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Year 3: Prosthetics and Orthotics > Lecture 8: Intro to Amputation > Flashcards

Lecture 8: Intro to Amputation Flashcards

1
Q

Facts about limb loss

A

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

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2
Q

non-traumatic causes of amputation

A

Dysvascular (i.e. PAD, PVD, diabetes)
- non-healing wounds from osteomyelitis or gangrene are 2ndary dysvascular

limb deficiencies/congenital

infections

tumors

disease

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3
Q

traumatic causes amputation

A

high energy trauma

burns

electrocution

motor vehicle accident

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4
Q

most frequent causes of adult amputations

A

PVD
burns
tumors
trauma

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5
Q

most frequent causes of amputation with children

A

congenital limb deformities

tumors

trauma

infection

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6
Q

what is a limb deficiency or congenital amputation, types, and causes

A

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

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7
Q

what is a transverse limb deficiency

A

distal structures do not exist

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8
Q

what is a longitudinal limb deficiency and possible sx interventions

A

partial or total absence of a structure along the axis of a segment

possible sx interventions:
- limb lengthening
- amputation

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9
Q

tibial deficiency longitudinal limb deficiency possible sx interventions

A

knee disarticulation

brown procedure- centralization of the fibula

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10
Q

possible sx interventions for proximal femoral focal deficiency (type of longitudinal limb deficiency)

A

limb lengthening

foot amputation

rotationplasty

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11
Q

goals of PT for a limb lengthening sx

A

maintain ROM above and below fixator

strengthen the limb

encourage weight bearing

increase endurance

restore function

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12
Q

indications for amputations for primary tumor control

A

bone sarcomas (i.e. osteosarcoma)

soft tissue tumors

metabolic disease

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13
Q

risk factors for amputation with diabetes

A

males
smoking
poor glycemic control
depression

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14
Q

risk factors for re-amputation, re-ulceration, and mortality with diabetes

A

previous amputation

level of amputation

comorbidities

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15
Q

osteomyelitis can be a complication or consequences of what conditions

A

PVD
diabetes
RA
corticosteroid therapy
poor nutritional status
post-prosthetic implantation (i.e. TKA)
trauma
fracture

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16
Q

infection types that may warrant an amputation

A

osteomyelitis and sepsis

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17
Q

type of burn injuries

A

electrical: due to contact with high voltage electrical current

chemical

thermal: extreme heat or frostbite

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18
Q

common types of trauma that can lead to amputations and common demographic for these type injuries

A

MVA/MCA

non-union fractures

military conflicts

work accidents

tend to be young adults, frequently males

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19
Q

reasons that recent wars in Iraq and Afghanistan have lowest fatality rates in American history

A

improvement in body armor

tourniquet use

in-theater trauma system; surgeons deployed

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20
Q

what are the 3 amputation rehab centers for the US military

A

MATC and Walter Reed National Military Medical Center

C5 at Naval Medical Center in San Diego

CFI at Brooke Army Medical Center

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21
Q

disarticulation vs trans- type amputations

A

disarticulation = through the joint/joint separation

trans- = through the bone

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22
Q

level of amputation is dependent on

A

vascular status of the limb

neuropathy

infection

necrosis

malignancy

bone and joint condition

age

function and rehab potential

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23
Q

general priciples of amputation in children

A

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

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24
Q

common traumatic amputation complications for adults

A

infection

slow wound healing

DVT

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25
Q

traumatic amputation complications for children

A

phantom limb pain

residual limb pain

terminal overgrowth (common in humerus and fibula)

26
Q

general surgical principles for amputation

A

maintain adequate length of residual limb

protect neuromuscular structure

stabilize mm

non-tender/non-adherent scar/skin

functional shape of residual limb

27
Q

surgical procedure for amputation

A

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

28
Q

surgical techniques for mm stabilization

A

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

29
Q

residual limb shapes

A

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

30
Q

things to examine for residual limb

A

length and circumference

integ and vascular status

sensation

pain

ROM

strength

31
Q

purpose of soft post op dressings and examples

A

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

32
Q

purpose of semirigid post op dressings

A

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

33
Q

purpose of rigid post op dressing, complications, and example

A

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

34
Q

key domains of care for amputees

A

post op pain

physical health

function

psychosocial support and well being

pt satisfaction

community reintegration

healthcare utilization

35
Q

amputation CPG highlights

A

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

36
Q

goals of rehab for pts with amputation

A

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

37
Q

phases of rehab

A

pre surgical

acute post sx (1-2 weeks)

pre-prosthetic training (2-8 weeks)

prosthetic training (8 weeks -18 months)

lifelong care (throughout lifespan)

38
Q

factors impacting rehab potential

A

level of amputation

comorbidities (i.e. DM, CVD, renal disease)

emotional/social support

cognitive impairment

physical conditioning

smoking

visual impairment

psychological factors

pt compliance

39
Q

important component throughout all stages of amputation rehab to help develop individualized treatment plans

A

consider pts birth sex and self identified gender identity in developing individualized treatment plans

40
Q

suggested things to do with amputees throughout all phases of rehab process

A

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

41
Q

good outcome measure to measure pain intensity

A

pain interference from PROMIS

pt reported outcome measurement information system

42
Q

types of pain

A

immediate post sx

residual limb pain

phantom limb pain/sensations

secondary MSK pain

43
Q

causes of residual limb pain

A

expected from sx trauma

poor prosthetic fit

brushing/chafing

poor perfusion/ischemia

heterotypic ossification

neuroma

44
Q

treatment for residual limb pain

A

oral meds = antidepressants, tricyclics, antiepileptics, opioids

intravenous = ketamine, opioids

nerve block

PT = exercise, massage, TENS, desensitization exercises

prosthetic mods

45
Q

what is phantom limb pain

A

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

46
Q

treatment for phantom limb pain

A

massage
US
ice
TENS
non-narcotic analgesics
biofeedback
guided imagery
nn block
mirror therapy

47
Q

implications of secondary MSK pain for pts

A

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

48
Q

recommendations (Grade A) for preoperative phase of amputations from CPG

A

include both open and closed chain exercises with progressive resistance to improve gait, mobility, strength, CV fitness, and ADL performance to maximize function

49
Q

suggestions for preoperative phase from CPG

A

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

50
Q

expert opinion suggestions for perioperative phase

A

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

51
Q

CPG for perioperative phase post amputation has insufficient evidence for or against what

A

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

52
Q

post op timeline for lower limb amputation

A

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

53
Q

ROM considerations for PT exam

A

check for contractures

liner/socket limited ROM

*think about reference for moving arm (i.e. does pt still have fulcrum landmark)

54
Q

common contractures with transfemoral

A

hip flexion
hip abduction

55
Q

common contractures with transtibial

A

knee flexion
hip flexion

56
Q

causes of contractures

A

poor positioning

prolonged sitting position/WC use

57
Q

management of contractures

A

appropriate positioning
ambulation
prosthetic modification
casts
sx

58
Q

consequences of contractures

A

functional leg length discrepancy

poor prosthetic alignment

59
Q

proper positioning for contracture prevention

A

neutral hip RT

knee extension

hip and knee ext when prone

knee ext in sitting

for TFA, avoid hip ABD

60
Q
A

Year 3: Prosthetics and Orthotics (10 decks)

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