expensive
requires proper training
Pre-prosthetic Phase
generally 6 weeks
goals are to protect the limb, prevent contractures, develop single limb mobility, prepare pt for prosthetic
Pre-prosthetic Eval includes
history/chart review
systems review
integumentary
residual limb shape
vascularity
ROM
msucle strength
neurological
mobility
balance
outcome measures
Serosanguineous Drainage
typical in wound healing
drainage should decrease over time
When should drainage be reported?
bright red or darker blood should be reported
thickening, discolored drainage, odor
Cylindrical Shape
distal circumference slightly less than proximal
ideal shape
Conical shape
distal circumference < proximal circumference
Bulbous shape
distal circumference > proximal circumference
Dog ears
squared off shape at the end of residual limb
Transfemoral measurement
measure from proximal thigh/ischial tuberosity and then every 8-10 cm distal
Transtibial measurement
measure from tibial tubercle and then every 8-10 cm distal
DIstal limb circumference should be …
equal to or no more than 1/4 in greater than proximal limb circumference
smaller distal circumference is desirable so that shear forces on soft tissue will be minimal when the prosthesis is donned and used
Residual Limb Length Components
actual length of residual tibia or femur
total length of limb including soft tissue
Transtibial Length Considerations
5-6 in of tibia ensures sufficient lever arm for prosthetic control
<3” may be insufficient for prosthetic control and poor skin tolerance due to reduced surface area
longer limbs may be unable to flex knee beyond 90° in sitting
Joint ROM
patients are at risk for developing contracture at joint proximal to the amputation
risk of hip and knee flexion contractures from increased time sitting
Goni measurements with amputation
lack of distal malleolus as landmark
accuracy decreases as limb length decreases
hip contracture can be eval with thomas test
Muscle Strength of RL
MMT should be avoided in acute post surgical period on residual limb to avoid undue stress on surgical site
subjective strength grade may be somewhat inflated due to RL length
consider UE and hand function as an assessment for strength
Negative Prognostic Factors for Prosthetic Potential
presence of co-morbidities
pre-operative ambulatory status
age > 60
level of amputation
presence of post op complications/impairments
impaired cognitive status
environmental barriers preventing return to previous living environment
Preprosthetic Goals
Overall goal of preprosthetic period is to prepare the pt for fitting and training
protect remaining limb
independence in transfers, mobility, etc
proper positioning
independence in residual limb care
HEP independence with ROM, strength
adequate ROM
Pre-prosthetic PT interventions
postioning
bed mobility training
mobility training
stretching program
strengthening
balance training
transfer training
pain management
residual limb care
Transfemoral contractures
hip flexion, hip abduction, and hip ER
Transtibial contractures
hip and knee flexion
“Do’s” of positioning
knee in extension while in bed
knee in extension while sitting
residual limb support in w/c
keep limb adducted in bed for TF
“do nots” for positioning
place pillow under knee in bed
keep knee in flexed/hanging position sitting
keep RL in abducted position TF
Balance Training
falls occur often during transfers, and due to reduced awareness
also loss of mass and change in COM affects balance. COM shifts upward, backwards, towards intact extremity
Sitting Balance
more often affected in BL amputation or higher TF/hip disarticulation
Transferring
easiest to transfer toward intact side
helps to protect RL from injury
W/C mobility
shift in COM posterior following amputation
move the wheels more posterior or adding anti-tippers
W/out IPOP Gait
work toward swing through gait patterns. start in bars and progress to crutches are able
w/IPOP Gait
teach the pt how to limit WB on IPOP
PWB restrictions on IPOP
Hip extension stretching
watch for excessive lumbar lordosis to make up for hip flexor contracture
encourage periods of lying supine or prone to provide prolonged low-load stretch on hip flexors
SL active hip motion through pain free ROM
UE strengthening
important for supporting the body during transfers and with use of an AD
emphasize shoulder stabilizers, adductors, depressors, elbow extensors, wrist
Core strengthening
functional mobility and balance
need strong and flexible back/abdominal flexors, rotators, extensors and hip extensors
Transtibial residual limb strengthening
emphasize hip extensors and abductors, knee flexors and extensors for eventual prosthetic use
Transfemoral residual limb strengthening
emphasize hip extensors and abductors for prosthetic use
Hip disarticulation strengthening
must be able to perform posterior pelvic tilt to initiate swing phase with prosthesis
Hemipelvectomy strengthening
UEs, abdominals, contralateral lower limb must be maximized
Compression devices are indicated for
residual limb shaping
edema management
prevention of contractures
reducing adductor roll in TF amputations
desensitization
Shrinkers
used once the incision is healed
worn 24 hours/day except when bathing
supplied by prosthetist
Residual Limb Wrapping
pressure distal > proximal
smooth, wrinkle free application to avoid excessive pressure
should be worn 24 hours a day
helps to promote full knee extension for TT and full hip extension for TF
Residual Limb Care
scar tissue mob once primary healing has occurred
pt should handle RL to adapt to new body
visually inspect skin daily
Phantom Limb Sensation
erroneous interpretation of sensory nerve impulses traveling along the pathway of nerves that formerly provided sensory feedback from RL
includes numbness, tingling, pressure, itching, muscle cramps
Phantom Limb Pain
shoot pain, severe cramping, burning sensation localized in amputated limb
typically more episodic or intermittent than phantom sensation
those that have dysvascular pain are more likely to have phantom pain
Central origin of pain
hyperirritable foci develop in dorsal horn of SC after peripheral nerve transection possibly as result of loss of high threshold input to dorsal horn neurons
Management of phantom limb pain
desensitization techniques
heat modalities
TENS
firm pressure applied to RL
massage
consistent use of prosthesis
mirror therapy
Desensitization
helps make RL less sensitive to touch and improves tolerance
2-3x/day when soft dressing is off
start with soft material, and rub in circular motion. Progress to rougher materials
Mirror Therapy
Can be used as treatment for phantom limb pain
perform gentle movements while looking in mirror for 20-25 min daily
cortical restructuring hypothesized to occur by activating mirror neurons of contralateral side, can help recreate body image and impact internal motor control
