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PHTH 550 - Orthopedics > Lecture 21 - LE amputation > Flashcards

Lecture 21 - LE amputation Flashcards

1
Q

What are the 6 guidelines for patients with neuroischemic feet?

A
  1. Examine feet daily
    - broken skin, blisters, swelling, or redness
  2. Report worsening symptoms
    - decreasing walking distance
    - pain at rest
    - pain at night
    - changes in skin colour
  3. Keep the skin moist
    e. g. 50/50 white soft paraffin and liquid paraffin mix
  4. Shoes
    - well fitting, free of friction and pressure points
    - check them for foreign objects (such as stones) before wearing
    - avoid open toed sandals and pointed shoes
    - never walk barefoot
  5. Smoking cessation
  6. Regular exercise
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2
Q

What are the 3 main management component with foot ulcers

A
  1. pressure relief
  2. debridement dans infection control
  3. modalities
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3
Q

What are the prevention and treatement component related to pressure relief of foot ulcers?

A 
Prevention / prophylaxis:
Protective footwear / diabetic shoes
- Extra padding
- Soft fabric / seamless
- Lots of styles

Treatement

  • Mobility aids: crutches, walkers, wheelchairs
  • Specialized shoes
  • Felt padding
  • Total contact cast: redistributes weight bearing directly to the leg
  • Prefabricated cast (Aircast, Scotchboot)
  • Pressure relief ankle/foot orthosis (heel ulcers)
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4
Q

What are the components related to debridement and infection control of foot ulcers?

A
  • Remove all necrotic or devitalized tissue (including callus, slough, etc.).
  • Cleanse wound with sterile saline
  • Apply appropriate wound dressing
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5
Q

Name different modalities used in the management of foot ulcers

A

Negative pressure (vacuum) wound therapy

Electrical modalities

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6
Q

what’s the Lisfranc procedure?

A

amputation of the tarsal metatarsal joint

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7
Q

what’s the chopart procedure?

A

amputation at the midtarsal (talonavicular and calcaneocuboid) joints

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8
Q

What’s the syme ankle disarticulation

A
  • talus is removed from its mortise
  • distal points of malleoli are trimmed to create a flat surface
  • posterior heel pad is drawn upward to close the wound
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9
Q

Why is short transtibial amputation not the standard/preffered?

A

Too short for a prosthetic

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10
Q

what’s a simple knee disarticulation?

A

no modification of patella or femur

residual limb is long and bulbous
center of the prosthetic knee is generally lower than that of the intact limb

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11
Q

what’s a transcondylar amputation

A

shape of residual femur resemble a long transfemoral residual limb

bulbous shapes can lead to sin breakdown

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12
Q

Describe a transfemoral amputation

A
  • residual limb is a tapered cylinder
  • knee center generally matches that of the intact limb
  • difference based largely on length of femur that is preserved in the former
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13
Q

When doing an amputation, there is a loss of distal insertion point of the muscle attatchement that requires surgical repair

What are the 3 types?
Which one is preffered?

A

muscle-to-bone fixations (myodesis) - preferred

muscle-to-muscle fixation (myoplasty)

muscle-to-fascia fixation (myofascial)

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14
Q

What’s the biomechanical effect of the amputation on the musculature (4) ?

A
  • altered line of pull of the muscles
  • loss of force generating capacity (loss of muscle mass)
  • altered / loss of distal connective tissue (tendon, etc.)
  • shift in functional position on the length-tension curve
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15
Q

As the length of the residual femur decreases, power and efficiency of ?????? muscles groups are more and more compromised.

Which muscle group are we talking about?

A

Adductors

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16
Q

What should be included in patient/family education about amputation?

A 
Wound insepction
residual limb care
mobility*
locomotion*
Self-care/ADL
Exercise program*
Follow up plan (MD, PT...)
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17
Q

The projection of rehabilitation potential and prosthetic use after amputation is based on what 3 component?

A

pre-morbid level of mobility
ADL status
level of amputation

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18
Q

What caracteristics are we evaluating on the residual limb (6)

A
  1. Residual limb length (bone length, soft tissue length)
  2. Residual limb girth: Circumference measures – multiple levels
  3. Redundant tissue (“dog ears,” adductor roll)
  4. Residual limb shape (bulbous, cylindrical, conical)
  5. Assessment of type and severity of edema
  6. Effectiveness of edema control strategy being used
    “shrinkers” are worn for the initial period following amputation, when not using prosthetic
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19
Q

What are the requirements for the prosthetic (6)?

