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PHTH 550- Orthopaedic Management Final > Lecture 20 & Lab: LE Amputation > Flashcards

Lecture 20 & Lab: LE Amputation Flashcards

1
Q

What is a socket?

What are the two types of sockets?

A

Socket: Component of the prosthetic that contains the residual limb.

Hard Socket: Rigid plastic interface. More durable, minimizes shearing and friction. Does not accommodate to changes in shape or size (swelling) of the residual limb.

Flexible Socket in a Rigid Frame: Rigid around pressure-tolerant areas and open around pressure-intolerant areas.

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2
Q

Where are the pressure tolerant areas on a transtibial socket?

Where are the pressure intolerant areas on a transtibial socket?

What is an example of a transtibial sockets?

A

Pressure-Tolerant: Femoral condyles, anterior compartment, posterior compartment.

Intolerant: Fibular head, distal anterior tibia, hamstring tendons.

Patellar-tendon bearing (PTB) socket: Anterior-posterior forces from a patellar tendon bar and posterior popliteal bulge (helps suspend and stabilize residual limb w/in the socket)

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3
Q

What are the two types of transfemoral sockets?

A
  1. Quadrilateral socket: Narrow ant-post dimension and the ischium sits on the socket brim.
  2. Ischial-ramal containment: narrow med-lat dimension and the IS sits inside the socket.
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4
Q

What is a socket liner?

What are the three kinds of liners?

A

Socket Liner: Interface b/w socket and residual limb.

  1. Prosthetic sock (Most common)
    Provides: cushion forces, wick mosture, accomodate changes in volume of limb.
  2. Roll-on Liners
    - Too tight, cannot pull on like a regular sock.
    - Protect the residual limb (skin integrity)
    - Can be incorporated into socket suspension.
  3. Soft Liners: Other types of soft liners used in a hard socket to get a more exact fit. Used for pt w/ fragile skin, bony prominence, high activity level. Provide protection and comfort.
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5
Q

What is suspension?

A

Suspension is what keeps the prosthetic in place on the residual limb.

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6
Q

What types of transfemoral suspensions exist?

A
  1. Silesian belt: belt around pelvis, does not counteract rotary forces between limb and socket during vigorous walking (used less).
  2. Total elastic suspension belt: Wider elastic suspension. Simple and comfortable.
  3. Pelvic belt w/ a hip joint: Rigid joint helps control rotation of the prosthetic socket and increases media-lateral stability of residual limb w/in the socket. Limits hip motion to frontal plane.
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7
Q

What types of transtibial suspensions exist?

A
  1. Waist belt w/ an anterior elastic strap: elastic elongates to allow for knee flexion and hip extension and recoils during swing phase of gait.
    - Neoprene suspension may be worn.
  2. Supracondylar cuff strap suspension: May be used w/ PTB socket, or other sockets that inherently provide a degree of suspension.
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8
Q

What type of suspension systems work for both transfemoral and transtibial protheses?

A

Silicone roll-on liners w/ a shuttle lock system (pin and lock. Locking mechanism built into based of socket and pin is in the silicone sleeve.

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9
Q

Why is the knee unit important for transfemoral prostheses?

What types of knee units exist?

What types of mechanisms exist to lock a knee into extension?

A
  1. Allow for a normalized gait pattern.

Trade off b/w stability (not allowing the unit to bend when not wanted) and mobility (allowing the unit to bend when required for function).

  1. Type depends on needs and capabilities of the pt.
    - Single-axis knee: single point of rotation
    - Polycentric Knee: provide more realistic movement: changing centre of rotation four-bar linkage.
  2. Lock knee into extension provides stability.

Manual locking mechanism: Cable and lever system (Single axis usually).

Weight-activated locking mechanism: lock knee extension when loaded and allow knee flex when unloaded.
Many different mechanisms (hydraulics…)

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10
Q

What is the Trochanteric-Knee-Ankle Line?

TKA anterior to knee axis?
TKA through centre of knee axis?
TKA posterior to knee axis?

A
  1. Helps to determine the amount of muscular control necessary to maintain knee unit in extension during WB. Trade-off w/ how easily the knee can be bent at terminal stance of gail.
  2. A) Knee will be stable and is unlikely to bend during stance. Pt w/ short RL and weak muscles.

