Lecture 21 - LE amputation Flashcards
What are the 6 guidelines for patients with neuroischemic feet?
- Examine feet daily
- broken skin, blisters, swelling, or redness - Report worsening symptoms
- decreasing walking distance
- pain at rest
- pain at night
- changes in skin colour - Keep the skin moist
e. g. 50/50 white soft paraffin and liquid paraffin mix - 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 - Smoking cessation
- Regular exercise
What are the 3 main management component with foot ulcers
- pressure relief
- debridement dans infection control
- modalities
What are the prevention and treatement component related to pressure relief of foot ulcers?
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)
What are the components related to debridement and infection control of foot ulcers?
- Remove all necrotic or devitalized tissue (including callus, slough, etc.).
- Cleanse wound with sterile saline
- Apply appropriate wound dressing
Name different modalities used in the management of foot ulcers
Negative pressure (vacuum) wound therapy
Electrical modalities
what’s the Lisfranc procedure?
amputation of the tarsal metatarsal joint
what’s the chopart procedure?
amputation at the midtarsal (talonavicular and calcaneocuboid) joints
What’s the syme ankle disarticulation
- 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
Why is short transtibial amputation not the standard/preffered?
Too short for a prosthetic
what’s a simple knee disarticulation?
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
what’s a transcondylar amputation
shape of residual femur resemble a long transfemoral residual limb
bulbous shapes can lead to sin breakdown
Describe a transfemoral amputation
- 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
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?
muscle-to-bone fixations (myodesis) - preferred
muscle-to-muscle fixation (myoplasty)
muscle-to-fascia fixation (myofascial)
What’s the biomechanical effect of the amputation on the musculature (4) ?
- 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
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?
Adductors
What should be included in patient/family education about amputation?
Wound insepction residual limb care mobility* locomotion* Self-care/ADL Exercise program* Follow up plan (MD, PT...)
The projection of rehabilitation potential and prosthetic use after amputation is based on what 3 component?
pre-morbid level of mobility
ADL status
level of amputation
What caracteristics are we evaluating on the residual limb (6)
- Residual limb length (bone length, soft tissue length)
- Residual limb girth: Circumference measures – multiple levels
- Redundant tissue (“dog ears,” adductor roll)
- Residual limb shape (bulbous, cylindrical, conical)
- Assessment of type and severity of edema
- Effectiveness of edema control strategy being used
“shrinkers” are worn for the initial period following amputation, when not using prosthetic
What are the requirements for the prosthetic (6)?
- Potential for functional prosthetic use
- Readiness for prosthetic fitting/prescription
- Prosthetic design, components, suspension
- Residual limb characteristics
- Energy cost of ambulation:
- older patients, deconditioning, co-morbid conditions
- level of amputation: loss of joints, long bone length, muscle insertion - Level of amputation
For the level of amputation (prosthetic requirements), what are the differences between:
- transtibial amputation w/ intact anatomical knee joint
- Bilateral transfemoral amputation
- 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 - 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
how is the pain managed in LE amputation?
Primarily pharmacological
Other: - acupressure/acupuncture - modalities (varying degrees of success) T.E.N.S. ultrasound cold or ice massage
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. Neuroplastic changes in the brain
(Areas responsible for amputated limb are taken over due to disuse)
C. Spinal cord factors
E. Psychological factors
How is phantom limb sensation or pain managed?
Medical / pharmacological management is common
Experimental therapies “exercise” for phantom limb:
Mental imagery
Mirror box
Is there a hyposensitivity or a hypersensitivity problem, or both?
Explain.
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)
What are some tips to reduce edema?
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
What does adhesions around incision scar & surrounding area affects?
prosthetic tolerance, comfort, and use
What is important in soft tissue mobility of the residual limb?
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)
T/F
functional single limb ambulation is a prerequisite for prosthetic fitting
F
functional single limb ambulation is not a prerequisite for prosthetic fitting
With ??? type of amputation there is a high risk of knee flexion contracture.
- what is the type of amputation?
- what’s the negative impact?
-
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
What can be done to increase ROM for transtibial amputation in prone position?
Prone positioning for stretching of posterior soft tissue manual passive stretching PNF prevention of knee flexion contracture deep effleurage massage moist heat or ultrasound
what are the consequences of a decreased hip extension
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
what are the consequences of a decreased hip adduction
Abducted stance in gait
Abductor lurch on ipsilateral side in gait
what are the consequences of a decreased hip IR
Toe-out stance and gait
Knee joint pain or pathology due to lack of anterior/posterior orientation of knee joint
what are the consequences of a decreased knee ext
Limb functionally shorter w/ associated gait deviations
Decreased mid-stance stability in gait
Prosthetic alignment adjustments to compensate
what are the consequences of a decreased knee flex
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
T/F with a transtbial amputation, attachments of the quadriceps and hamstrings are typically affected
F
attachments of the quadriceps and hamstrings are typically intact
In a transtibial amputation, pre-prosthetic strengthening exercises emphasize on what?
control of the knee
hip strength for stability in stance
Give one exercise example for (transtibial amputation)
- hip extensors
- hip abductors
- hip flexors
- hip er/ir
- knee extensors
- knee flexors
- 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. - 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 - Hip flexors
Supine SLR +/- manual resistance or weights
Standing hip flexion with pulleys or elastic bands - Hip ER/IR
Seated hip ER and IR
+/- manual resistance or elastic bands
caution re: knee ligaments - Knee extensors
Seated knee extension
CKC or OKC
+/- manual resistance or weights - 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.
With transfemoral amputation, the risk of ??? contracture is increased
- Which contracture
- What’s the impact
- What positionning can avoid that?
- Risk of hip flexion contracture
- negative impact on future prosthetic use; associated risk of tightness of hip abductors & ERs
- Patients sit with hip out to increase BoS - Positioning
Prone, towel roll under the distal anterior residual limb
Pelvis neutral / slight posterior tilt (avoid Lx lordosis)
With transfemoral amputation, which muscles have their distal attachement altered (7)?
What’s the consequence?
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
With transfemoral amputation, which muscles have their distal attachement intact?
gluteus maximus
gluteus medius
Iliopsoas
+/- adductors (Pectineus, Add Brevis, Add. Longus, Add. Magnus)
Give an example of exercise for transfemoral amputation
- hip ext
- hip abd
- hip add
Hip ext: Slide 72
Hip abd: slide 73
Hip add: slide 74
What should be addressed in a posture and balance training?
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
Give some examples of gait and balance training (tot:10)
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
Knee stability in stance is an important goal in transfemoral prosthetics
Name an important trade off, and 3 main variables.
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
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
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
Gve some examples of advances exercises and activities
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.