A
  1. Potential for functional prosthetic use
  2. Readiness for prosthetic fitting/prescription
  3. Prosthetic design, components, suspension
  4. Residual limb characteristics
  5. Energy cost of ambulation:
    - older patients, deconditioning, co-morbid conditions
    - level of amputation: loss of joints, long bone length, muscle insertion
  6. Level of amputation
20
Q

For the level of amputation (prosthetic requirements), what are the differences between:

  1. transtibial amputation w/ intact anatomical knee joint
  2. Bilateral transfemoral amputation
A
  1. transtibial amputation w/ intact anatomical knee joint
    - more energy-efficient prosthetic gait pattern and postural responses
    - more likely to ambulate without additional assistive devices (walkers, crutches, or canes)
    - more likely to be full-time prosthetic wearers
  2. Bilateral transfemoral amputation
    - Increased energy consumption for prosthetic ambulation: can prevent long-distance ambulation
    - wheelchair mobility may be more energy-efficient and effective means of locomotion
    - ambulation potential depends on cardiac function, strength, balance, and endurance
21
Q

how is the pain managed in LE amputation?

A

Primarily pharmacological

Other:
- acupressure/acupuncture
- modalities (varying degrees of success)
T.E.N.S.
ultrasound
cold or ice
massage
22
Q

To what is due phantom limb sensation / pain
A. Neuroplastic changes in the brain
B. Neuroplastic changes in the periphery
C. Spinal cord factors
D. The one ring to rule them all
E. Psychological factors
F. Modification of the vasculature

A

A. Neuroplastic changes in the brain
(Areas responsible for amputated limb are taken over due to disuse)
C. Spinal cord factors
E. Psychological factors

23
Q

How is phantom limb sensation or pain managed?

A

Medical / pharmacological management is common

Experimental therapies “exercise” for phantom limb:
Mental imagery
Mirror box

24
Q

Is there a hyposensitivity or a hypersensitivity problem, or both?

Explain.

A

Both!

Hyposensitivity

  • Risk for skin breakdown
  • Must be monitored: Skin inspection with mirror, Before and after prosthetic use
  • Sensory testing

Hypersensitiity:

  • Common
  • bombard with tactile stimulus (various textures and pressures, intensity based on tolerance… slide 44)
25
Q

What are some tips to reduce edema?

A

WB activities in prosthetic socket

  • decreases limb edema
  • accelerates maturation of the residual limb
  • contact within the socket
  • pumping from muscle contractions

Accommodating for fluctuation of residual limb size over course of the day
- add/remove of layers socks

26
Q

What does adhesions around incision scar & surrounding area affects?

A

prosthetic tolerance, comfort, and use

27
Q

What is important in soft tissue mobility of the residual limb?

A

Adhesions around incision scar & surrounding area

Deeper scarring/adhesions from surgical procedure

Soft tissue must move independently of scar tissue or skeletal structures (stress can lead to tissue breakdown and discomfort)

28
Q

T/F

functional single limb ambulation is a prerequisite for prosthetic fitting

A

F

functional single limb ambulation is not a prerequisite for prosthetic fitting

29
Q

With ??? type of amputation there is a high risk of knee flexion contracture.
- what is the type of amputation?
- what’s the negative impact?
-

A

Transtibial amputation

  • high risk of knee flexion contracture
  • negative impact on future prosthetic use

prolonged dependence of residual limb in knee flexion when sitting causes distal edema

  • can delay readiness for prosthetic fitting
  • wheelchair with elevating leg rests
  • posterior trough splint
30
Q

What can be done to increase ROM for transtibial amputation in prone position?

A 
Prone positioning 
for stretching of posterior soft tissue 
manual passive stretching
PNF
prevention of knee flexion contracture
deep effleurage massage
moist heat or ultrasound
31
Q

what are the consequences of a decreased hip extension

A

Inability to achieve upright posture in stance

Compensatory knee flexion causes instability in gait

LBP due to compensatory anterior pelvic tilt

Decreased stride length of contralateral limb in gait

32
Q

what are the consequences of a decreased hip adduction

A

Abducted stance in gait

Abductor lurch on ipsilateral side in gait

33
Q

what are the consequences of a decreased hip IR

A

Toe-out stance and gait

Knee joint pain or pathology due to lack of anterior/posterior orientation of knee joint

34
Q

what are the consequences of a decreased knee ext

A

Limb functionally shorter w/ associated gait deviations

Decreased mid-stance stability in gait

Prosthetic alignment adjustments to compensate

35
Q

what are the consequences of a decreased knee flex

A

Inability to place foot flat on the floor when sitting

Inability to bear weight through prosthesis during sit-to-stand transfers

Difficulty managing steps and curbs

36
Q

T/F with a transtbial amputation, attachments of the quadriceps and hamstrings are typically affected

A

F

attachments of the quadriceps and hamstrings are typically intact

37
Q

In a transtibial amputation, pre-prosthetic strengthening exercises emphasize on what?