B) Neutral stability. Some hip extensor activation required.

C) Inherently unstable: Stability is provided by locking mechanism or muscle activity hip extensors. Relatively easy to flex knee during stance and swing.

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11
Q

What is the role of a prosthetic foot?

What are the four types of designs of prosthetic feet?

A
  1. Shock absorption, accommodation uneven terrain, during gait (dorsiflexion, stability, heel rise, double support).
    • Non-articulating feet (SACH)
    • Articulating designs (single or multi-axis)
    • Prosthetic feet w/ elastic keels (SAFE)
    • Dynamic response or energy storing designs
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12
Q

Epidemiology of LE Amputation:

-Gender, age

A
  • Men>Women
  • Amputation rates increase w/ age
  • # 1 cause dysvascular disease
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13
Q

What are the causes of amputation by percentage?

A

Congenital Anomalies- 0.8%
Cancer-0.9%
Trauma-16.4%
Neuropathy and vascular conditions-81.9%

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14
Q
  1. What is peripheral vascular disease?

2. What are some trends relating to PVD and amputation?

A
  1. Compromised BF to limbs, cannot have a nerve w/ out a blood supply so nerves are affected.
    • Most amputation > 65 years due to PVD b/c prevalence increases w/ age.
    • LE amputation due to PVD more frequent then UE
    • PVD complicated by neuropathy (high incidence of amputation in Type 2 diabetes).
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15
Q

What are 2 common predisposing factors to LE amputation?

A

PVD

Peripheral Neuropathy

  • Complications of T2 diabetes
  • Non-healing or infected neuropathic ulcers precede 85% of non-traumatic LE amputations in individuals w/ diabetes.
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16
Q

What are signs and symptoms of peripheral neuropathy?

A
  • Deficits of sensation
  • Loss of reflexes (patellar, achilles)
  • Motor impairments (especially atrophy of intrinsic muscles of the foot)
  • Autonomic dysfunction
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17
Q
  1. What are common subjective complaints w/ peripheral neuropathy?
  2. How can you differentiate btwn intermittent claudication and peripheral neuropathy?
A
  • Numbness or cold feet
  • Pain (stabbing, pins and needles)
  • Pain is worse at rest and night
  • Muscular companies (night cramps, spasms or aching).
  1. IC: pain is relieved w/ rest, cramping or aching pain in the claves w/ walking vs PN: Worse w/ rest.
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18
Q

What is a sensory neuropathy?

A

Sensory:

  • Loss of thermal, pain and protective sensations.
  • Increase vulnerability of the foot to acute high-pressure and repetitive low-pressure trauma.
  • May be unaware of minor trauma (poor fit of shoes, don’t know anything is wrong until they see the blood on their sock)
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19
Q

What is a motor neuropathy?

A

Motor:
-Weakness+Atrophy leads to bony deformities of the foot (map-alignment of joints, altered WB)

  • May present w/ gait deviation (Foot drop w/ perineal neuropathy b/c of weakness in ankle DF).
  • Classic Intrinsic-Minus foot (prominent extensor tendons, high arch, prominent bones, claw toe deformity)
  • Associated w/ skin break down due to altered pressure distribution. High plantar pressure at MT heads. Dorsal surface of the PIP joints, distal tip of the toe.

How does this relate to amputation: contractures lead to hammer toe, inappropriate WB, ulcers, infection, osteomyelitis, amputation.

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20
Q

What are autonomic dysfunction associated w/ peripheral neuropathy?

A

Sudomotor dysfunction: impairment in sweat gland function, reducing hydration of tissue leading to dry skin and prone to fissuring (bacteria and infection can enter)

Vasomotor dysfunction: Dilation of arterioles of the foot leads to increased blood flow (hyperaemia) of soft tissue and bone.

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21
Q

What is Charcot’s Arthropathy?

How does it present clinically?

