Lecture 8: Intro to Amputation Flashcards
Facts about limb loss
those with diabetes = 30x greater risk for amputation
55% of those with diabetes and LE amputation will undergo an amputation of the other limb within 2-3 years
by 2050, it is projected to be 3.6 million individuals living with limb loss in the US
non-traumatic causes of amputation
Dysvascular (i.e. PAD, PVD, diabetes)
- non-healing wounds from osteomyelitis or gangrene are 2ndary dysvascular
limb deficiencies/congenital
infections
tumors
disease
traumatic causes amputation
high energy trauma
burns
electrocution
motor vehicle accident
most frequent causes of adult amputations
PVD
burns
tumors
trauma
most frequent causes of amputation with children
congenital limb deformities
tumors
trauma
infection
what is a limb deficiency or congenital amputation, types, and causes
malformation of limb bud around 28 days in utero
can be transverse or longitudinal
causes:
- meds or toxins
- viral infections rubella
- diabetes
- abortion attempts
- unknown
what is a transverse limb deficiency
distal structures do not exist
what is a longitudinal limb deficiency and possible sx interventions
partial or total absence of a structure along the axis of a segment
possible sx interventions:
- limb lengthening
- amputation
tibial deficiency longitudinal limb deficiency possible sx interventions
knee disarticulation
brown procedure- centralization of the fibula
possible sx interventions for proximal femoral focal deficiency (type of longitudinal limb deficiency)
limb lengthening
foot amputation
rotationplasty
goals of PT for a limb lengthening sx
maintain ROM above and below fixator
strengthen the limb
encourage weight bearing
increase endurance
restore function
indications for amputations for primary tumor control
bone sarcomas (i.e. osteosarcoma)
soft tissue tumors
metabolic disease
risk factors for amputation with diabetes
males
smoking
poor glycemic control
depression
risk factors for re-amputation, re-ulceration, and mortality with diabetes
previous amputation
level of amputation
comorbidities
osteomyelitis can be a complication or consequences of what conditions
PVD
diabetes
RA
corticosteroid therapy
poor nutritional status
post-prosthetic implantation (i.e. TKA)
trauma
fracture
infection types that may warrant an amputation
osteomyelitis and sepsis
type of burn injuries
electrical: due to contact with high voltage electrical current
chemical
thermal: extreme heat or frostbite
common types of trauma that can lead to amputations and common demographic for these type injuries
MVA/MCA
non-union fractures
military conflicts
work accidents
tend to be young adults, frequently males
reasons that recent wars in Iraq and Afghanistan have lowest fatality rates in American history
improvement in body armor
tourniquet use
in-theater trauma system; surgeons deployed
what are the 3 amputation rehab centers for the US military
MATC and Walter Reed National Military Medical Center
C5 at Naval Medical Center in San Diego
CFI at Brooke Army Medical Center
disarticulation vs trans- type amputations
disarticulation = through the joint/joint separation
trans- = through the bone
level of amputation is dependent on
vascular status of the limb
neuropathy
infection
necrosis
malignancy
bone and joint condition
age
function and rehab potential
general priciples of amputation in children
preserve proximal joints
preserve length growth plates
amputate through the joint if distal bone cannot be salvaged
proximal osteotomies or external fixator techniques (i.e. limb lengthening) may be needed to accomodate growth
common traumatic amputation complications for adults
infection
slow wound healing
DVT
traumatic amputation complications for children
phantom limb pain
residual limb pain
terminal overgrowth (common in humerus and fibula)
general surgical principles for amputation
maintain adequate length of residual limb
protect neuromuscular structure
stabilize mm
non-tender/non-adherent scar/skin
functional shape of residual limb
surgical procedure for amputation
major nn are cut high and retract into soft tissue to prevent neuromas
ligation (tied/closed off) of major arteries and veins; cauterize smaller vessels
distal bone is beveled to help prosthetic fit
surgical techniques for mm stabilization
myofascial closure = mm to skin
myoplasty = mm to mm
myodesis = mm to bone
tendodesis = tendon to bone
posterior skin flap (posterior skin generally has better blood supply than anterior); scar on anterior
residual limb shapes
bulbous = common post op due to swelling
conical = common in congenital amputations
dog ears = typically due to poor sx technique
complicated = common in traumatic amputations
cylindrical = IDEAL; durable; well vascularized; tolerates pressure and friction
things to examine for residual limb
length and circumference
integ and vascular status
sensation
pain
ROM
strength
purpose of soft post op dressings and examples
use if pt is at high risk for infection to allow wound infection
worn all day except bathing
reapplied every 4-6 hours
can teach pt or caregiver how to apply
common!