A

control of the knee

hip strength for stability in stance

38
Q

Give one exercise example for (transtibial amputation)

  1. hip extensors
  2. hip abductors
  3. hip flexors
  4. hip er/ir
  5. knee extensors
  6. knee flexors
A
  1. Hip extensors
    Manual resistance +/- gravity
    Prone leg lifts +/- weights
    Bridging - residual limb over ball, padded stool, etc.
    Standing (parallel bars) vs. pulley, elastic bands, etc.
  2. Hip abductors
    Manual resistance +/- gravity
    Side lying abduction – residual limb on top
    +/- manual resistance or weights
    Side-lying bridges – residual limb on bottom
    small ball or padded stool under knee of residual limb
    Standing hip abduction with pulleys or elastic bands
  3. Hip flexors
    Supine SLR +/- manual resistance or weights
    Standing hip flexion with pulleys or elastic bands
  4. Hip ER/IR
    Seated hip ER and IR
    +/- manual resistance or elastic bands
    caution re: knee ligaments
  5. Knee extensors
    Seated knee extension
    CKC or OKC
    +/- manual resistance or weights
  6. Knee flexors
    Seated knee flexion
    manual resistance, pulleys, elastic bands
    Prone knee flexion
    manual resistance or weights
    Bridging - residual limb over ball, padded stool, etc.
39
Q

With transfemoral amputation, the risk of ??? contracture is increased

  1. Which contracture
  2. What’s the impact
  3. What positionning can avoid that?
A
  1. Risk of hip flexion contracture
  2. negative impact on future prosthetic use; associated risk of tightness of hip abductors & ERs
    - Patients sit with hip out to increase BoS
  3. Positioning
    Prone, towel roll under the distal anterior residual limb
    Pelvis neutral / slight posterior tilt (avoid Lx lordosis)
40
Q

With transfemoral amputation, which muscles have their distal attachement altered (7)?

What’s the consequence?

A 
hamstrings
rectus femoris
sartorius
tensor fasciae latae/iliotibial band
\+/- adductor longus
\+/- adductor magnus

Consequence

  • altered line of pull
  • loss of muscle mass
  • change in length-tension profile relative to joint ROM
41
Q

With transfemoral amputation, which muscles have their distal attachement intact?

A

gluteus maximus
gluteus medius
Iliopsoas
+/- adductors (Pectineus, Add Brevis, Add. Longus, Add. Magnus)

42
Q

Give an example of exercise for transfemoral amputation

  • hip ext
  • hip abd
  • hip add
A

Hip ext: Slide 72
Hip abd: slide 73
Hip add: slide 74

43
Q

What should be addressed in a posture and balance training?

A

Sitting & Standing
- with and without prosthetic

Specific balance training
- Change in CoM & BoS due to amputation

  • Loss of proprioceptive sensation from amputated limb

Address ↓ ROM & muscle function

44
Q

Give some examples of gait and balance training (tot:10)

A 
Static weight bearing 
Simple dynamic weight-shifting activities 
Reaching activities 
Repeated stepping activities
Parallel-bar training
Step-up/stairs (with the uninvolved limb)
Gait training 
Sit-to-stand and stand-to-sit activities
Floor-to-sit-to-stand
Community activities
45
Q

Knee stability in stance is an important goal in transfemoral prosthetics

Name an important trade off, and 3 main variables.

A

Trade-off with ability to flex knee during swing

Three main variables:
- voluntarily control using muscular strength / power
(primarily hip extensors)
- alignment of prosthesis vs. trochanter-knee-ankle line
- inherent mechanical stability of the knee unit

46
Q

T/F

oxygen uptake for patients with unilateral transtibial amputation is correlated to residual limb length and may be slighlty higher than that of individuals without amputation

A

F

oxygen uptake for patients with unilateral transtibial amputation is correlated to residual limb length and may be 10% to 40% higher than that of individuals without amputation

47
Q

Gve some examples of advances exercises and activities

A

Range of motion & flexibility training
- Independent stretching of hamstrings, quadriceps, hip flexors, hip internal rotators, and external rotators

Resistance training
- hip musculature, quads and hamstrings
- closed-chain exercises
step ups, leg press, wall or ball squats, involved limb lunges
- involved limb stance with opposite limb resistance
- multiple plane stepping exercises

Balance and coordination

  • Involved single-limb stance; Static and Dynamic
  • Uneven & unstable surfaces
  • Beam walking

Speed and agility

  • Figure-of-eight walking, progressing to running,
  • Shuttle walk to run
  • Sprinting
  • Obstacle course

Cardiovascular activities
- Swimming, running, cycling, treadmill walking, stair/stepper climbing, etc.

PHTH 550 - Orthopedics (10 decks)

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