A

Combination of factors usually contributing to LE amputation:
Sensory-motor neuropathy (ex: ms weakness)
Minor Trauma (ex: repetitive loading)
Autonomic Neuropathy (ex: loss of vasomotor control)
Other factors (metabolic abnormalities, renal transplants…)

  1. Pt w/ neuropathy present w/ sudden onset of localized swelling, warmth, erythema (redness of skin) in the absence of an open wound.
22
Q

What is the second leading cause of amputation? Most prevalent among? Causes?

A

Trauma

  • Young adults
  • Leading injuries involve: machinery> appliances and power tools>firearms>MVA, war is variable.
23
Q

How does PT relate to the level of the amputation?

What are the most common levels of amputation?

A
  1. Role of the PT increase as amputation goes up the leg.

Transtibial and transfemoral are more likely for the PT to be involved then toe.

  1. Toe>Transtibial>transfemoral>Foot and ankle.
24
Q

What are the two ways of classifying the level of amputation?

A
  1. Joint disarticulation: named by the joint

2. Long bone transection: named by major bone.

25
Q

What is the name for a toe amputation?

What are the names for amputations done in the foot? (forefoot and mid foot)

What are the names for amputations at the ankle?

A
  1. Phalangeal
2. 
Forefoot: 
-Ray resection (1+ metatarsal) 
-Transmetatarsal (across shat metatarsal) 
-Lisfranc(Tarsal/metatarsal jt)

Mid foot: Chopart procedure at the mid tarsal (talonavicular and calcaneocuboid joints)

  1. Syme disarticulation:
    -talus removed.
    -requires rehab
26
Q

Knee amputations:

  • Below the knee
  • At the knee
  • Above the knee
A

Below: Transtibial amputation either short, midlength or long.
-Surgeons will try to preserve as much as the limb as possible. More residual limb is better in terms of lever arm for ms and prosthetic control.

At knee: Knee disarticulation

  • Simple knee disarticulation no modification of patella or femur.
  • Transcondylar amputation remove femoral condyles and the patella. This is preferable b/c it gets rid of potential areas for skin break down.

Above: Transfemoral amputation.

  • Transcondylar amputation (as above, knee disarticulation)
  • Traditional transfemoral amputation
27
Q

Amputation at the hip versus at the pelvis?

A

Hip disarticulation-at the hip

Hemipelvectomy- at the pelvis

28
Q

What are the differences between a knee disarticulation and a transfemoral amputation?

Which type is preferred?

A
  1. Knee disarticulation: the residual limb is long and bulbous. The centre of the prosthetic knee is usually lower than on the intact side- this can cause problems. B/c at the prosthetic joint has to go at the distal end of the residual limb, it ends up below the anatomical joint on the other side.

Transfemoral: Residual limb is tapered cylinder. Knee centre generally matches that of the intact limb.

  1. Transfemoral is preferred over a knee disarticulation.
29
Q

What effect does a LE amputation have on musculature?

  • Transtibial vs femoral
  • How can the distal insertion point of ms be repaired?
  • Biomechanics
A
  1. Transtibial you just loose the gastroc.

Transfemoral, ms lost will depend on the level of the amputation.

  • The higher the transfemoral amputation, the power and the efficiency of the adductor ms decreases. Magnus lost first, then longus, brevis.
  • Not likely to loose hip extensors (iliopsoas) or flexors (gluts)
  • Adductor function is the most likely to be affected over abductors, rotators or flex/ext hip.
  1. Myodesis: ms to bone fixation (preferred b/c may still retain some function)

Myoplasty: ms to ms

Myofascial: ms to fascia

  1. Altered line of pull of the ms may change function
    - Decrease force generating capacity
    - Altered connective tissue
    - Shift in functional position on the length-tension curve.
30
Q

What are the main roles of PT in pt and family education?

A

3 main: (from 1 day post-op)

  • Mobility: bed, transfers…
  • Locomotion: crutches, w/c
  • Exercise program: PROM, UE ex, setting ex, isometrics.

Interdisciplinary or team effort:

  • wound care
  • residual limb care (shaping)
  • Self-care/ADL
31
Q

What is the role of the PT in LE amputation?