i.e. shrinker or elastic wrap
purpose of semirigid post op dressings
better edema control than soft but not as good as rigid
impregnated bandage with a paste compound of zinc oxide, gelatin, glycerin, and calamine
typically 4 in wide
not common
purpose of rigid post op dressing, complications, and example
can be removable or non removable
can have a pylon and foot component
common complications = infection, damage to wound, pressure or traction from poisoning
i.e. = plaster of Paris cast; typically left on 1-3 weeks
key domains of care for amputees
post op pain
physical health
function
psychosocial support and well being
pt satisfaction
community reintegration
healthcare utilization
amputation CPG highlights
promote pt centered transdisciplinary team
address key aspects of rehab focused on maximizing pt functional independence and QOL
- prosthetic selection/fitting
- ADLs
- IADLs w/ and w/o prosthesis
- promote physical conditioning
- optimize pain/medical management
develop recommendations that are consistent with evidence based rehab methods
provide rehab providers with algorithm of appropriate rehab interventions to improve pt outcomes and reduce practice variation
provide PCPs with algorithm to assist with referral process
establish priorities for future research that will generate evidence for practice improvement
goals of rehab for pts with amputation
manage pain
prevent injuries
improve/maintain physical health
become independent and safe in walking and ADLs
participate in community, return to work, and leisurely activities
maintain QOL
foster healthy body image and self esteem
find satisfaction with independence, prosthesis and rehab team
improve functional independence with and without a prosthesis
phases of rehab
pre surgical
acute post sx (1-2 weeks)
pre-prosthetic training (2-8 weeks)
prosthetic training (8 weeks -18 months)
lifelong care (throughout lifespan)
factors impacting rehab potential
level of amputation
comorbidities (i.e. DM, CVD, renal disease)
emotional/social support
cognitive impairment
physical conditioning
smoking
visual impairment
psychological factors
pt compliance
important component throughout all stages of amputation rehab to help develop individualized treatment plans
consider pts birth sex and self identified gender identity in developing individualized treatment plans
suggested things to do with amputees throughout all phases of rehab process
provide edu
measure intensity of pain and interference with functioning for each type of pain and location using standardized tools
offer multimodal transdisciplinary approach to pain management including transition to non-narcotics; consider physical, psychological, and mechanical modalities
offer peer support interventions as early as feasible and throughout rehab process
good outcome measure to measure pain intensity
pain interference from PROMIS
pt reported outcome measurement information system
types of pain
immediate post sx
residual limb pain
phantom limb pain/sensations
secondary MSK pain
causes of residual limb pain
expected from sx trauma
poor prosthetic fit
brushing/chafing
poor perfusion/ischemia
heterotypic ossification
neuroma
treatment for residual limb pain
oral meds = antidepressants, tricyclics, antiepileptics, opioids
intravenous = ketamine, opioids
nerve block
PT = exercise, massage, TENS, desensitization exercises
prosthetic mods
what is phantom limb pain
occurs in 80% pts with amputatuions and can last decades
typically episodic
lasts seconds to days; can be continuous
unclear mechanisms:
- abnormal regeneration of primary afferent neurons
- central sensitization
- chronic pre amputation pain
treatment for phantom limb pain
massage
US
ice
TENS
non-narcotic analgesics
biofeedback
guided imagery
nn block
mirror therapy
implications of secondary MSK pain for pts
traumatic LE amputations:
- many develop overuse injury w/I first year
- unilateral amputees more likely to develop UE/LE MSK injury
- bilateral amputees were more likely to develop L/S injury and UE injury
traumatic UE amputations:
- many develop overuse injury in first year
recommendations (Grade A) for preoperative phase of amputations from CPG
include both open and closed chain exercises with progressive resistance to improve gait, mobility, strength, CV fitness, and ADL performance to maximize function
suggestions for preoperative phase from CPG
rehab goals and outcomes should be included in shared decision making
rigid or semi-rigid dressings to promote healing and early prosthetic use (rigid preferred if limb protection is priority)
cognitive screening for to prior to setting goals to help determine type of prosthesis
physical rehab and appropriate DME
acute inpatient rehab over a SNF
initiate mobility training ASAP; may include ipsilateral WBing ambulation with pylon to improve function and gait parameters
expert opinion suggestions for perioperative phase
decision to amputate based upon medical standards of care
communication between surgical and non-surgical team
ensure pt is optimized for rehab tp enhance functional outcome
care team should ensure pt achieves their highest level of functional independence WITHOUT PROSTHESIS
CPG for perioperative phase post amputation has insufficient evidence for or against what
one surgical procedure over the other
procedure should be determined after conversation with surgeon and pt, involving rehab team, to better ak=lign expected sx outcomes with rehab outcomes
post op timeline for lower limb amputation
days 1-2 = ROM, bed mobility, transfers, sound limb exercises, post op dressing
days 3-14 = pre-prosthetic ambulation with crutches, post op dressing
weeks 2-3 = staples removed, shrinker or wrap, dynamic resistive exercises, ROM, and ambulation
weeks 4-6 - shrinker, monitor healing, prevention of complications, casting for prosthesis socket fi incision healed
ROM considerations for PT exam
check for contractures
liner/socket limited ROM
*think about reference for moving arm (i.e. does pt still have fulcrum landmark)
common contractures with transfemoral
hip flexion
hip abduction
common contractures with transtibial
knee flexion
hip flexion
causes of contractures
poor positioning
prolonged sitting position/WC use
management of contractures
appropriate positioning
ambulation
prosthetic modification
casts
sx
consequences of contractures
functional leg length discrepancy
poor prosthetic alignment
proper positioning for contracture prevention
neutral hip RT
knee extension
hip and knee ext when prone
knee ext in sitting
for TFA, avoid hip ABD