A
  • Rehab: post-op and pre-prosthetic. Mobility and prepare for prosthetic training.
  • Pt readiness for prosthetic fitting (assist w/ choice of prosthetic based on ms strength)
  • Prosthetic training: Ambulation
  • Monitor condition remaining extremity (often involvement on both sides if PVD, neuropathy or other)
  • Assit w/ return to pre-amputation activities
32
Q

What is the prognosis for rehab following an amputation?

A

How well a person will recover and if they are able to use a prosthesis largely is determined by:

  • pre-morbid level of mobility
  • ADL status
  • Level of amputation (not usually the primary factor)

Study of the timeline of the progression through rehab shows that not as many individuals will be independent in the long term w/ prosthetics (1/3).

33
Q

What are some specific areas that are important to assess w/ LE amputation?

A
  1. Presence of phantom limb pain or sensation.
  2. Residual limb characteristics (shape, length, circumference, edema)
  3. Assess for factors required to use a prosthetics:
    - Potential for functional prosthetic use
    - Readiness for prosthetic
    - Prosthetic design best suited to pt
    - Residual limb characteristics
    - Energy cost of ambulation: are they older, deconditioned, co-morbid conditions, level of the amputation (the more limb transected the greater energy required to walk)
34
Q

How does a transtibial amputee w/ intact anatomical knee compare to a transfemoral amputee (bilat) in terms of prosthetic requirements?

A

Transtibial:

  • More energy efficient prosthetic gait pattern and postural responses.
  • More likely to be able to be a full-time prosthetic wearer and ambulate w/ out assistive devices.

Transfemoral:
-Increase energy consumption required for ambulation w/ prosthetics. So w/c mobility may be more effective. Ambulation potential depends on many factors like cardiac function and balance.

35
Q

What are the components of pre-prosthetic rehab?

A 
Pain management 
Sensation 
Volume and shaping of residual limb
Edema control of residual limb 
ROM and ms function 
Bed Mobility and transfers 
Ambulation and locomotion.
36
Q
  1. What are pain management strategies used during pre-prosthetic rehab?
  2. What is a unique pain that has to be managed in amputees? How can it be managed?
A
    • Primarily pharmacological
    • Other: acupuncture, modalities (cold, ice, message, TENS, US)
  2. A. Phantom limb pain/sensation. Thought to occur b/c areas of the context responsible for the amputated limb are taken over by other functions b/c of disuse. B. Phantom limb pain/sensation can be managed medically or with exercises such as mental imagery or mirror box.
37
Q

How are changes in sensation managed?

A

Hyposensitivity: monitor b/c at risk for skin breakdown.

Hypersensitivity: Is commonly encountered in residual limb. Manage by bombarding residual limb w/ tactile stimuli such as massage, soft fabric. Intensity of stimuli is based on the pt’s tolerance and is graduated progressed to cause sensory desensitization: build a tolerance to unpleasant sensations.

38
Q

What are methods for shaping the limb and managing swelling?

A
  • Custom, removable post-op cast
  • Removable rigid dressing: first layer is a nylon sheaths, then a prosthetic sock and a foam pad, then a cast.
  • Custom, flexible polyethylene semirigid dressing.
  • Airsplints and prosthetic frames. This is a pressurized inflated splint that allows pts to ambulate. Does not allow WB, but does help w/ balance bc a bit of weight can be put through.
  • Ace wrap: Dista to proximal pressure gradient, by figure of 8 loops. Helps create cylindrical residual limb.
  • Shrinker garments
  • Layered elastic stockinet or tubigrip.
39
Q

What can be done to manage edema in the residual limb?

Soft tissue adhesions?

A
  1. WB activities in prosthetic socket: help to decrease edema b/c it allows for ms activation and pumping from ms contraction really helps w/ BF, accelerate maturation of the RL/
    - RL size is quite variable so layers of socks can be used so the socket and RL have a good fit.
  2. Adhesions may occur around the incision scar or deeper scarring due to surgical procedure.
    - It is important to have good scar mobility b/c this can impact prosthetic tolerance etc.
40
Q

What are other aspects of pre-prosthetic rehab?

A
  • Independence-> early goal
  • Training will be highly dependent on pre-amputation functional status.
  • General strength, ROM and flexibility (trunk, UE, shoulders), transfer, gait.
  • w/c training
  • Encourage ambulation for individual able to stand or use assertive devices (parallel bars, crutches)

*Functional single leg ambulation is not a prerequisite for prosthetic fitting.

41
Q

What is this biggest issues w/ transtibial amputations?

A

Loss of terminal knee extension- none of the extensors are effected, however gastroc contracture are possible, so always keep the knee in passive extension.

  • Knee flex contractures can impact future prosthetic use.
  • Prolonged dependence of RL in knee flex when sitting causes distal oedema which may delay readiness for prosthetic fitting.
42
Q

What position do amputees tend to sit in?

What ROM limitations affect prosthetic use in transtibial amputees?

A
  1. Abducted and ER, which is the loose pack position of the hip, which causes issues for prosthetic use due to limitations in ROM.
  2. Decrease in Hip extension, adduction, IR, knee ext/flex
43
Q

What ms remain intact w/ a transtibial amputation?

What are important exercises to tare pre-prosthetic for strength?

A
  1. Quad and Ham are usually intact-good knee function. Except gastroc.
  2. Strength hip for stability in stance.
    Control of the knee.
44
Q

What are some ms groups to work on w/ transtibial amputees and associated exercises for each group?

A

Hip Extension: prone leg lifts, bridging.
Hip Abductors: Sidelying abd or bridges.
Hip Flexors: supine SLR
Hip IR/ER: seated (MR or EB)
Knee Ext: Seated extension (CKC or OCK, MR or weights)
Knee Flex: Seated, prone or bridging.

Manually resisted, pulley, elastic bands.

45
Q

What is a major risk w/ transfemoral amputees and what can be done to target it?

A

Hip flexion contractions can develop. Pt tend to sit in abduction and ER to increase their BOS. This can increase contracture that negatively impact future prosthetics use.

Have the pt lie prone w/ a towel under the distal anterior RL (Neutral pelvis).

46
Q

What distal ms attachments are altered w/ a transfemoral amputation?

A

-hamstring
-Rec Fem
-Sartorius
-TFL/ITB
+/- adductors.

Altered line of pull, ms mass and change in length-tension profile.

47
Q

What distal ms attachments remain intact?

A

-Glut max, med
Iliopsoas
+/- adductors

EXTENSION, ABDUCTION and FLEXION of hip should be well preserved.

48
Q

What are some important pre-prosthetic strengthening targets for transfemoral amputees and why?

A

Hip Extension: To control the prosthetic knee unit. Strength of hip extensors helps determine type of prosthetic pt will use.

Hip Abduction: Keep pelvis level during stance.

Hip Adduction: Adjust new ms mechanics.

49
Q

What areas are worked on in rehab during prosthetic training?

A
  1. Posture and balance:
    - Sit/standing w/ prosthetic
    - specific balance training b/c 1. COM and BOS have changed due to amputation and 2. Loss of proprioceptive sensation from amputated limb.
    - Address decrease ROM and ms function.
  2. Gait/Balance:
    - Floor to sit to stand important
    - Stairs: non-reciprocal, then reciprocal if possible.
    - WB, weight shift, reaching activities, parallel bars, stepping, stairs, gait, sit to stand, community activities.
  3. Cardiorespiratory Endurance:
    - No restrictions specifically.
    - Oxygen uptake may be higher in amputees because of increased demands associated w/ walking.
  4. Advanced Ex:
    -ROM and flexibility: independent stretch hams, quads…
    -Resistance training
    -Balance and coordination: SLS, uneven surfaces.
    -Speed and agility: obstacle course, figure of 8 walking.
    -CV activities: swim, run…
    Activity specific.
50
Q

How is gait altered in transfemoral amputations?

A
  1. Loss of ankle and knee musculature means energy efficiency and quality of gait is compromised.
  2. Knee stability in stance is an important goal.
    - There are different models of prosthetic to allow for knee control in stance. There is a trade off between having this stability in stance (knee locked in extension) and being able to voluntarily initiate knee flexion for swing. The amount o knee stability is dependent on: type of knee hinge, TKA, and voluntary knee control.

PHTH 550- Orthopaedic Management Final (13 decks)

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